Professor Helmut Brand, president of the European Health Forum Gastein (EHFG), Jean Monnet Professor of European Public Health and head of the Department of International Health at Maastricht University, The Netherlands. He serves on the European Advisory Committee on Health Research (EACHR) of WHO Europe and on the Expert Panel on “Investing in Health” (EXPH) for the European Commission.
Europe is undergoing a period of profound demographic change. Populations are ageing, fertility patterns are changing, modern living has impacted our habits, and consequently, there is an increasing prevalence of people living with one or more chronic disease. Cases of diabetes, for example, are expected to rise from 58.9 million cases in 2015 to 71.1 million by 2040. Today over 10 million people are living with dementia in Europe and it is set to double by 2050. All the while, governments struggle to manage health care spending as much of the continent recovers from the damaging global recession and faces a rising cost of treatments.
With so many potential stumbling blocks for European health systems, can we all truly access quality care?
I say we can. Demographics do not define Europe’s destiny. By proactively considering the challenges and seizing opportunities for new approaches to health care, we can influence our health outcomes for the better. A key lesson for individuals and governments alike: we stand to learn a lot from our neighbours. Working together, we can avoid reinventing the wheel, and promote a better understanding of health care at individual and community level to support health systems as a whole.
Mind the gap: measuring health system performance
Though each country starts from its own context and its health system serves a unique population, most have a similar end goal: well-equipped, efficient and sustainable health system to meet the needs of all citizens. As such, there is value to be derived from measuring how well countries are doing against comparable health indicators.
This is already well underway. In the recent report “So What?”, prepared by the European Commission Expert Group on Health System Performance Assessment (HSPA), the OECD, the World Health Organisation Regional Office for Europe and the European Observatory on Health Systems and Policies, the authors state: “Countries often benchmark with other countries. Whilst the challenges involved in these comparisons are well known, it is also evident that information deriving from international comparisons can provide the basis of further scrutiny and a deeper comprehension of the policies required to improve the status quo.”
Platforms such as the European Union and the OECD offer an excellent means by which governments can share where they are succeeding and where there are gaps. Which prevention tactics are effective in reducing childhood obesity? How can we improve outpatient care for the elderly? Particularly pertinent as government resources are challenged in keeping up with demographic change, this exchange of best practices can facilitate sound strategies for quality health interventions.
Such cross-border collaboration is also the objective of the annual European Health Forum Gastein (EHFG), taking place on 28-30 September. This year’s conference theme, Demographics and Diversity in Europe, places the focus on what new solutions for health one country can learn from the other, to better respond to demographic trends.
Close the gap: accelerating health literacy in Europe
Health literacy, the competence to understand and apply information to make decisions for health care, disease prevention and health promotion, remains a public health challenge in Europe. In the most recent publication of Health Promotion International, I discuss together with colleagues research that demonstrates health literacy on this continent is still at its infancy.
The ability for an individual and their community to be fully informed and engaged in their own care is a necessary step in tackling the burden of chronic diseases in Europe. Take diabetes for example. The HSPA report examines the incidences of hospital admissions for diabetes patients across Europe. Such acute deterioration in the health– such as cardiovascular, renal and neurological complications – is traumatic for patients, expensive for health systems, and often, avoidable.
An effective primary health care system should be capable of implementing a baseline of access to quality health care that prevents the emergence and progression of many major chronic diseases. But to respond to rising populations and limited health system resources, we must also strengthen what is below primary care – community level care. The more each patient, carer, and member of a community is empowered and involved in their own health care delivery and the greater the health literacy amongst the population, the better.
As highlighted by the European Patient’s Forum, empowered patients are part of the healthcare team, crucial for the performance of health care systems. This concept was explored in depth at last year’s EHFG, and is a discussion that will continue to be of pertinence to the Forum for the foreseeable future. A key recommendations of HSPA’s reports states: “In future, greater attention should be given to the assessment of patient experiences, such as patient reported experiences and patient reported outcomes. Health care in most countries is still not sufficiently patient-centred, despite the patients’ participation being increasingly emphasised in recent decades.”
Learning from our neighbours, whether they be neighbouring countries or neighbouring members of the community, will help us keep up with the health care demands of demographic change.
Today’s post is by Francesca Colombo, Head of the OECD Health Division
That population is ageing across the world is well known. As fertility rates drop and life expectancy improves, a bigger share of the population is greying. At least one in four people will be aged over 65 by 2050 in about two-thirds of OECD countries. The share of those aged over 80 years will more than double, from 4% in 2010 to 10% in 2050. In Japan, Spain and Germany, this trend will be even more pronounced, with the proportion of the over-80s expected to triple, rising from 5% to 15% in Spain and Germany, and from 6% to 16% in Japan. The speed of ageing will be even more dramatic in some emerging economies. China, for example has taken only 40 years to increase life expectancy from 40 to 70 years, something that took Germany 80 years.
Such a demographic shift has an impact on societies and economies. The size of the workforce will shrink, putting pressure on governments to reform labour markets, pension entitlements and retirement age thresholds, so that older people can remain productive and employed longer. We’re already seen employment rates of older people improving over the past decade in many G20 countries. Rising education levels and skills will help more people work for longer periods of time, although differences in opportunities throughout individual life-course trajectories will affect their ability to remain fit for work as they grow older. The experience individuals gain through education and work will help to raise productivity and keep economies growing as populations age.
In the face of the speed of population ageing, though, our health systems are still too slow at reforming and remain ill-prepared for the consequences of greying societies.
The health care delivery model prevailing today has not kept pace with the changing epidemiology and health needs of the population. The focus often remains on building new hospitals, buying expensive new equipment and upgrading acute service delivery structures. The management of care processes remains to a large extent focussed around episodic care needs. However, population ageing requires a different approach, involving a shift from acute, episodic and hospital centric care to the management of chronic conditions, the delivery of continuity of care across different care settings and providers, and a strong role for primary care professionals such as general practitioners.
A main challenge will be the management of complex combinations on chronic conditions. In many OECD countries, more than half of individuals aged over 65 have more than one chronic condition, and from age 75, many people will have three or more. Health and social care systems are still grappling with how to manage the diversity and uniqueness of this complex combination of diseases and care needs in an effective way, in relation to how to organise care teams, how to identify the right measurement metrics, or how to equip health professionals with the skills they need to address changing population structures and epidemiological profiles.
A compelling example of how health systems struggle to respond adequately to the rising complexity of population ageing is dementia. Dementia affects a growing number of people worldwide – currently estimated at 47 million but expected to rise to 76 million by 2030. In the OECD, France, Italy, Switzerland, Spain, Sweden and Norway have the highest prevalence rate, with 6.3% to 6.5% of the population aged 60 years and over now estimated to live with dementia. For a person affected by dementia, the outlook is pretty grim. For a start, there is no cure as yet nor disease-modifying treatment. Several clinical trials have failed miserably in the past. There is hope that international processes – started with the G7 Summit in London in December 2013, continued with G7 Legacy Events during 2014 and ending with an international Health Ministerial Conference hosted by the WHO with the support of the UK government and the OECD in Geneva in March 2015, will bear some fruit.
But beyond changing incentives for public investment in research and encouraging private investment to finding a cure, the lives of people living with dementia remains poor in most countries. This must change through training doctors and caregivers, and equipping them with better tools to assess the needs of people with dementia; facilitating improved care co-ordination, particularly across health and social care services; and encouraging a better focus on measuring outcomes for people with dementia (such as quality of life, safety of services and medical products, effectiveness and responsiveness), as well as for the many families and friends who look after people with dementia. OECD work has shown 10 basic features that would make a differences, ranging from minimising the risk developing dementia to unleashing the potential of technology to support people with dementia, and helping people die with dignity.
Underpinning some of the difficulties of health systems in addressing population ageing is a failure to understand and monitor adequately the care processes through the data we have today. In an era of ‘big data’, health systems remain poor at using the massive amount of administrative, clinical, population-based, and biological data that are routinely generated from the millions of contacts individuals have with different parts of the health system. Most often, such contacts remain unrecorded; or records are paper -based, not standardised, nor shared across the care pathway. To improve care for old patients with complex care need, we need these data to be stored and linked so as to display a more granular picture of the quality of the care delivered to patients, especially those affected by chronic or multiple chronic conditions. Addressing weaknesses in the governance of this data infrastructure, including through generating better outcome measures to monitor care delivery and through enabling a privacy respectful use of personal health data, will be key priorities for the future.
How many diseases are there? An expert would probably look for the answer in ICD-10, the WHO’s catalogue of over 12,000 calamities that could hit you.
The eponymous hero of Jules Romains’ play Knock, or the Triumph of Medicine would probably have replied that there as many as you can convince people to have. According to him, a healthy person is merely a sick one who doesn’t know it yet.
The ICD can give you that impression too. Some of the characteristics of F60.5 (anankastic personality disorder if you must know) sound more like my job description, and in fact few of my colleagues would escape intact from even a superficial check against sections F60-69, Disorders of Adult Personality and Behaviour. Who hasn’t worked with/for “There may be excessive self-importance, and there is often excessive self-reference”?
According to a special issue of PLoS Medicine, the expansion in the number of diseases these past years is not due to the population becoming sicker or diagnostics getting better. The real reason is “disease mongering” – interested parties creating an all-in-one package of a new treatment and a new condition it can treat, or a new use for an old treatment whose patent is about to expire.
This may play a role in increasing health costs, but the main reasons are that patients expect more from health care systems and that the type of conditions the systems have to treat are changing.
Scanners and other modern imaging techniques are expensive, but are now commonplace, as are sophisticated testing techniques. Many diseases that would once have killed the sufferer can now be treated, but the treatment may last for years. The population is ageing, and more people are living to an age when costly care is needed on a daily basis.
These are postive developments, and investment in health pays dividends. For example, up to 40% of the increase in life expectancy since the early 1990s could be due to increased health spending.
That doesn’t mean that the 9% of GDP an average OECD country devotes to health is all money well spent. Health ministers meeting at the OECD this week will be looking at how to get the best value for money, and ensure that the progress we’ve seen in treating those 12,000 diseases continues. They’ll also be looking at prevention, how to stop us getting them in the first place.
The MRI brain scan is courtesy of Dwayne Reed
This week the Insights blog will be focusing on health care issues.
It is amazing how a single word can distort a debate. Take the word ‘rationing’. What does that mean to you? To me, it conjures up a world of little cardboard booklets, which record whether or not you have been allocated your personal portion of eggs, butter, or flour. A world in which it makes sense to ask whether or not someone has had his or her ration.
In the US debate on health care reform, conservatives warned US citizens that, aside from the horrors of state control, universal health-care would inevitably lead to UK style health rationing. The debate about rationing largely focused on the question of whether it is a lesser evil than a system which, despite pouring much more money into health care per person than any other in the world, still left perhaps as many as 50 million people without health insurance.
I was completely bemused by this debate, and couldn’t understand why ‘progressives’ were prepared to let it be structured this way. For consider. Do we have rationing in the UK or elsewhere in Europe? Where do you keep your ration card? Has your NHS doctor ever refused to see you because you had used up your allocation of appointments? Has a hospital told you that you had already spent your share of nights on the ward?
What we have in England and Wales is the National Institute of Health and Clinical Excellence (NICE) with the job of deciding whether or not a new treatment or intervention is cost-effective. Sometimes, to the fury of patient groups and pharmaceutical companies, it decides that a drug is not worth the price asked for it, and recommends that it is not ‘refunded’ by the National Health Service.
Now, this is bound to cause dispute, and makes excellent news stories. It is easy to find someone who believes that their condition would be massively improved if an excluded drug was made available, and that NICE heartlessly puts a price on life. And indeed, we can argue that NICE may have erred in particular cases, or, more generally goes about its decision-making the wrong way. But it is hard to argue that considerations of cost are never relevant. If a drug cost ten thousand pounds and extended a life by an hour, it would be a difficult to argue that it should be made available at public expense. Sometimes we must put ‘a price on life’, somehow or other. (more…)