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EU enlargement: new blood, new ideas


Brian Edwards CBE
Emeritus Professor of Healthcare Development
University of Sheffield

The expanded European Union is already beginning to experience the impact of its 10 new members. They have brought vitality and excitement back into the daily life of the Community. They bring new perspectives to old problems and ask simple but basic questions that the founding members stopped asking themselves years ago. We can expect challenging and robust debates in the coming months as discussions about a new constitution near a conclusion. All the new countries bring with them the familiar problem of matching their community’s expectations for healthcare with low levels of health investment. Easier and quicker access to better healthcare services is second only to better-paid jobs in the political wish list. In the short term, almost all of the new countries will struggle to cope with the migration of many of their key health professionals, but as national investment in health systems increases, many will return to their home country. Hungary faces a particularly tough challenge. Doctors and other health professionals are poorly paid in comparison with neighbouring countries. Slovakia pays its doctors twice as much as Hungary, the Czech Republic pays three times as much, and Poland seven times more. Levelling up is going to be expensive. Comparison is one function the Commission is very good at, and in the health sector, variations abound. Greece has the highest rate of practising physicians (438 per 100,000 population) but the lowest number of nurses (391 per 100,000). Belgium also has a high number of physicians (386), and so does Germany (359). Holland (192) and the UK (179) have the lowest number of physicians.

The number of pharmacists has risen steadily in recent years, with Finland having most at 148 per 100,000 population. Finland also has the highest ratio of nurses to population at 2,181 per 100,000. The respective roles of health professionals must vary significantly between countries in the face of these differences, but our understanding of the effects of these variations is still poor. Only a few countries will allow anybody other than a doctor to prescribe drugs. The principal exception here is the UK, where prescribing by nurses and pharmacists, albeit in controlled settings, is expanding rapidly. The take-up of generic medicines is very varied across Europe, as is the range of drugs sold over the counter without prescription. Rationalisation in this field may well be on the long-term agenda for the Commission. It is certainly a topic of much discussion amongst ministers of health when they meet. Some of the new countries, such as Malta, plan to be expansionist and offer specialist healthcare to neighbouring countries. For these countries, health is a vital part of their economic future rather than a drain on national revenues.

One trend that is emerging more clearly across many parts of Europe is the move away from state-managed hospitals to other forms of governance and ownership. In Germany, a number of municipalities have sold their local hospitals to the private sector. In the UK, foundation hospitals straddle the public and private sectors. The ownership is vested in local communities rather than the Department of Health. If they make operating surpluses they keep them for local reinvestment rather than share them with shareholders. In Slovakia, almost all hospitals will shortly be operating in a not-for-profit or profit mode rather than being directly controlled by the Ministry of Health. Poland is moving in the same direction with a great deal of international investment in the for-profit sector. Across Europe, it is the traditional hospital public sector that is shrinking and the profit and not-for-profit sectors that are expanding. Meanwhile, the argument about the laws governing mutual recognition of professional qualifications continues. It now seems clear that a professional who wants to provide services across a national border will be required to make a declaration about their nationality first, provide proof that they are legally established to practise in a member state and present evidence of professional qualifications. As far as the Working Time directive is concerned, the Commission has now recommended that a third category of time be discussed by employers and trade unions which would cover inactive on-call time. The policy ground is moving at last to recognise the reality of day-to-day life in the health field.

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