With the release of the European Commission’s communication on cross-border health services [Communication from the Commission, follow-up to the high level reflection process on patient mobility and healthcare developments in the European Union, COM(2004) 301 final, 20 April 2004] and the proposed services directive which will implement the various rulings of the European Court of Justice on cross-border health care [Proposal for a Directive of the European Parliament and of the Council on Services in the Internal Market, COM(2004) 2 final, 13 January 2004], momentum will now build to really understand the potential for a European health system.  While a wholly integrated “European Health Service” seems unlikely, the status quo is also not sustainable.  So what is to be done?  One approach is to learn from countries with federal health systems, where responsibilities are split between the national/federal government and lower levels of jurisdiction, and how they accommodate the different objectives of service delivery at one level, and integration of systems at another.

Canada offers a particularly interesting example since its highly decentralised health system is composed of the autonomous health systems of the provinces, with a federal Canada Health Act [Canada Health Act, 1984] to enshrine particular national standards.  Such an approach offers a way forward for the EU since it recognises that there are legitimate issues that overarch the responsibilities of member states, yet accords to the member states their own sphere of autonomy.

The Canada Health Act sets out specific standards which form the cornerstone of the health system’s national design:

1. public administration: the administration of the health care insurance plan of a province or territory must be carried out on a non-profit basis by a public authority;
2. comprehensiveness: all medically necessary services provided by hospitals and doctors must be insured;
3. universality: all insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions;
4. portability: coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country; and
5. accessibility: reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers.

The important step that the EU must take is to move beyond the development of a purely bureaucratic approach to cross-border health care (by simply making existing regulations more complex [Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons and their families moving within the Community]) and embrace a few good principles.  I would propose the following as a starting point, to create a simple basis (no mean feat in European affairs!) for member states, the Council of Ministers and the Commission to establish the basis for an agreed approach:

1. portability: insured individuals may seek health services throughout the EU in a uniform manner;
2. accessibility: reasonable access is assured to insured individuals to medically necessary health care with fair administration of cross-border entitlements;
3. comprehensiveness: all medically necessary care that meets international standards is covered;
4. accountability: consistency of services and adherence to standards across the EU is provided by public bodies.

It would be a good founding agenda for the new ”High Level Group on Health Services and Medical Care” to explore whether principles such as these might provide a cornerstone for cross-border health services in Europe.

Learning from federal health systems will reveal the potential scope for a European agenda, driven by shared values and principles.  It is important and timely for health care professionals, policy makers and everyone concerned with health to understand the implications of greater Europeanisation of health care as it will drive much of the logic around quality, standards and accreditation to the EU level.  But this will also require greater scrutiny that can only come from a single, EU-level tier.  That is why key design principles, such as the ones suggested, are needed.

Having a set of guiding principles will help to ensure that future European health care developments are sensible, productive, transparent and benefit us all, while respecting national and European interests.