Health Policy Today - 2 July 2008

by Andy Cowper

With apologies to Garrison Keillor, it has been a busy day in the health policy village.

Parlez-vous NHS?
The Guardian reported a potentially major development, in the form of the European Union’s draft legislation on a right to travel to any of the EU’s 27 member states for free treatment (www.guardian.co.uk/uk/2008/jul/02/euro.health).

David Batty’s coverage suggests that as the draft stands, treatment costs overseas will be met by the domestic national health scheme. The legislation proposes patients should have the right to be treated overseas more quickly for any treatment on offer in the NHS. While patients will need to pay upfront for the costs of overseas treatment (thus ruling the option out for a significant proportion of the population), they will be reimbursed in full up to the NHS tariff cost. The directive also suggests that if ‘health tourism’ begins to demonstrably disrupt any nation’s planning of operations, then a system could be introduced requiring prior agreement by the national authority to overseas care.

The Department of Health’s quoted response emphasises that this is merely a draft for consultation, and acknowledges case law in the European Court of Justice permits travelling abroad for treatment when facing a lengthy delay should be funded by the national system, as in the 2006 case of Yvonne Watts (http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:62004J0372:E...) However, the DH spokesman tells The Guardian that since the Watts ruling, “there has been no significant increase in numbers in recent years”. LATE ADDITION: Nigel Hawes of The Times has pointed out (www.timesonline.co.uk/tol/life_and_style/health/article4258519.ece) that Watts was awarded all costs, not just a funding of the NHS tariff treatment cost.

Elisabetta Zanon, director of the NHS Confederation’s European Office said in a statement, “we welcome the aim of the proposals. As patients can already go abroad to receive healthcare, it is crucial to be clear about where responsibility for patient safety lies, and how the costs of treatments will be met”.

Zanon acknowledged the potential uncertainty for PCTs’ financial planning, given that prior authorisation is not initially required. However, her statement added, “the new proposals present an opportunity to clarify some of these uncertainties for the benefit of both patients and NHS organisations … it would be helpful to have clear confirmation that where patients decide to travel abroad for care, the NHS retains the ability to decide what treatment is most appropriate given their individual circumstances, to ensure the sustainability, quality and safety of healthcare for all patients”.

Zanon’s statement concludes that the draft legislation includes “some new elements which may be of concern, such as new data collection requirements which may increase the bureaucratic burden on the NHS”.

The development of this discussion will prove interesting as a guide to Britain as a member of the EU. The majority of the population appears sceptical of closer EU integration in opinion polls. Moreover, with the pound’s slide in value of almost 15% against the Euro during the past nine months, the financial barrier to taking up this right if enacted is raised yet higher. And NHS waiting times are heading in the right direction - downwards. The trigger point for the right to travel for treatment may thus be causing DH finance director general David Flory fewer sleepless nights.

Moreover, the Conservative opposition that is currently enjoying a comfortable and sustained lead in opinion polls is intending a bonfire of waiting time targets, to replace them by outcome measures. There could be interesting times ahead if the English NHS slows down for higher quality in response, thus triggering any new EU right to opt overseas.

Healthcare costs
Director of Edinburgh University’s Centre for International Public Health Policy Professor Allyson Pollock, writing for The Guardian’s ‘Comment Is Free’ section, suggests that the Darzi Review will privatise the NHS.

In ‘Farewell to a free NHS’ (www.guardian.co.uk/commentisfree/2008/jul/01/nhs.health1), Professor Pollock suggests that “Lord Darzi, the unelected health minister, has signalled that Labour will continue to dismantle and privatise the NHS delivery system, its staff and services – handing taxpayers' funds to multinational companies, and remodelling the service along the lines of US healthcare”. Pollock adds that “Darzi provides the clearest sign yet that Labour is planning to introduce charges for healthcare, crossing the final rubicon of NHS privatisation - its funding base”.

Perhaps through a hurry to file copy, or maybe through inelegant sub-editing, this is not Professor Pollock’s finest hour. A tireless critic of the economic rationale behind the private finance initiative, her forensic and sustained work has attracted admirers even among those who supported or used PFI: a not unnatural position, as PFI became the sole option permitted by HM Treasury under Gordon Brown’s chancellorship to finance major new hospital builds. She was in the vanguard of exposing the non-transfer of risk under many PFI contracts. As a consequence of her PFI work, a smear against Pollock’s academic integrity was inserted in a 2002 House of Commons Health Select Committee report by a minority intervention (machinations that were subsequently exposed by the committee chair in a Commons debate).

Her comment pieces unfortunately tend towards over-exaggeration. By suggesting that the Darzi Review “introduces the notion that there will no longer be NHS open-ended care according to need, following in the footsteps of NHS dentistry and long term care”, Pollock appears unaware of the contradiction inherent in the two clauses of this sentence. Dentistry and prescription charges date back 56 years, to 1952.

Of personal budgets for patients with long-term conditions, Professor Pollock writes that “there is no logic to these because individual budgets pass risk down to the patient”. Risk is of course also passed down to service users by bad services in a system offering no option except to exit the system - and that only for the wealthy. For conditions such as mental health, which can easily get squeezed by more sympathy-inducing illnesses, direct payments (while not risk-free) have real potential to make services more patient-centred. An anecdote to illustrate this assertion - a mental health service user of over two decades once described to me his involvement in a ‘virtual individual budgets’ pilot run by a primary care group. This person described how they were given a financial figure to manage and allocate as they saw fit. This pilot showed that service users were willing to pay for only 20% of the NHS services provided to them. Anecdotes are not perfect, to be sure – but they do provide useful evidence.