Table Of ContentThe Politics of EU Health Policies pb:The Politics of EU Health Policies pb 1/6/09 16:00 Page 1
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S T A T E O F H E A L T H
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E HE
The Politics of European Union Health Policies
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“This book provides a unique insight into what is going on, O
unnoticed by most, 'below the surface' in EU health policy. It L
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serves as a wake-up call for those who continue to believe T
that the EU is of marginal interest and relevance in national I POLITICS
C
level debates about the direction of health care. In addition, S OF
in an engaging and lively style, it provides essential guidance
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for students of health policy who seek to understand the F
labyrinthine processes and the wide ranging unintended E
consequences –for good and for bad –of EU policy making.” U EUROPEAN
Naomi Chambers, Manchester Business School R
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“In this insightful book, Scott Greer describes how European
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health policy has long been developed in a secret garden, E
where a small number of people find pragmatic solutions to A
immediate problems while avoiding the fundamental N UNION HEALTH
questions … Yet the logic of European integration is tearing U
down the garden's walls, creating a public park where N
pragmatism takes second place to principles. Something I
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must be done, but it is not clear what. Greer's book will be
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essential reading … for anyone who is responsible for
POLICIES
organising how health care is delivered in Europe.” H
Martin McKee CBE, London School of Hygiene E
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and Tropical Medicine, UK
L
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This important new book explains how European Union (EU) developed
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policies shape and constrain health services. It answers the key
questions asked of EU health policy: What is it? Why did it happen? P
What does it take to influence it and how can it be changed? O
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Using extensive new data, Greer discusses how EU policy is I
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influenced by lobbies in Brussels and by four big member states:
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France, Germany,Spain and the United Kingdom. E
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The book examines the ways that the successful health lobbies and
member states work, identifies weaknesses, and emphasizesthe
challenge to health policymakers: if they do not influence EU health G
R SCOTT L. GREER
policies, they will lose influence over their own health systems. E
E
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Scott L. Greeris Assistant Professor of Health Management and Policy
at the University of Michigan School of Public Health and Senior
Research Fellow at LSE Health, London School of Economics, UK. S T A T E O F H E A L T H
www.openup.co.uk
THE POLITICS OF
EUROPEAN UNION
HEALTH POLICIES
STATE OF HEALTH SERIES
Edited by Chris Ham, Professor of Health Policy and Management
at the University of Birmingham and Director of the Strategy Unit
at the Department of Health.
Current and forthcoming titles
Noel Boaden: Primary Care: Making Connections
Michael Calnan and Rosemary Rowe: Trust Matters in Health Care
Angela Coulter and Chris Ham (eds): The Global Challenge of Health Care
Rationing
Angela Coulter and Helen Magee (eds): The European Patient of the Future
Chris Ham (ed.): Health Care Reform
Chris Ham and Glenn Robert (eds): Reasonable Rationing: International
Experience of Priority Setting in Health Care
Rudolf Klein, Patricia Day and Sharon Redmayne: Managing Scarcity
Ruth McDonald: Using Health Economics in Health Services
Nicholas Mays, Sally Wyke, Gill Malbon and Nick Goodwin (eds): The
Purchasing of Health Care by Primary Care Organizations
Martin A. Powell: Evaluating the National Health Service
Ray Robinson and Andrea Steiner: Managed Health Care: US Evidence and
Lessons for the NHS
Anne Rogers, Karen Hassell and Gerry Nicolaas: Demanding Patients?
Analysing the Use of Primary Care
Marilynn M. Rosenthal: The Incompetent Doctor: Behind Closed Doors
Richard B. Saltman and Casten von Otter: Planned Markets and Public
Competition: Strategic Reform in Northern European Health Systems
Richard B. Saltman and Casten von Otter: Implementing Planned Markets in
Health Care: Balancing Social and Economic Responsibility
Richard B. Saltman, Josep Figueras and Constantino Sakellarides (eds):
Critical Challenges for Health Care Reform in Europe
Claudia Scott: Public and Private Roles in Health Care Systems
Ellie Scrivens: Accreditation: Protecting the Professional or the Consumer?
Peter C. Smith (ed.): Reforming Markets in Health Care: An Economic
Perspective
Kieran Walshe: Regulating Health Care: A Prescription for Improvement
Peter A. West: Understanding the NHS Reforms: The Creation of Incentives?
Charlotte Williamson: Whose Standards? Consumer and Professional
Standards in Health Care
Bruce Wood: Patient Power? The Politics of Patients’ Associations in Britain
and America
THE POLITICS OF
EUROPEAN UNION
HEALTH POLICIES
Scott L. Greer
Open University Press
McGraw-Hill Education
McGraw-Hill House
Shoppenhangers Road
Maidenhead
Berkshire
England
SL6 2QL
email: [email protected]
world wide web: www.openup.co.uk
and Two Penn Plaza, New York, NY 10121-2289, USA
First published 2009
Copyright © Scott L. Greer 2009
All rights reserved. Except for the quotation of short passages for the
purposes of criticism and review, no part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise,
without the prior written permission of the publisher or a licence from the
Copyright Licensing Agency Limited. Details of such licences (for
reprographic reproduction) may be obtained from the Copyright Licensing
Agency Ltd of Saffron House, 6–10 Kirby Street, London, EC1N 8TS.
A catalogue record of this book is available from the British Library
ISBN-13: 978-0-33-523624-4 (pb) 978-0-33-523623-7 (hb)
ISBN-10: 0335236243 (pb) 0335236235 (hb)
Library of Congress Cataloging-in-Publication Data
CIP data applied for
Typeset by RefineCatch Limited, Bungay, Suffolk
Printed in the UK by Bell and Bain Ltd, Glasgow
Fictitious names of companies, products, people, characters and/or data
that may be used herein (in case studies or in examples) are not intended to
represent any real individual, company, product or event.
CONTENTS
Series Editor’s Introduction ix
Preface xi
1 Health policy in the European Union: from secret garden
to public park 1
Images of European Union 4
Understanding EU policymaking 9
Methods 15
The rest of the book 16
2 EU health policymaking 18
Treaties 18
Court 22
Commission 23
Legislation and representation 28
Reforms 31
Conclusion 33
3 European Union health policies: the key issues
facing states 34
Regulation 1408/71 35
Patient mobility 36
Services 38
Health legislation: the Patient Mobility Directive 41
Quality and support for health services 43
Working Time Directive 45
Professional mobility 46
Public health 48
vi The politics of European Union health policies
Public procurement 49
State aids and competition law 51
Open Method of Co-ordination and new governance 52
Further issues 53
Conclusion 53
4 Doing something about it 57
What works in EU politics 57
Conclusion 63
5 Lobbies 65
EU lobbying 67
Who are the health lobbies? 72
Conclusion 77
6 Member states 79
Diplomatic, departmental and deliberative 79
What member states do 82
Problems that states face 88
Conclusion 93
7 France 96
System and stakes 96
Explaining France’s EU health policy 99
France’s EU model in health 103
Conclusion: informed, co-ordinated, nimble? 109
8 Germany 111
System and stakes 112
Explaining Germany’s EU health policy 114
Germany’s EU model in health 117
Conclusion: informed, co-ordinated, nimble? 122
9 The United Kingdom 125
System and stakes 126
Explaining the UK’s EU health policy 129
The UK’s EU model in health 135
Conclusion: informed, co-ordinated, nimble? 140
10 Spain 143
System and stakes 144
Explaining Spain’s EU health policy 148
Contents vii
Spain’s EU model in health 152
Conclusion: informed, co-ordinated, nimble? 157
11 Conclusion 159
Future EU health policy models 161
Doing something about it 166
Conclusion: feedbacks 167
References 169
Index 191
SERIES EDITOR’S
INTRODUCTION
Health services in many developed countries have come under crit-
ical scrutiny in recent years. In part this is because of increasing
expenditure, much of it funded from public sources, and the pressure
this has put on governments seeking to control public spending. Also
important has been the perception that resources allocated to health
services are not always deployed in an optimal fashion. Thus at a
time when the scope for increasing expenditure is extremely limited,
there is a need to search for ways of using existing budgets more
efficiently. A further concern has been the desire to ensure access to
health care of various groups on an equitable basis. In some coun-
tries this has been linked to a wish to enhance patient choice and to
make service providers more responsive to patients as ‘consumers’.
Underlying these specific concerns are a number of more funda-
mental developments which have a significant bearing on the
performance of health services. Three are worth highlighting.
First, there are demographic changes, including the ageing popu-
lation and the decline in the proportion of the population of work-
ing age. These changes will both increase the demand for health care
and at the same time limit the ability of health services to respond to
this demand.
Second, advances in medical science will give rise to new demands
within the health services. These advances cover a range of possi-
bilities, including innovations in surgery, drug therapy, screening
and diagnosis. The pace of innovation quickened as the end of the
twentieth century approached, with significant implications for the
funding and provision of services.
Third, public expectations of health services are rising as those
who use services demand higher standards of care. In part, this is
