Worrying about the wrong thing: Patient mobility versus mobility of health care professionals

In summer 2011, I was invited to Turin university hospital to present on the free movement of patients and health care professionals in the EU to receive or to provide health care. The event was intended to gather evidence for the Piedmont authorities who were seeking to reform their regional health system. Italy faces particular workforce challenges: while producing too many doctors who, in the face of unemployment and unenviable working conditions, emigrate, the country lacks an estimated 70,000 nurses. Every tenth nurse is foreign-trained and between 500,000 to a million foreign care workers from countries including Moldova, Ukraine, Romania and Peru look after the nation's ageing population, particularly in the wealthier northern regions. ¹ My presentation reflected these trends, giving less attention to the few Italians who seek treatment abroad. Upon my arrival, however, five interviews with newspapers, radio stations and the regional TV news channel all focussed on what the new patients’ rights Directive would mean for the Italian health system. ² Adding to the irony and highlighting the plight of Italian health care workers, the conference was nearly cancelled when trades unions marched onto the stage protesting against staff and budget cuts announced as part of reforms. This anecdote illustrates three issues.

Patient mobility is systematically over-rated. While it is impossible to know the exact numbers of patients travelling for health care within the EU – the famous 1% estimate of all health care consumption put forward by the European Commission is elusive since it is unclear what this percentage covers and how it has been calculated – it is tempting to suggest that there might be more policymakers, lobby groups, researchers and commentators devoting attention and working hours to patient mobility than there are EU patients who travel to another Member State for planned care at the expense of their home state. One obstacle to accurate measurement and meaningful debate is the lack of a commonly accepted definition. A frequent mistake is to confuse travelling for planned treatment with the emergency needs for health care while abroad, despite their different origins, motivations and policy implications. Health care bills from tourists, expatriates and students treated abroad may well be significant, but patient mobility is not.

Patient mobility represents a noble pretext for those eager to see more market, more EU, or both, in health care. Flying the banner of patients’ rights and needs, EU policy-makers, liberal lobbyists, and profit-oriented health insurers and providers often argue that patient flows are bound to increase. The “Europe for patients” campaign shows how eager the European Commission is to enter the health care sphere, jealously guarded by Member States. Yet, the potential of patient mobility in terms of its scale remains highly questionable. It will probably remain a niche phenomenon for three reasons.

First, people want to be treated by providers and in a system they feel familiar with. For as long as this holds true, national politicians have few reasons to encourage patient mobility and the majority of health care will continue to be delivered domestically. Second, patient mobility requires a conjunction of highly specific circumstances: a particular population group with a particular health care need and insurance profile in a particular geographical setting (distance being one factor) combined with the presence of a ‘better’ alternative abroad. In practice, people most likely to seek care abroad are: residents of border-regions for whom special cross-border schemes are in place; those with time to travel and generous insurance cover; those who are cost-aware with no cover looking for affordable options; patients with rare diseases; impatient, wealthy patients on waiting lists; those seeking care not available at home (including where particular treatments are outlawed); and expatriates who return home for care. This may seem like a crowd but it remains a small proportion of total consumption. In the Netherlands, care received abroad represented 0.8% of the 36 billion EUR health care spending in 2010, ³ and the percentage may include costs from Dutch tourists and expatriates. No country usually has more than two or three patient mobility types and not all types are covered by public funding or represent an extra financial burden. Third, the new Directive does not create any new patient entitlements but merely clarifies existing ones. Legal clarity narrows the room for interpretation. EU citizens are bound by the scope of their national benefit entitlements and are required to seek authorization prior to treatment abroad, even for ambulatory care if this is subject to planning or requires expensive equipment. Despite the fears of some and hopes of others, the Directive does not encourage patient mobility.

By comparison, health care professional mobility is overlooked. This is remarkable given the level of workforce migration and the current workforce environment. In the UK and Ireland, about 35% of doctors are foreign-trained. More importantly, some countries rely on foreign health care professionals to replenish their workforce. Out of 17 European countries, ¹ the UK (42%) and Belgium (25%) saw the highest proportions of foreign inflows to the medical workforce in 2008, while Spain recognised 40% more foreign degrees in medicine than Spanish universities produced. In Finland, 43% of newly licensed dentists in 2006-2008 were foreign-trained, with similar proportions in Austria. One in three nurses entering the nursing workforce in Italy (2008) and one in five in Spain (2007) were foreign-trained or foreign-nationals. Estimates suggest numbers of undocumented foreign care workers soaring in Italy, Germany (100,000) and Austria (40,000). Source countries complement the story: 9000 Romanian doctors requested certificates to move to another EU Member State between 2007 and 2010; around 2% of doctors in Estonia and in Hungary have done so annually since 2004. An average of 1500 Slovak health care professionals are estimated to emigrate annually; 2650 Slovak nurses (8% of nursing workforce) went to Austria in 2003–2008. By 2008, 6.5% of Polish doctors and dentists had received certificates to migrate. Outflow data are by nature patchy but can be verified in destinations.

Data reflect not only some countries’ reliance on foreign inflows but a more general trend: that receiving countries are mainly ‘old’ Member States. While all countries face outflows, these are rarely compensated by inflows in new Member States. This asymmetry should be seen in context. Sixteen out of 17 European countries face current and/or forecasted workforce shortages either in all professions or in particular specialties (GPs, specialized nurses, an aesthesiologists, paediatricians, psychiatrists, internists and general surgeons), whether nationwide or in particular regions or hospitals. Moreover, the trend is global. Projections suggest a shortfall of 130,600 doctors in the USA by 2025 and almost a million nurses by 2020.^4,5 China is said to currently lack 5 million nurses. ⁶ Almost one in two nurses in the UK is expected to retire within the next 10 years. ⁷ According to European Commission estimates, the EU will lack 230,000 doctors and 590,000 nurses by 2020. ⁸

This raises several questions. Can countries afford not to plan for current and future needs? Can they rely on foreign inflows? Is it acceptable to recruit from Romania but not from India? As populations age so does the health care workforce, reinforcing pressures on demand for and supply of care. Several countries report difficulties in filling posts whether due to retirement, attrition, emigration or underproduction of health professionals. Flows are unpredictable, they might come, they might go, they might match the needs of the health system, or not. Failing to plan means someone else paying. Slovakia spends 59,000 EUR to educate and train a specialist doctor. Loosing 1% of the workforce is not marginal; it accumulates over the years and may damage service delivery and access where shortages already exist. EU countries compete with each other and globally for health care professionals. While the WHO global code of practice on international recruitment was adopted in 2010 to encourage ethical recruitment, a different logic applies in the EU. Immigration from outside the EU is subject to national laws and restrictions but within the EU mobility is a core value and may not be hindered. With huge salary differentials between Member States (up to 10 fold for doctors), competition is tough for poorer countries.

Back to the angry, worried protests of Turin hospital staff. How do health care workforce issues and professional mobility resonate in a context of economic austerity? According to recent data, many EU countries have reduced national health care spending. ⁹ Greek hospitals have seen budget cuts of up to 40%, ¹⁰ Romania has reduced salaries by 25% and frozen all new public sector recruitments in 2010, and France, Greece, Ireland and Lithuania have reduced health care professionals’ salaries. Recent data (2009 or 2010) from Romania, Hungary and Estonia show an increase in numbers of doctors and nurses leaving, and anecdotal evidence suggests a surge in Greek doctors emigrating. Existing salary differences may widen further – between Member States and between the public system and commercial sector within countries, encouraging health care professionals to leave the country or the public sector. Yet resource constraints can also mean fewer opportunities in destinations.

These tensions will likely intensify as health care professionals increasingly move between Member States rather than between the EU and third countries. The notion of EU-wide solidarity is often mentioned when patient mobility advocates argue that all EU patients should be entitled to the same quality and range of health services. If worried about access to health care in smaller or poorer Member States, however, then a good place to start would be to encourage their health care workforce to stay in their country and for other Member States to produce a sufficient health care workforce so as to not to rely on foreign inflows. Mobility of health care professionals may lead to much larger problems with access to health services than ever envisaged in patient mobility debates.