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Brian Edwards CBE
Emeritus Professor of Healthcare Development
University of Sheffield
UK
President
HOPE
(European Hospital and Healthcare Federation)
There was an important debate with MEPs in December about the increasing migration of health professionals across national boundaries. What began as a trickle has become a flood. Free movement of labour is a cardinal principle of the European Union and is serving the rich countries well as they recruit expensively trained health professionals from other countries to fill their vacant posts and reduce their waiting lists. However, the consequences for the accession countries are very damaging indeed. Poland expects to lose 15% of its anaesthetists and 6% of its surgeons in the coming months. Many will return in due course, but in the meantime the Polish population will miss them. Those doctors who get on a plane to work a weekend shift in Holland or the UK will return richer but exhausted. We have no accurate numbers for nurses and pharmacists, but they must be significant. The problems are even more acute in the Baltic States: 56% of health professionals in Estonia have indicated a wish to work abroad. Latvia, which has the lowest health outcomes in Europe, is in similar difficulties. The majority will migrate for economic reasons rather than professional training. One answer is for the poorer countries to increase the comparative income levels of health professionals. They do not need to match the rates paid in other countries, but they do need to address national inequalities. If they continue to pay doctors and nurses at the bottom end of public sector pay tables, they will lose them in increasing numbers. Another solution would be to insist that those who migrate pay back their undergraduate training costs (which might be refunded on their return home).
The pricing of drugs must be one of the most discussed issues at meetings of health ministers. Pharmaceutical products now soak up 15-20% of most countries’ overall health investment. This might be very appropriate, but one suspects it is more a consequence of clever and sustained marketing. Routine medicines reviews with patients are now part of the new payment structure for pharmacists in the UK, but opinion is very divided about their relevance and impact on patients. The push by governments to increase the use of cheaper generic products has been very successful, and it has put real pressure on the traditional pharmaceutical industry. Some European countries still have a long way to go down this road. What is likely is the development of mechanisms for price comparison across Europe despite the difficulties of interpretation this will generate. A European-wide price agreement is most unlikely, but some agreed methodology for building in research and development costs might be possible.
The voluntary intergovernmental code designed to stop unreasonable poaching will have little impact. Most Ministries of Health have no idea who is being recruited and little power to intervene if they did know. All it does is allow politicians to feel they have done something to respond to the problem. What might slow migration down is the sharp financial retrenchment taking place in the health sector in many countries, and particularly those trying to meet the economic criteria necessary for entry into the Euro zone. Hungary is but one example, where 75% of hospitals have a financial deficit and major hospital closures look likely as the national bed stock is reduced perhaps by as much as 30%. The large black economy in Hungary, which reduces the taxation yield, exacerbates the problem, as does the lack of a clear boundary between primary and secondary care. Co-payment by patients looks to be inevitable but pitched at perhaps one euro per doctor contact. This will both deflate demand and generate income, providing the costs of collection are contained.
As always, countries are looking at their drug expenditure in an attempt to reduce costs and switch wherever possible to generics. They are also beginning to compare prices, having discovered that the countries in Eastern Europe are sometimes paying more than their neighbours in the West. Talks about a new EU services directive about health are increasingly concentrating on generating legal certainty for citizens about their rights to healthcare. This may lead to national or regional baskets of care being defined, with treatments outside the basket needing prior approval before they can proceed. This could of course include lists of approved drugs. The size and shape of the basket would vary according to the wealth of the community concerned. The problem is that the basket could never be set in stone as medicine develops and economic circumstances change. The European Court of Justice will still, I am afraid, be involved in this issue.
