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The European Cross-Border Healthcare Directive (CBD) began operating in Ireland in June 2014, offering patients the option of receiving healthcare in another EU or European Economic Area (EEA) country, with the cost of the treatment refunded to the patient.
The CBD covers treatments that are publicly funded and available in Ireland, including inpatient and outpatient treatments. Some services are not included, however, including organ transplantation, long-term care, nursing home care and public health initiatives.
While few patients availed of the directive initially, its usage has been growing year-on-year, data from the HSE shows.
In 2014, just seven reimbursements under the CBD were processed in Ireland, valued at €29,000, according to the HSE.
In 2015, some 150 reimbursements were processed, at a value of €542,000.
The following year, 2016, saw a huge jump in the number of reimbursed treatments, with the total full annual figure rising to 1,025. The cost of reimbursements that year was €1.4 million.
Last year, the number of reimbursements processed doubled to 2,011, at a cost of €4.4 million to the HSE.
The numbers for last year are full-year figures, according to the HSE. But they are subject to change as patients submit documents in arrears.
As awareness of the scheme continues to increase, along with the ongoing problem of lengthy hospital waiting lists — currently standing at almost 700,000 for inpatient and outpatient appointments across the HSE — the number of patients using the CBD looks set to rise further in the future.
The HSE declined to provide a list of the most commonly-used hospitals under the directive, stating that the information could be “interpreted as a recommendation by the HSE of one healthcare provider abroad over another”.
But the HSE did state that Northern Ireland, France, Poland, Lithuania and Latvia are the most commonly-used countries under the directive.
It has also been revealed that a number of European citizens living in Ireland are using the CBD to access care in their home countries.
Cork GP Dr Mary Favier told the Medical Independent (MI) that she knows of some Eastern European patients who have used the directive to undergo treatment in their countries of origin.
An information campaign on the provisions of the CBD for patients, GPs and consultants was launched by the HSE in recent years due to a lack of awareness among the public and health professionals.
The HSE has written to all consultants and hospitals nationally, asking that they inform patients in their consulting rooms and/or via waiting list letters of their entitlements under the directive.
The HSE has also worked with the ICGP in relation to informing GPs of the directive, as they are the first point of contact for patients.
“GPs, by the nature of their work, have ongoing contact with individual patients, therefore while information pertaining to the CBD may not be relevant today, it may be relevant to that patient in the future and as such, it ensures information about the CBD is kept alive now and into the future,” the HSE explained in a response provided to a member of the Dublin North East Regional Health Forum in August 2017.
“On an ongoing basis, the general manager with responsibility for the Cross-Border Directive provides information sessions to hospitals and other groups upon request. This has included addressing patient conferences (ICGP conference), GP forums and grand rounds in hospital. The promotion of the CBD in this way is ongoing and will remain a key function of the office,” the HSE further noted at the Health Forum meeting.
But the HSE has clarified that under the provisions of the CBD, it is prohibited from promoting the directive, a spokesperson told MI.
Furthermore, the spokesperson remarked that “the HSE does not recommend services abroad. Decisions in relation to any service abroad is a matter for the patient and/or his/her referring physician”.
“The HSE has had considerable engagement with both the ICGP and NAGP. The HSE acknowledges and thanks both organisations for engaging with the HSE so that patients can be informed at primary care level about the provision of the CBD,” the spokesperson added.
In July 2017, the NAGP announced its intention to highlight information about the CBD due to huge waiting lists for hospital-based care in Ireland.
The NAGP developed a poster and leaflet for GP surgeries with information on the CBD in a bid to increase awareness among patients and GPs.
The leaflet was produced with the support of Age Action; IMED Hospitals, Spain; Kingsbridge Private Hospital, Belfast; MSC Eurocare; and St Joseph’s Hospital, Wales.
A number of NAGP officials have travelled to these hospitals and others abroad as part of the information campaign.
Dublin GP Dr Andy Jordan, NAGP Chairman, explained that, to date, 18 of his patients have used the CBD to access care.
Dr Jordan confirmed that NAGP members have travelled to the Kingsbridge Private Hospital, Belfast, and other private hospitals in the UK, Spain, north Wales, Portugal and France to examine units “on the ground”.
“We went ourselves to look at different hospitals and to get a feel for them and to get an idea of the set-up,” he said.
Dr Andy Jordan
But he emphasised that no payment between the NAGP and hospitals abroad has taken place for referrals, despite a number of private hospitals being named on the NAGP information leaflet.
Dr Jordan stressed that the real purpose of the campaign is to promote the CBD itself and not individual hospitals.
“If every GP in Ireland sent just 10 patients abroad for care, this would take about 30,000 patients off waiting lists,” Dr Jordan claimed.
NAGP CEO Mr Chris Goodey said that feedback to the CBD awareness campaign has been very positive to date.
“GPs are tired of apologising to patients for not being able to provide them with a date for a simple cataract procedure or hip replacements, etc. The CBD programme is a welcome development — while not ideal, as it would be better to treat patients locally, it has worked for thousands of patients to date,” Mr Goodey said.
Despite some concerns being raised about the NAGP’s involvement in highlighting the directive, Mr Goodey said the NAGP has “had no complaints to date”.
He explained that the NAGP has undertaken site visits to hospitals, as some GPs were cautious about referring patients to hospitals without any information about their standards of care.
He stated that the hospitals named on the NAGP information leaflet are all accredited and attached to local universities.
Mr Goodey also stressed that no payment or exchange of money has taken place between the NAGP and recommended hospitals.
“We didn’t specifically pick hospitals — that was the job of MSC Eurocare. However, we investigated whether we could recommend these hospitals to GPs. There have been situations where patients have selected their own hospitals and the outcome has not been satisfactory,” he said.
Mr Chris Goodey
“As I understand it, MSC Eurocare connected with hospitals across France, UK, Germany, Austria and Spain. There are about 30 hospitals that are recommended at the moment.”
Mr Goodey confirmed that NAGP employees and members had travelled to hospitals in four countries to date as part of the campaign.
MSC Eurocare is a recently-established Irish company that helps people wishing to avail of the CBD. Patients sign an agreement with the company and pay a small deposit.
The company can provide a short-term loan to patients, if required, to pay for treatment. The loan is repayable when the HSE refund for the cost of treatment is issued, usually within 28 days of receipt of application.
MSC Eurocare has ‘partner hospitals’, which are specifically-selected hospitals that it directs patients towards when seeking healthcare abroad under the directive, it is understood.
Some of the company’s partner hospitals are IMED Elche, a private hospital in south-eastern Spain; St Joseph’s Hospital, south Wales; and Kingsbridge Private Hospital, Belfast.
According to a spokesperson for MSC Eurocare, several Irish patients are being facilitated by it via the directive and are having successful procedures.
One patient recently used MSC Eurocare to attend a clinic in Bristol for care for several weeks.
The patient, who lives in Limerick, was depressed and on suicide watch. He was reportedly being sent to various counsellors for help but was not receiving appropriate treatment or care.
His family contacted MSC Eurocare on a Tuesday and by that Thursday, the patient was in a secure unit in the UK receiving appropriate care. He remained there for several weeks and has since returned home. He is doing much better now and has a more positive outlook on life.
Another patient who used the company went to Wales for back surgery. But after an MRI, he instead ended up receiving injections in the hope that they could provide relief before resorting to complicated surgery. The patient is now able to sleep, as the injections have eliminated the pain.
Separately, there was much publicity in December, when 13 elderly patients from Cork and Kerry travelled on a bus together, organised by local politicians, to avail of cataract surgery under the CBD in Kingsbridge Private Hospital in Belfast. There are more such trips scheduled for this month and February.
Age Action became a partner of the NAGP’s campaign in raising awareness about the CBD following a blog on its website on the directive.
“It was hugely popular with our members and supporters. Many of them contacted us through our social media platforms to tell us this was the first time they’d heard of the directive. It’s still, by some distance, the most popular blog we’ve ever published on the website,” a spokesperson for the charity, which promotes positive ageing, said.
The NAGP then approached Age Action about the campaign they were planning to run to try and ensure people were informed about the directive, the spokesperson added.
How the CBD works
The Cross-Border Healthcare Directive (CBD) (EU Directive 2011/ 24/EU) allows for Irish residents to avail of healthcare in other EU member states that they would be entitled to within the public health system in Ireland, which is not contrary to Irish legislation. The costs must be borne by the individual and he/she then seeks reimbursement for the cost of the healthcare upon return to Ireland.
Similarly, under the CBD persons resident in other EU member states may access healthcare in Ireland.
The cost of the services patients avail of under the CBD in another EU/EEA member state will be reimbursed at the cost of the service in the country where they availed of and paid for it or the identified cost here in Ireland — whichever is the lesser.
Travel, accommodation and other costs are not refundable under the scheme.
It is unlike the Treatment Abroad Scheme, which covers treatments that are not available in Ireland.
While patients do not need to be on a waiting list to be eligible to apply for healthcare abroad, they must be referred by a clinician (which can be a consultant or GP) for treatment.
According to the HSE, under the provisions of the CBD, it is the responsibility of the patient and/or the referring clinician to identify an appropriate clinician and health service abroad.
If a patient’s treatment involves an overnight stay in hospital, the treatment will require prior authorisation from the HSE in advance of travel.
Prior authorisation is also required for highly-specialised and cost-intensive medical infrastructure or equipment and treatments presenting a particular risk for the patient.
Once a location for care is identified, patient healthcare information is collected and a date for the procedure or treatment is arranged.
When a patient arrives at their chosen hospital, they pay for the treatment. When the patient is discharged, they keep their paperwork in order to submit their refund application to the HSE.
Further details can be obtained at: http://www.hse.ie/eng/services/list/1/schemes/cbd/.
While it is evident that many Irish patients have had successful procedures abroad under the CBD, concerns about the scheme, on a number of levels, have been raised by clinicians here. Many GPs are not informing their patients about the scheme and are concerned about a lack of follow-up care and protocols. Some GPs fear medico-legal repercussions if a patient was to have a negative experience in a hospital abroad that they recommended/referred to under the scheme. Others believe that the money spent treating patients abroad under the CBD would be better spent in the Irish system to allow treatment here, and point out that it allows patients to be treated in private hospitals only based outside Ireland.
Monaghan GP Dr Illona Duffy said that a number of patients at her practice have used the directive to access care in Northern Ireland. The most common procedures availed of by patients include cataract, knee and hip operations, Dr Duffy said.
In her experience, the standard of care provided to patients has been very good, but Dr Duffy raised safety concerns about the lack of follow-up care provided by hospitals where the procedure is undertaken.
Furthermore, Dr Duffy raised what she described as the “long-term” issue of money going out of the country instead of being retained in the Irish system.
Mayo GP Dr Ken Egan has never referred a patient using the directive and said that it was only recently, for the first time ever, a patient had mentioned the CBD to him.
Overall, Dr Egan stated that he is not in favour of the scheme, labelling it a “disgrace”. He believes that the funding should be kept inside the State, with funding going to private hospitals here instead of elsewhere.
Dr Ken Egan
Dr Favier said that if her patients request to use the CBD, she facilitates their request, but that she does not suggest it to patients.
She raised health and safety concerns about the lack of follow-up for patients using the directive, explaining that once a treatment has occurred, patients are discharged from hospitals abroad with no follow-up plans if a complication arises, with patients returning to their GP or local hospital for further care, if required.
Dr Favier added that she receives brochures in the post from Kingsbridge Private Hospital, Belfast, every three months advertising its services under the directive. It is also understood that a representative from the private hospital gave a presentation at an NAGP meeting in Cork on the directive in recent months.
Dr Mary Favier
She added that a number of GPs have called into question the NAGP’s involvement in promoting the CBD, given the extra unpaid workload for GPs in form-filling and the potential for follow-up issues.
“There have been a lot of questions asked on the GP forums about what is in it for the NAGP,” Dr Favier said.
The NAGP has maintained that its only motive is helping patients to access timely healthcare.
Dr Favier also took issue with the scheme itself, describing it as, “a great idea in theory”. But as money is going outside the State for treatment, she said, “it is not any better than the National Treatment Purchase Fund in its day”.
Information received by MI also raises concerns about the lack of international accreditation of the hospitals recommended under the NAGP campaign.
None of the hospitals currently listed on NAGP leaflets or on the MSC Eurocare website have Joint Commission International (JCI) accreditation. JCI accreditation is considered the gold standard in global healthcare and has been achieved by almost 30 private healthcare units in Ireland.
Furthermore, an unannounced, independent healthcare inspection at St Joseph’s Hospital, Wales, in August 2016, while positive overall, identifies areas for improvement.
“We found that staff had not received training in a number of areas,” the report found.
“Some improvements are needed in the quality assurance and governance arrangements of this service to ensure compliance with the relevant regulations and standards. This is important to ensure the safety and effectiveness of the service provided.” Supporters of the NAGP campaign, however, pointed out that HIQA has had similar findings about a number of public hospitals in Ireland.
A spokesperson for the HSE stated that “it is not a matter for the HSE to recommend or otherwise comment in respect of any facility abroad to which a patient is referred by his/her GP or chooses to access under the provisions of the CBD. The HSE would only intervene as provided for under the directive, where it can be demonstrated that a service abroad is of concern in respect of individual patient or general public safety.”
The European Commission is currently drafting an implementation report on the CBD, which will be published later this year. The report will cover the state of play of transposition, compliance checks and important provisions (eg, the use of prior authorisation, reimbursement practices, information to patients), and will identify good practices, patient flows and financial dimensions, as well as challenges.
Ms Françoise Grossetête, Member of the European Parliament and Former Rapporteur on the Directive on Cross-Border Healthcare, commented last October that implementing the directive is a long and complex process and there is much left to do, particularly regards raising awareness of the CBD.
“To take full advantage of their rights, citizens first need to know that they have them. It must be said that the situation in this regard differs greatly from one member state to another, as the Commission pointed out in its latest implementation report. National contact points have been set up to inform citizens, but many are still not being used. We must get the message out effectively that the directive and the reference networks exist, not only to the citizens, but also to the national authorities. Finally, I would like to place greater emphasis on the interconnection of our healthcare systems, in the framework of increasingly rapid development of e-health. This interconnection is indispensable, and yet, when I was working on the directive, not all the member states, unfortunately, were ready to join forces. In the future, this gap must be filled,” she said.