Reaction of the European Forum for Primary Care to the COMMUNICATION FROM THE
COMMISSION: Consultation regarding Community action on health services.
February 2007.
The European Forum for Primary Care welcomes the Consultation of the Commission on
Community Action on Health Services. Our patients deserve to get access to healthcare
across borders and our professionals deserve to be able to practice across borders as well.
The European Forum for Primary Care applauds the attempts of the Commission to bring
clarity in these matters and encourages the Commission to take this trajectory further.
We acknowledge the tension between the Commission’s task to provide for a regulatory
framework for cross border care, and the subsidiarity principle with regard to the member
states’ responsibility for health services. The result is unfortunate, because it may impede
proper balancing of interests and priority setting. We hope this contribution may help to
establish a balance between the interest of patients to seek cross border care and the
interest of patients to have access to good quality care.
Primary Care is care that is delivered to people in the community. Indeed, addressing the
needs of individuals in the context of their families and communities is one of the key
features of primary care. Another feature is that Family Physicians (General Practitioners)
operate in the framework of a primary health care team, which implies a multidisciplinary
approach. A patient-centred responsiveness, with special attention to the most dependent
and vulnerable groups in society is another key feature of primary care. It requires
unrestricted access of patients to primary care services. The navigation function is essential:
related to the undifferentiated range of complaints that are presented at the primary care
level and to the fact that specialist care offers fragmented services, primary care practitioners
help patients to navigate through the health care system. In a number of European countries
the gate keeping role of general practitioners and other professionals at the primary level
makes them responsible for adequate referral and guidance of patients, under the right and
safe conditions. Below, the notion of case manager is introduced. The General Practitioner
currently fulfils that role, in many situations.
There is ample evidence to support the claim that Primary Care offers better care and health
outcomes for lower costs. However, accessibility, quality and financial sustainability of health
and social services in a Primary Care system are the result of a complex pattern of
interactions. The value of Primary Care depends on its cohesion. Picking individual elements
and transplanting them to other systems may very well result in ineffective or sub-optimal
services or an unsatisfactory cost reduction.
The Report “European Primary Care” published by the Dutch Health Council in 2004
provides for a thorough description of Primary Care and its benefits.
Primary Care is more than health care alone, it includes other services as well: home care,
day care, provision of meals, etc.. So, Primary Care encompasses a number of social
services as well. Health and social services are very much interwoven and interdependent.
Therefore, we regret that the Commission has chosen different trajectories for social services
and health services. There is a risk that different regulatory frameworks create new obstacles
to the smooth integration – or at least collaboration – of health and social services.
We propose to bring these trajectories together as yet.
Question 1 + 2
Increasingly situations occur in which a patient returns home from a treatment abroad and
asks for further treatment or advice from an uninformed practitioner in his home country.
Without precise information from his foreign colleague, this practitioner may not be able to
ensure the follow up necessary. This affects quality of care and may jeopardize the patient
safety of services.
We propose to formulate a number of conditions under which cross border care is delivered.

One practitioner is responsible for the complete treatment trajectory. We call that a
case manager. When a patient seeks a treatment abroad, pre-care and after-care in
the patient’s home country may be needed. The case manager is responsible for
attuning pre- and after-care and the main treatment. In general, the practitioner who
provides the main treatment should be designated as case manager. However, in
many cases, also the General Practitioner may be the case manager, who refers the
patient for treatment abroad.
The element of referral is crucial: referring a patient brings a responsibility for the
referring practitioner. When a patient seeks cross border care on his/her own
account, there is no referring practitioner.
Therefore, the role, responsibilities and tasks of the case manager need to be further
defined.

Also, we propose that the patient has a right to adequate and complete information
on the treatment to be provided, allowing the patient to make a balanced decision on
the choice of treatment and provider. The information needs to be provided by the
practitioner who is the case manager. Quality standards for the information need to
be developed and regulated.

The case manager also is responsible for adequate information to the other
practitioners that provide care to the patient, be it in the home country of the patient
or abroad. Quality standards for this type of information need to be developed and
regulated as well.
Question 4
From our previous points follow that the case manager is responsible for designing and
implementing the trajectory of the patient and the authorities of the country in which the case
manager operates designate the competent authority for the exercise of control. In order to
be able to accept this responsibility, the case manager needs to work within a clearly
developed legal framework of responsibilities and tools. It is indispensable that disputes are
settled by an international or EU authority – to be developed.
Question 5
While a financial balance certainly is of major importance, system coherence is important as
well. Therefore, all health providers need to respect the standards and regulations in the
country of practice, irrespective of the duration of their practice. EU action needs to respect
national regulations on access, quality and professional competence.
Question 8
In the communication, no connection is made between public health objectives and health
services. Health Care in general and Primary Care in particular has a strong potential to
contribute to Public Health objectives, in the sense of health promotion, prevention and
surveillance. This potential - that may vary between member states -can only be fulfilled
under certain conditions. These conditions need to be defined, which contributes to
strengthening this role of health systems.
In the introduction to this Communication “protecting the values and principles that underpin
health systems in the EU” is mentioned as an important issue. We suggest the Commission
continues and stimulates the debate on which are these values and principles, because we
cannot assume common understanding and agreement without debate. Taking the so-called
Madrid framework as one of the starting points, the debate may help to understand and
respect the diversity between member states and their different priorities. One example may
be the way trade offs are being made by member states in terms of efficiency and patient
choice.