EUROPE

Published: 14/07/2005, Volume II5, No. 115 Page 14 15

Britain's presidency of the EU offers oppor tunities to encourage pan-European support for key elements of our public health policy. But the EU is also broadening its remit on health - and that will inevitably impact on the UK. Lyn Whitfield reports

The EU may be going through one of its periodic crises, but the government will be hoping its six months in charge will be about more than constitutional wrangles and rebate rows.

On the health front, it has set an ambitious agenda for the UK presidency, which started on 1 July.

Summits on patient safety and health inequalities are scheduled for the autumn, with a formal meeting of ministers in December.

Meanwhile the government will need to build European support for some of its domestic public health policies, particularly those relating to food and nutrition, since up to 90 per cent of the UK's food law now comes from Brussels.

Both of the chosen health themes demonstrate how the EU is broadening its remit. The Maastricht treaty gives it general responsibilities to secure the well-being of its citizens and to consider the health impact of its own legislation and policies.

But it limits legislative activity to a few areas, most of which relate to the EU's core concerns of agriculture and securing the free movement of goods and people.

Funding, organising and running health systems remain the responsibility of member states - which suggests that patient safety should not be a subject for European debate.

However, Professor Mark McCarthy, chair of the Faculty of Public Health Medicine's Europe working group, says it moved onto health ministers' agendas when the European Court of Justice ruled, in the late 1990s, in favour of the free movement of patients.

'The rulings made governments much more interested in talking about services, ' he says. 'This [patient safety] is also an area in which states are very interested in learning from each other.' The ripple effect of the European Court of Justice rulings is a good example of how the EU's relatively limited social policy remit means that it tends to have most impact when its core concerns affect other areas.

The way that the European working-time directive has forced member states to rethink how hospitals are run is also significant.

However, NHS Confederation international policy lead Mike Ponton says the directive shows that Europe's influence is growing all the time.

'Professional mobility, crossborder healthcare and centres of reference [identifying the leading institutions and localities that are likely to become a source of policy ideas] are all important issues for us, ' he says. 'We need to get in and influence what is going on.' The big question is whether the EU will go on to develop its own social policies. Or, perhaps, whether some of the grand strategies it has produced will start to carry more weight.

EU health ministers adopted a public health programme in 2002, which is due to run until 2008.

It has three objectives: to improve public health information and knowledge; to enhance Europe's capacity to respond to health threats; and to address how other policies and activities affect people's health.

It has done some work on the first by funding research into inequality and effective ways of tackling it, much more work on the second - not least by establishing a new centre for disease prevention and control in Stockholm - and little on the third.

This makes the government's decision to focus on health inequalities during the presidency something of a departure.

At a recent conference organised by the Westminster diet and health forum, Department of Health head of inequalities Imogen Sharp argued that 'health inequalities is an international issue'.

All European states, she said, face similar issues in terms of inequality, and the impact of heart disease, stroke, cancer and rising obesity.

At the UK Public Health Association's annual conference, she said the presidency would need to find 'common values and from that common issues' for member states to work on.

This may be difficult. Ms Sharp told the Westminster health and diet forum that 'member states are at very different stages' in recognising the existence and impact of health inequality.

And Professor McCarthy points out that even in the UK there is little agreement on how inequalities should be tackled. Member states have taken radically different approaches.

'The Netherlands, for example, has funded research into projects and engaged at a much more local level than the UK, which has tended to adopt a more top-down approach, ' he says.

Public health experts also wonder if this agenda will be sustained once the presidency moves on.

'The big issue is whether this will go anywhere, ' says UK Public Health Association president Professor David Hunter. 'A high-level event will raise the issue, but then it has been raised anyway in this country.

The question is whether other states will engage.' Ms Sharp told the Westminster diet and health forum that she hoped the European Commission would establish a health inequalities forum to continue the work.

In August 2004 the European Commission launched a health policy debate and has since put forward proposals for a new health and consumer protection programme, to run from 2008.

The commission justifies the joint programme on the grounds that there are many links between public health and consumer protection.

It also argues that people's health is affected by the choices they make as individuals, although these may be affected by other issues such as the environment, transport and education.

This will sound eerily familiar to anyone who has read the November public health white paper, which focuses on what it calls 'health in a consumer society' and how to encourage a 'demand' for healthier choices from individuals.

Professor Hunter believes this is another issue on which the EU seems to be taking its lead from the UK.

He says the last health and social affairs commissioner, David Byrne, borrowed freely from the reports produced by Sir Derek Wanless on future healthcare spending, and how it could be limited if individuals 'engaged' with their own health.

'He quoted a lot from Wanless' fully-engaged scenario, and really got that onto the agenda, as well as doing a lot on smoking, ' says Professor Hunter (see box).

'[The new commissioner] Markos Kyprianou has come in and picked it up, particularly in relation to food.' The commission has proposed that the three main objectives for the new strategy should be: to protect citizens from threats beyond their control; to help them make better decisions; and to mainstream health and consumer protection in EU policy-making.

Practically, this should relate to action plans or strategies for mental health, alcohol, and diet and nutrition.

Nutrition is likely to be a very important issue during the UK presidency since both the UK government and the commission are talking tough on food labelling and advertising 'junk food' to children.

The white paper promised to simplify food labelling and the Food Standards Agency is conducting consumer research on how this might be done.

Michelle Smyth from Which? magazine says this is a welcome development, but the outcome will not be binding on companies in the UK unless there is action across the EU.

'We have been calling for many years for the commission to update its labelling directive because at the moment companies only have to label four nutrients and we think that at the very least they should have to label all eight, ' she says.

Similarly the Food Standards Agency and media regulator Ofcom are working on new guidelines on promoting food that is high in fat, sugar and salt to children - but Ms Smyth says there may be scope for European action under the TV without borders directive, which is up for revision.

The commission has established an obesity task force, which is due to publish a consultation paper this autumn, ready to produce a EC-wide strategy on diet, physical activity and health by the end of 2006.

But Mr Kyprianou has already said that the commission may resort to legislation if the food industry does not improve on both food labelling and advertising to children.

'Kyprianou has become very committed to strong action on food, and the UK is seen as moving forward, ' says Professor Hunter.

'Nothing as high profile is happening [in other member states], so the UK is seen as a bit of a leader.' In the wider context, it is worth noting that the row over the UK's budget rebate could have a health dimension.

At least as presented by prime minister Tony Blair, the row has its roots in the common agricultural policy which swallows up 40 per cent of the EU's budget and 'distorts' the contributions of member states.

But the CAP also has well-known health impacts. It supports southern European tobacco growers, for example. And Scandinavian research has suggested that it pushes sugars, high-fat milk and red meat into the diet of a continent where 20-30 per cent of the population are overweight.

'We do not need to support products, but we do need to support farmers and their local communities, ' says Professor McCarthy. 'We have seen some movement in that direction, but the government might like to do more. I am quite pleased this is on the agenda.' .

THE LONG ROAD TO EU POLICY

The EU has a bureaucracy, the European Commission; an executive, generally known as the Council of Ministers; and a parliament.

The commission proposes policy, while the council and parliament debate it, pass legislation and approve budgets. The EU also has the European Court of Justice, to interpret legislation and rule on disputes.

Member states hold the presidency of the EU in turn and are expected to promote existing policy and legislative proposals, as well as building support for their own initiatives.

Policy-making can be tortuous, as the fiveyear move towards putting 'graphic' warnings on cigarette packs demonstrates.

Canada added pictures of diseased gums and lungs and other stark images of the effects of smoking to its cigarette packs in 2000, an approach since followed by Brazil, Singapore and Thailand.

After months of lobbying and wrangling, the European Parliament voted back in May 2001 to require member states to put larger warnings on cigarette packs and to allow them to use graphic images if they wanted to.

However, Action on Smoking and Health research manager Amanda Sandford says the commission is still finalising a catalogue of approved images.

And even when it is ready, the government will have to opt to use them and then run a consultation on which images to use and where they should appear on the pack.

'That should come up during the presidency, ' says Ms Sandford. 'But it will probably be next year before we see the new warnings in place.'