Download health - ARCES

Health Governance through Europe
Brussels April 16th 2012
Investing in Progressive and Affordable Health
Systems
Barrie Dowdeswell
Director of Research ECHAA
Agenda
• Setting the context:
• The Cohesion Fund policy for healthcare
• The changing ‘Health’ circumstances – embedded pressures
• The dominance of the economic agenda – superimposed pressures
• How the EU is responding
• Hungarian Presidency
• EU Council
• High Level Reflection Process
• Reconciling Cohesion Policy and Europe 2020 with SF planning
• Lessons from Euregio III
• Conclusions and questions
Health, a defining EU societal value
Unprecedented pressures
Population health
status
The macro view
Personal
care
The citizen
• Citizens rights and MS responsibility:
• Safe, accessible, reliable, affordable and progressive healthcare
• EU Policy aims
• Social cohesion through principles of equity and inclusiveness
• Contribution to economic growth
• Twin challenges
• Embedded health pressures: ageing, chronic illness, technology
• Superimposed pressures: the economic crisis
Health equity – slow improvement and some regression
Total
Male
Female
EU 15
78.7
76.9
82.7
Bulgaria
72.6
70.0
76.2
Czech Republic
76.1
72.9
79.3
Estonia
72.8
67.3
78.2
Hungary
73.0
68.7
77.2
Latvia
70.9
65.4
76.4
Lithuania
71.1
66.3
77.1
Malta
79.4
77.2
81.4
Poland
75.3
70.8
79.7
Romania
72.6
69.2
76.2
Slovakia
74.3
70.3
78.2
Slovenia
77.5
74.5
82.0
Comparative health outcomes will become
an important measure of health equity
•
As judged by reductions in mortality rates
UK health had improved on average over the
past 50 years, but in recent decades
inequalities in health had either remained
static or widened. "Independent inquiry into
inequalities in health 2004"
•
National reports highlighting how inequality
and disadvantage damages health have
been published by other Member States
including Sweden, Holland, Norway and
Spain.
•
INSERM (Institut national de la santé et de la
recherche médicale) says that mortality in
France among blue-collar workers aged 4559 years is 71% higher than among their
white-collar peers.
•
To reduce the unnecessary ill-health and
shortened life span of disadvantaged people
in Europe, key policy areas must be
addressed. Working alone, the health sector
can do little to reduce inequalities in illness,
injury and life expectancy. "Independent
inquiry into inequalities in health"
Will ‘health’ receive a reasonable share of the
next SF cycle - 2014/20 - and how ?
• Health received specific earmarked HEALTH allocations in 2000/6 &
2007/13 (Euro 15 bn) – so far there is no earmarking for 2014/20
• Cohesion Policy guidelines - HEALTH is not a thematic priority but is
featured in specific contributing terms
• Europe 2020 - HEALTH is not a thematic or flagship target but is also
featured in a number of ways
The challenge
• Overcome the widely held view that health is a cost to the economy
• Understand how to translate guidelines and policy to reinforce
health as:
•
•
•
•
•
Delivering measurable benefit to the economy
Delivering measurable improvement in health equity
Delivering measurable improvement in quality
Addressing other key strategic issues e.g. cross border care, workforce.
Implementing reform
Cohesion Policy guidelines – there are important
references - (Attachment 5, COM(2011) 615 final, 6/10/2011)
Promoting social inclusion, (Annex IV, §10.2, p149),
discussion of the health sector becomes much more
explicit.
• "The existence of a national or regional strategy for health ensuring
access to quality health services and economic sustainability:
• contains coordinated measures to improve access to quality health
services;
• contains measures to stimulate efficiency in the health sector,
including deployment of effective innovative: technologies, service
delivery models and infrastructure;
• contains a monitoring and review system.”
There is more
• “A Member State or region has adopted a framework outlining
available budgetary resources for health care“
• Annex IV notes under Enhancing access to ICT that there should be
measurable targets for outcome of intervention in eHealth
• Under Promoting employment, active and healthy ageing is
mentioned as a priority - as contributing to sustaining and
improving the scale and scope of the employment pool
We might reasonably conclude that health has sufficient reference
points to ensure access to SF.
But health will be in direct and vigorous competition from more
obvious economy related priorities which may be flagship initiatives
“Europe 2020”
Shaping future EU (SF) policy
• SMART, SUSTAINABLE AND INCLUSIVE GROWTH
Where do we want Europe to be in 2020?
• “Three priorities should be the heart of Europe 2020:
• Smart growth – developing an economy based on knowledge and
innovation.
• Sustainable growth – promoting a more resource efficient,
greener and more competitive economy.
• Inclusive growth – fostering a high-employment economy
delivering economic, social and territorial cohesion.”
Europe 2020
7 Flagship initiatives
• Innovation Union
• Youth on the move
• A digital agenda for Europe
• Resource efficient Europe
• An industrial policy for the globalisation era
• An agenda for new skills and jobs
• European platform against poverty
Health features as contributing to achievement of flagship targets
Europe 2020
Health does have several explicit references.
• Smart Growth
• the Innovation Union - the need to focus on challenges including
healthy ageing.
• Digital agenda for Europe - promoting online health.
• Inclusive Growth
• the European platform against poverty - commits "To undertake
an assessment of the adequacy and sustainability of social
protection and pension systems, and identify ways to ensure
better access to health care systems" with parallel MS action.
• Sustainable growth
• "Fiscal consolidation and long-term financial sustainability will
need to go hand in hand with important structural reforms, in
particular of pension, health care, social protection and
education systems”
• Resource Efficient Europe - the carbon agenda dimensions of capital
and service strategy
The basis of a strategic framework for Health SF
• Understanding the context
• The economic crisis – impact on growth and employment – achieving
economic sustainability
• Needs assessment and concept development
• identify ways to ensure better access to health care systems
• Strategic priorities - and policies
• Social - Equality of Access and Quality
• Economic - long-term financial sustainability will need to go hand in hand
with important structural reforms
• Tactical measures
• Enhancing access to ICT - promoting online health
• Healthy ageing programmes
• Stimulating efficiency – effective innovation, technologies, service delivery
models, infrastructure
• Evaluation and accountability - an effective monitoring and review system
The past two programmes – how has SF been
applied ?
• The structure of the SF process has predisposed projects towards
single focus spending:
• Separate ERDF and ESF funding streams
• Complexity of developing cross-sectional integrated projects
• Projects tend to be focused on specific ‘headlined’ elements of
policy guidelines to ‘guarantee’ success e.g.
• eHealth – on-line health projects
• Infrastructure – facility modernisation
• Time constraints (and continuity) for large scale reform
• The programme projects have in the main delivered specific (but
usually narrow focus) benefit
• Projects rarely, if ever, achieve whole systems integrated strategic
value
Evidence demonstrates problems (SG2)
• The level and limitations of strategic thinking
• strategy is loosely coupled with the problem and mainly focuses on
the elaboration of attractive project ideas without an evidence base
• lack of strategic integrative coordination e.g.
• Imbalance between the magnitude of infrastructure investments and the
development of related human resources
• The problem of dual power or division of power / accountability
• (e.g. between the Ministry of Health as the professional arm of
policy making and the Managing Authority)
• Structural Fund bureaucracy
• Limited expert capacities
• Time issues (long project preparations, postponing
announcement of projects, delays in payments etc.) and cost of
preparation of projects
• Political instability
What has changed
Looking ahead to 2014 /20
The economic crisis will dominate future health policy
Consensus between almost all authoritative reviews
• “The current economic crisis will bring about a period of
budgetary constraints associated with the need to reduce
large government deficits and put public finances back on the
right track”
• “Depending on its severity, we will see public authorities
contracting their spending on health services as a reaction to
the observed economic crisis”
EPC-Commission Report on Health Systems
GDP and health spending
Healthcare costs are rising faster than levels of
funding available through taxation and insurance
• Ageing populations and the related rise in chronic
disease
• Costly technological advances
• Patient demand driven by better information and by
less healthy lifestyles
• Legacy priorities and financing structures that are
not suited to today’s needs
Accumulated debt
Spending
Available
resources
Europe has been (and is still) repeating patterns of
investment in healthcare from the 80’s and 90’s
The hospital-centric model has often been stimulated and sustained
through high levels of debt made possible by high levels of GDP growth
Increasing Government debt
PPP – long-term commitments
e.g. UK NHS private finance initiative - £90 billion
over 25 years
Hospital Deficits
starting to spiral out of control
There is an overwhelming consensus that this model is unsustainable and
knowledge, capability and capacity has moved on
We are paying a high price for a hospital-centred
model often without good evidence that it offers best
value
95%
5%
Total patient care numbers
50% / 70%
Share of total health spending
In an average district hospital:
• 70% of patients are over 65
• 40% to 50% of patients could be better cared for outside hospital
• May have contributed up to 50% of improvement in amenable mortality
•Within the average population chronic disease costs are 5 times ‘other’
hospital
primary care
WHO view of changing focus in healthcare
*
*
*
*
*
*
* typical SF projects – but not integrated and insufficient critical mass for reform
Influencing change in EU and SF policy
• The Hungarian Presidency Programme Jan / June 2011
• The Informal meeting of Health Ministers, Godollo, April 2011
• EU Council Conclusions, June 2011
• The EU Council High Level Reflection Process
• The work of Sub-group 2 on SF
• Exemplar SF ‘good practice’ projects
Hungarian Presidency
“Investing in Health Systems of the future”
“Patient and Professional Pathways”
Themes
• An EU wide ‘common reflection’ process on health
systems, structures and priorities
• Monitoring and measuring the effectiveness of EU
Structural Funds – and working together to introduce
more innovative application
• Shift healthcare from the dominance of cost containment
to contribution to and investment in economic growth
• Coping better with healthcare manpower mobility and
volatility
Pathways for change – (Godollo 2011)
Changing focus
What works and what
Doesn’t in the ‘new’
healthcare landscape ?
Whole systems
disease management
• Coherence
• Population sensitivity
• The patient as co-producer
• More effective commissioning
• Resource reallocation
• Workforce realignment
Institutional / sector delivery
Care pathways
Societal and
economic benefit
EU Council Conclusions
• The Health Sector should play a role in implementation of
Europe 2020 Strategy – investments in health should be seen
as a contributor to economic growth
• In order to create modern, responsive, efficient, effective and
financially sustainable health systems SF resources can be
used in complementing the financing of health sector
development, in particular:
• Achieving social cohesion
• Developing new generation approaches to healthcare will
require appropriate funding to foster transformation and
rebalance investment towards new models and facilities
• Sharing and analysing experiences, best practices to build up
success factors for more effective use of SF
• Decision to undertake a High Level Reflection Process
The High Level Reflection Process of the EU
Council – 4 sub-groups
1.“Enhancing the adequate representation of health in the
framework of the Europe 2020 Strategy and in the process of the
European Semester” – led by DG Sanco
2.“Defining success factors for the effective use of Structural Funds
for health investments” - led by Hungary
3.“Finding adequate responses to society's growing and changing
health needs particularly due to ageing population, and designing
effective and efficient investments in the health sector” – led by
Poland
4.“Measuring and monitoring the effectiveness of health
investments” – led by Sweden
Deliverables identified by the Working Party on
Public Health at Senior Level (10th October 2011)
“Very early progress should be made on key deliverables”
• “common sense “success factors”, which should be present in
advance as to ensure effective investments from the Structural
Funds in the health sector
• a tool box for the use of Member States on the effective use of
Structural Funds for direct health investments
• Sharing and analysing experiences and best practices
• Discuss opportunities to implement PPPs or other financial
engineering instruments in the health sector
Sub-group 2 SF
Examples of Euregio case studies that will be referenced as
guides to good practice and shaping process and policy:
•
•
•
•
Sicily
Brandenburg, Germany
Kymenlaakso, Finland
Norbotten, Sweden
Sicily
Strategic focus:
Improving accessibility
and quality
1. Needs assessment
2. Technology benchmarking
3. Technology investment
Brandenburg, Germany
Improving accessibility to healthcare support for CVD
•Understanding the problem – and need
•eHealth technology as a facilitating process
•The patient as co-producer of care - empowerment
•Investing in healthy and active ageing
•Using social networking principles to disseminate healthy
living messages
•Creating the basis for healthcare reform – reducing the
reliance on a hospital-centred system
Brandenburg - Chronic illness (cardiovascular disease)
Changing the location and focus of investment
– patient-centred care
Patient centred
interventional support
Poverty
Diet
Transformational
investment
Housing
Smoking
Cardiovascular disease
Treatment
Current bias towards
curative investment
Death
Kymenlaakso, Finland
•Affordable and sustainable structural reform of the
health system
•Improving accessibility through integration of services
•Healthy and active ageing principles
•eHealth as a facilitating technology
Demography as a basis for economic risk assessment
The importance of healthy ageing in deciding
strategic priorities in health
Almost universal changes in EU retirement ages reinforces this priority
Epidemiological trend analysis
Risk assessment – future cost profiling
Developing a sustainable reform model
The key to unlocking the problem
• A community focused and innovative elderly care, chronic illness strategy
• Innovative hospital reorganisation
Reform – service integration
Moving on from the hospital culture, from illness to
wellness
Reforming hospital organisations
Kyemnlaakso
Karolinska Institute
A shift away from demarcated
/ territorial systems and structures
to multi-disciplinary ‘pole-based’
models
- Inflamation /Regenerative
- Cancer
- Neuro / Cardio-vascular
- Children
Changing cultures and strategies for the elderly
Innovative application of SF
Getting the reform planning right
• Total sum spent was 2.24 M€.
• Kymenlaakso Hospital District 700 000 € for new hospital and
local health plan plan
• Kouvola City 350 000 € for re-planning and modernisation of
local health service
• Järvenpää City 200 000 € for conceptual planning of new
Health Center
• Espoo City for improving home care by increased teleservice
• Helsinki University of Technology, (now Aalto University)
800 000 € for management and related research
A whole systems integrated
eHealth model as a transforming
service for healthcare delivery
Conclusions – the application of SF
• Health investments should make a measurable contribution to:
• Social inclusion and equity – accessibility and quality
• Economic growth
• The economic crisis has reinforced the critical need for affordable
and sustainable health reform
• This will require a new (integrated) strategic approach to
planning and investment
• The ‘common sense’ success factors will be designed to reinforce
and drive these strategic objectives
• SF may be one of the few facilitating funds available for many
MS, access will be dependent on demonstrating how success
factors will be achieved – in measurable terms
• There will be a new focus on accountability
Thank you for your attention
[email protected]