Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH European incorporating Euro Observer

on Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS

❚ Out-of-hours primary care & ❚ The new era of EU health policy

› 2015 Providing demand for emergency care ❚ eHealth services in the EU |

❚ Managing demand for urgent care emergency ❚ Convention on counterfeiting ❚ Waiting time policies of medical products

medical care Number 4

❚ Men’s health policies |

❚ Hospital reforms in Switzerland Volume 21 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of part No 2015. Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Sweden, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The consideration. for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available Guidelines Submission Article White: Caroline MANAGER SUBSCRIPTIONS North: Jonathan MANAGER PRODUCTION Still: Steve EDITOR DESIGN B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian Holland, Walter Figueras, Josep Busse, Reinhard Belcher, Paul BOARD ADVISORY EDITORIAL aboutUs/LSEHealth/home.aspx http://www2.lse.ac.uk/LSEHealthAndSocialCare/ 6803 7955 20 +44 F: 6840 7955 20 T: +44 Kingdom United 2AE, WC2A London Street, Houghton Science Political and Economics of School London Health, LSE Mossialos: Elias EDITOR FOUNDING Palm: Willy ADVISOR EDITORIAL 6381 7955 20 +44 McDaid: David Maresso: Anna 6194 7955 20 +44 Merkur: Sherry TEAM EDITORIAL SENIOR http://www.healthobservatory.eu Email: 0936 2525 +32 F: 9240 2524 T: +32 Belgium Brussels, 1060 Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European the of Quarterly EUROHEALTH [email protected] is a quarterly publication that provides a forum aforum provides that publication aquarterly is Saltman, Sarah Thomson Thomson Sarah Saltman, – [email protected] [email protected] 1030 http://tinyurl.com/eurohealth [email protected] [email protected] [email protected] [email protected] / 40 Hortaplein, Victor Eurohealth

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CONTENTS 1

EDITORS’ COMMENT List of Contributors 2 Oscar Alarcón-Jiménez w European Committee on Crime Problems, Council of Europe, Strasbourg, France Peter Baker w Global Action on Eurohealth Observer Men’s Health Michael Borowitz w The Global Fund, THE CHALLENGE OF PROVIDING EMERGENCY MEDICAL Geneva, Switzerland 3 CARE – Anna Sagan and Erica Richardson Ellie Brooks w Lancaster University, United Kingdom OUT-OF-HOURS PRIMARY CARE AND DEMAND FOR Paul Camenzind w Swiss Health Observatory, Neuchâtel, Switzerland Anna Sagan 6 EMERGENCY MEDICAL SERVICES – Tony Cornford w Department of and Erica Richardson Management, The London School of Economics and Political Science, United Kingdom MANAGING DEMAND FOR URGENT CARE – Luca Crivelli w Department of Business 10 THE ENGLISH NHS 111 EXPERIENCE – Janette Turner, Economics, Health and Social Care, University of Applied Sciences and Alicia O’Cathain, Emma Knowles and Jon Nicholl Arts of Southern Switzerland, Lugano Carlo De Pietro w Department of WHAT WORKS? WAITING TIME POLICIES IN THE Business Economics, Health and Social Care, University of Applied Sciences and 14 HEALTH SECTOR – Luigi Siciliani, Valerie Moran and Arts of Southern Switzerland, Lugano Michael Borowitz Margaret Ellis w LSE Enterprise, The London School of Economics and Political Science, United Kingdom Emma Knowles w School of Health and Related Research (ScHARR), Eurohealth International University of Sheffield, United Kingdom Jon Nicholl w School of Health and HEALTH OWNERSHIP OF HEALTH POLICY? Related Research (ScHARR), University 17 CHALLENGES AND CONCERNS IN THE NEW ERA OF of Sheffield, United Kingdom EU HEALTH POLICY – Ellie Brooks Valerie Moran w Centre for Health Economics, University

CONTENTS WHY HAS THERE BEEN VERY VARIABLE IMPLEMENTATION OF of York, United Kingdom EHEALTH SERVICES WITHIN THE EU? – Margaret Ellis, Sofia Moreno-Perez w Independent 20 Consultant, Madrid, Spain Tony Cornford and Sofia Moreno-Perez Alicia O’Cathain w School of Health and Related Research (ScHARR), THE MEDICRIME CONVENTION – FIGHTING AGAINST University of Sheffield, United Kingdom Wilm Quentin w Department of 24 COUNTERFEIT MEDICINE – Oscar Alarcón-Jiménez Health Care Management, University of Technology Berlin, Germany Erica Richardson w European Observatory on Health Systems Eurohealth Systems and Policies and Policies, United Kingdom Anna Sagan w European WORTH THE PAPER THEY’RE WRITTEN ON? THE Observatory on Health Systems and Policies, United Kingdom POTENTIAL ROLE OF NATIONAL MEN’S HEALTH POLICIES 27 Luigi Siciliani w Department of – Peter Baker Economics and Related Studies, University of York, United Kingdom HOSPITAL REFORMS IN SWITZERLAND – Wilm Quentin, Anne Spranger w Department of 30 Friedrich Wittenbecher, Anne Spranger, Luca Crivelli, Health Care Management, University of Technology Berlin, Germany Isabelle Sturny, Paul Camenzind and Carlo De Pietro Isabelle Sturny w Swiss Health Observatory, Neuchâtel, Switzerland Janette Turner w School of Health and Related Research (ScHARR), Eurohealth Monitor University of Sheffield, United Kingdom NEW PUBLICATIONS Quarterly of the European Observatory on Health Systems and Policies EUROHEALTH European incorporating Euro Observer 34 on Health Systems and Policies RESEARCH • DEBATE • POLICY • NEWS 35 NEWS Dreamstime.com | ❚ Out-of-hours primary care & ❚ The new era of EU health policy

› 2015 Providing demand for emergency care ❚ eHealth services in the EU |

❚ Managing demand for urgent care emergency ❚ Convention on counterfeiting ❚ Waiting time policies of medical products

medical care Number 4

❚ Men’s health policies |

❚ Hospital reforms in Switzerland Volume 21 © Mimnr1

Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 2

Providing timely emergency medical services for life- threatening situations as well as urgent care appropriate to patients’ clinical needs are the most enduring challenges facing national health care systems, particularly in light of rising numbers of unnecessary emergency department attendances in many countries.

In this issue’s Observer section, Sagan and Covering a neglected area, in our Systems and Richardson provide an overview of the main aspects Policies section, Baker discusses Ireland’s National of emergency care, highlighting some of the strategies Men’s Health Policy, which ran from 2008 to 2013, being adopted to consolidate emergency care the first of its kind in the world. Reporting the results and divert patients to more appropriate parts of of an independent review that he conducted, the the health system. In a related second article, they author concludes that such plans could also reap put the spotlight on out-of-hours urgent care most benefits if adopted by other EU countries. Moving to appropriately provided at the primary care level the hospital sector, in their article, Quentin et al look and how this may be improved in order to relieve at recent payment reforms in Switzerland, where the the pressure on hospital emergency departments. introduction of diagnosis-related groups considerably Providing an example of a telephone-based service improved hospital planning and co-ordination across designed to improve access to urgent health the country’s 26 largely independent cantons. care, Turner et al discuss the piloting and national implementation of NHS 111 in England which is As usual we also feature new publications in well liked by users but to date has not delivered our Monitor section, this time highlighting the the expected efficiencies or checked the growth in study Promoting Health, Preventing Disease: the emergency ambulance activity. Finally, it has been economic case, as well as a new policy brief on argued that one factor determining patients’ possible How can countries address the efficiency and equity use of emergency care is excessive waiting times for implications of health professional mobility in Europe? various treatments which can exacerbate conditions to The News pages provide a round-up of what’s the point of requiring urgent care. In the last article in been happening in health policy around Europe. this section, Siciliani et al assess the main policy tools that have been used in OECD countries to try to tackle We hope you enjoy the Winter issue! long waiting times, with varying degrees of success. Sherry Merkur, Editor In the International section, the article by Brooks looks Anna Maresso, Editor at EU health policy in the current climate of fiscal David McDaid, Editor and economic coordination. The author points to the European Semester and Health System Performance Cite this as: Eurohealth 2015; 21(4). Assessment as competing processes which are changing the policy landscape at EU level and are increasingly shaping policy responses at the national level. On the topic of eHealth services in the European Union, Ellis and colleagues discuss the variable levels and speeds of adoption and provide country examples. Rounding up this section, Alarcón-Jiménez explains how the international MEDICRIME Convention adopted by the Council of Europe functions as a major tool to criminalise the counterfeiting of medical products and similar crimes involving threats to public health and to protect the rights of victims. EDITORS’ COMMENTEDITORS’

Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 Eurohealth OBSERVER 3

THE CHALLENGE OF PROVIDING EMERGENCY MEDICAL CARE

By: Anna Sagan and Erica Richardson

Summary: Emergency medical care is a politically important aspect of health service provision as it is often the first contact point with the health system for many patients requiring urgent care and delays in access to treatment are understood to be a matter of ‘life or death’. Increasing pressure on emergency medical services has led to the adoption of various strategies, including a greater consolidation of emergency care and diverting patients to other parts of the health system. While there is great scope for cross-country learning, research on international comparisons of emergency medical services remains scarce and there is no universal group of evidence-based performance indicators.

Keywords: Emergency Medical Care, Health Care Provision, Health Care Organisation

Introduction reliance on paramedics during the “load” phase. In contrast, the Franco-German Emergency medical care is the provision “stay & stabilise” model, relies more of medical care to patients with life- on mobile medical doctors who provide threatening conditions who require urgent advanced medical care on site, with treatment. From a policy perspective, transported patients being admitted to the emergency medical services (EMS) are hospital directly rather than through the one of the higher profile aspects of the ED. In response to changes in medical health system as they are the first point of technologies and population health trends, contact with the health system for many most European EMS now have elements people. EMS also serve as a sentinel for of both organisational models – load & go weaknesses in the wider health system, for complex trauma care, such as in the such as financial or organisational barriers case of road traffic accidents, and stay & to accessing primary care or shortcomings stabilise for medical emergencies, such as in the provision of care for people with heart attack or stroke. Neither model, on long-term conditions. its own, is superior. 1 Anna Sagan and Erica Richardson are Researchers at the European Until recently, there were two distinct Observatory on Health Systems and EMS can be divided into out-of-hospital typologies in the provision of emergency Policies, London Hub, at the London EMS and in-hospital EMS. Out-of-hospital School of Economics & Political care. The first is the Anglo-American EMS typically refers to the delivery of Science and the London School “load & go” model, with a focus on of Hygiene and Tropical Medicine, medical care at the site of the adverse bringing the patient as quickly as possible United Kingdom respectively. medical event, including dispatch services to the hospital, usually to the emergency Email: [email protected] and mobile medical care units, such as department (ED). This model has greater

Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 4 Eurohealth OBSERVER

ambulances. In-hospital EMS refers to (as in Finland, Germany and also Norway, medicine specialists located elsewhere those subsets of medical institutions but with increased collaboration between in the hospital. However, an increasing and hospitals that have the capacity to municipalities). The concentration and number of European hospitals now staff deliver uninterrupted emergency care on consolidation has often occurred in order EDs with either emergency specialists or a 24 hours-a-day, 7 days-a-week basis. to make efficiency gains. trainee doctors in emergency medicine. In addition, urgent care services, mainly provided within primary care services, Many countries have stepped up efforts including out-of-hours (OOHs) primary to rationalise and reconfigure hospital care and services such as the fire brigade only care, categorising their hospitals into and police, contribute to providing, distinct levels that specify their remit both ameliorating and supporting EMS. 2 eleven in geographical terms and in the types (See also the article on access to OOHs of care to be provided, then integrating primary care in this issue). EU Member them into networks to encourage greater collaboration and coordination. The need Out-of-hospital EMS – ambulance and States have for a more concentrated and structured dispatch services provision of specialised hospital services, triage guidelines including emergency care, is not only There are two main types of road motivated by the need to increase ambulances used for EMS in European based on efficiency and contain costs but also by the countries: emergency ambulances need to ensure patient safety and improve designed and equipped for the transport, national quality of care. Policy-makers have sought basic treatment and monitoring of ‘‘ to increase the throughput of patients in patients; and mobile intensive care units standards order to maintain the skills of emergency designed and equipped for the transport, care specialist doctors and nurses (e.g. in advanced treatment and monitoring of Most European Union (EU) countries Sweden and the UK). Research conducted patients. 2 In some countries, ambulance have integrated dispatch centres, i.e. they in the UK found that concentrating services are considered part of primary have dispatch centres that coordinate expertise in trauma care led to a 30% care (e.g. Slovenia, Lithuania), in others the dispatch of vehicles and personnel improvement in survival rates despite they are hospital services (e.g. Latvia and of at least two principal emergency longer travel times. 5 Belgium), but they are often provided by management agencies (security services, local governments (e.g. Finland, Norway) EMS, fire department, etc.) Moreover, Diversification of hospital emergency care or are integrated into other emergency in most EU countries dispatch centres and concentration of the most complex services, such as fire departments transfer the call to another centre when cases are often also motivated by the need (e.g. France and Germany). As with a medical consultation is needed; as yet, to construct viable staffing rotas. Staff primary care, EMS are often organised in computerised triage systems in dispatch shortages in emergency medical care are relation to the resident population served centres are not common in the EU. 2 a problem across Europe as emergency – so policy-makers aim for a particular medicine is not considered the most ratio of ambulance teams per capita. In-hospital EMS prestigious branch of medicine to pursue However, this can place great burdens on (i.e. in Bulgaria and Hungary). In addition, hospital teams in big cities which have Emergency Departments the challenge of recruiting and retaining large commuter populations (as the day- staff in remote rural regions affects all During the 20th century, EDs developed time population is far greater than the branches of medicine, and emergency care in response to an increased need for rapid resident population) and in areas popular is no different. For this reason, building assessment and management of critical with holiday makers which may have a capacity in air ambulance services is a illnesses; they represent one of the most small resident population, but a very large priority in some countries (e.g. Ireland). important changes in the structure of number of seasonal visitors. hospitals and provision of health care in Triage Europe. 2 In all EU countries, EDs are now A review of information provided in the a legally required component of hospitals. 4 Triage ensures the efficient use of Health Systems and Policy Monitor 3 In the past, a patient arriving at an ED was available resources, e.g. personnel, found that as communications technology often seen by a physician specialised in supplies, equipment, means of has improved, greater centralisation and resuscitation or by an unsupervised trainee transportation and medical facilities; thus consolidation of ambulance services has doctor. Nowadays, a greater percentage it affects the extent and quality of care been made possible, and this has been a of patients is evaluated by more senior delivered by the EMS system. Almost all common aim in many reform strategies physicians. In most EU countries, trainee EU Member States use triage protocols (e.g. in Bulgaria, Croatia, Estonia, Ireland, doctors in many different specialties in their hospitals, while in 21 countries, Latvia, Lithuania, Norway and the UK). may rotate to the ED as part of their the ambulance service also uses triage. Consequently, it is quite rare for services postgraduate training, although their Detailed and specific guidelines and to still be organised at the municipal level supervision is primarily by non-emergency protocols can improve the quality of the

Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 Eurohealth OBSERVER 5

dispatch centre response. Potentially, the greater consolidation of both ambulance References use of different triage scales within the services and hospital care, including 1 Al-Shaqsi S. Models of International Emergency same EMS system may pose a patient emergency care. This has the benefit of Medical Service (EMS) Systems. Oman Medical safety risk. In only eleven EU Member increasing efficiency and reducing cost but Journal 2010;25(4):320–23.

States do triage guidelines for dispatch also increasing throughput of patients in 2 WHO. Emergency medical systems in the European 2 centres follow national standards. order to maintain the skills of emergency Union. Report of an assessment project co-ordinated In addition, it seems that most hospitals care staff. Strategies focused on diverting by the World Health Organization, 2008. Available at: or EDs use their own protocols, without patients to other parts of the health https://ec.europa.eu/digital-agenda/sites/digital- coordination or standardisation within the system are seen as a potential solution for agenda/files/WHO.pdf country and with other parts of the EMS reducing pressure on EMS as in a number 3 HSMP. Health Systems and Policy Monitor, 2015. (i.e. out-of-hospital EMS). of countries a significant proportion of Available at: http://www.hspm.org some ED admissions can be considered 4 Totten V, Bellou A. Development of Emergency Given the ever-increasing demands on inappropriate. 7 8 These strategies include Medicine in Europe. Academic Emergency Medicine the EMS system and referral of acute increasing the accessibility of primary 2013;20(5). Available at: http://onlinelibrary.wiley. care patients between different hospitals, care (especially OOHs), improving com/doi/10.1111/acem.12126/pdf triage guidelines and protocols that are patient pathways in the system, and 5 Wise J. More patients are surviving major trauma recognised and shared throughout the using financial incentives to reduce since reform of services. British Medical Journal EMS system, especially in the in-hospital demand for emergency care (See article 2014;349:g4369. doi: http://dx.doi.org/10.1136/bmj. g4369 environment, are seen as a way to on access to OOHs primary care in this improve the referral network and increase issue). While international comparative 6 Cooke MW, Jinks S. Does the Manchester triage efficiency in the whole system. New evidence in these areas remains scarce, system detect the critically ill? Journal of Accident & Emergency Medicine 1999;16(3):179 – 81. information and computer technology can there is potential for countries to learn help to better manage patient records at much from each other. In particular, 7 Berchet C. Emergency Care Services: Trends, all levels. Computerised versions of some there is a need for greater monitoring and Drivers and Interventions to Manage the Demand. OECD Health Working Papers No. 83. Paris: OECD of the most popular triage protocols may evaluation of innovations in order to build Publishing, 2015. modify health care provider behaviour a knowledge base. 8 positively and significantly improve the Siegel B, Wilson M J, Sickler D. Enhancing work flow to reduce crowding. Joint Commission evaluation and assignment of priority, The main indicators used to evaluate EMS Journal on Quality and Patient Safety although its clinical significance is still are process indicators: response times for 2007;33(11 Suppl.):57–67. under discussion. 2 Nurse-led triage is now ambulances and waiting times for patients 9 Madsen M, Kiurub S, Castrènd M, Kurland L. common in EDs in some countries, for in EDs. While timely access to emergency The level of evidence for emergency department example the UK, and has been shown to care is a frequently quoted concern, only performance indicators: systematic review. European be an accurate method of identifying high some countries have indicators around Journal of Emergency Medicine 2015;22(5):298 – 305. risk patients. 6 minimum travel times. It is also not clear to what extent process indicators Challenges and conclusions have an impact on care outcomes; there is currently no core group of evidence- Changing population health trends, based performance (outcome, process, particularly increasing multi-morbidity, satisfaction, equity and structural/ have been putting pressure on emergency organisational) indicators which can be care services, especially on hospital EDs recommended universally. 9 and ambulance services, which are often the most accessible points in the system. Many reform strategies have involved a

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Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 6 Eurohealth OBSERVER

OUT-OF-HOURS PRIMARY CARE AND DEMAND FOR EMERGENCY MEDICAL SERVICES

By: Anna Sagan and Erica Richardson

Summary: Major trauma and medical emergencies often constitute only a proportion of the workload of emergency medical services, as they also have to deal with many patients suffering from conditions better treated within primary care. This has renewed focus on urgent care as a means of reducing demand for emergency care services. While demand for emergency care is closely related to changes in population health trends and improvements in medical technologies, improving access to primary care through the provision of urgent care services has the potential to improve quality of care and financial efficiency.

Keywords: Emergency Medical Services, Primary Care, Access, Urgent Care

Introduction According to an OECD review, a lack of access to primary care and a shortage of Emergency departments (EDs) provide out-of-hours (OOHs) services are the main highly visible and critical services that supply-side factors influencing demand often form the frontline of health care for emergency care. 1 On the demand side, systems for patients facing difficult ED visits are influenced by individual circumstances. 1 The 2007 World Health preferences (EDs are convenient to Assembly Resolution 60.22 “Health access, especially OOHs), health needs Systems: Emergency Care Systems” (population ageing and increased highlighted the role that strengthened prevalence of chronic conditions) and emergency care systems can play in socio-economic factors (deprivation and reducing the burden of disease from lack of social support are associated with acute illness and injury. Further, it increased ED use). Bottlenecks in other called on governments and WHO to take parts of the health system can also affect specific and concrete actions. However, the demand for emergency care. Shortages in many OECD countries, the number of of specialist beds can contribute to Anna Sagan and Erica Richardson visits to EDs has increased since 2007 overcrowding in EDs as patients cannot be are Researchers at the European (see Figure 1), which poses questions Observatory on Health Systems and moved on from emergency care services about the efficient use of ED resources, Policies, London Hub, at the London to the appropriate department for further School of Economics & Political especially as a significant proportion specialist care (e.g. in France and the Science and the London School of patients attend EDs for non-urgent of Hygiene and Tropical Medicine, UK) and staff shortages in other parts conditions that could be managed in United Kingdom respectively. of the system can put greater pressure primary and community care settings. Email: [email protected] on emergency care services as they can reduce accessibility.

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Figure 1: Number of ED visits per 100 people in European OECD countries, It has been argued that gate-keeping may 2007 and 2012 lead to inappropriate use of EDs at acute hospitals with patients using emergency 80 35% care directly in order to bypass referrals 70 30% to specialists. 5 However, while increasing 60 25% numbers of non-emergency visits at EDs

50 20% have been observed in several gate- keeping countries, such as England, 40 15% Portugal and Spain, the same trend is also 30 10% evident in Germany and Switzerland, 6 20 5% where gate-keeping remains weak. Moreover, in Norway, where patients can 10 0 access EDs only with a referral from 0 -5% primary care or by ambulance,

Spain inappropriate use of EDs has not been Poland France Greece Ireland Estonia Belgium Germany Portugal Netherlands

Switzerland eliminated. According to one analysis of UK – England Czech Republic Czech emergency referrals from a single OOHs

2007 2012 Change 2007–2012 (%) primary care centre, around a fifth of all referrals could have been avoided. 7

Source: Based on data from Table A3 in Ref. 3 The Netherlands is one country where Notes: 2007 and/or 2012 data was not available for all countries included in the figure. Due to different definitions and gate-keeping by GPs plays a major role in identification of emergency care services, caution is needed when comparing countries. low ED attendances, but it is supported by a number of other measures. Many Blurred line between urgent care Primary care providers, such as General Dutch hospitals collaborate with GP posts within primary care and Practitioners (GPs)/family doctors, are (centrally located offices with a GP present emergency care generally required to have space in after hours) to provide emergency care their schedule to provide urgent care to in lieu of EDs, reducing the number of There is often not a strict delineation patients in normal working hours and unnecessary cases. Collaboration between between urgent care to be provided to make provisions for primary care these GP posts and EDs is encouraged and through primary care and emergency care. services to be available OOHs. The the majority of hospitals have a GP post. In many EDs, major trauma comprises most common models in OOHs care In addition, financial incentives are being only a part of the overall workload, with seem to be non-practice-based provision developed to keep patients out of EDs. For many patients suffering from minor (see Table 1). Where there are weaknesses example, as part of the health insurance ailments that could be better treated within in the provision of urgent and OOHs system, a compulsory annual deductible of primary care. 2 In many of those cases primary care, the patient traffic to €375 for accessing health services includes primary care provision is superior also emergency medical care will be greater – ED care but excludes GP services, thus in terms of lower costs, better continuity either because patients will access these incentivising the use of a GP. Moreover, and improved coordination. 3 However, services instead, or because they will a recent proposal has suggested that patients may not realise this and primary delay treatment and will need to access insurers do not need to cover patients care services may not be accessible when them as a medical emergency. The extent going to EDs without a referral from a they need them, for example at evenings to which EDs contribute to OOHs care GP, if it turned out that emergency care or weekends, and emergency services by varies across Europe, but it is notable was not required. In the Netherlands, their nature are often the most accessible that in countries such as Cyprus, Estonia, co-payments for patients using emergency points in the system. Latvia and Lithuania EDs have the sole services unnecessarily have been deemed responsibility for OOHs primary care unlawful but such co-payments already service delivery (see Table 1). A by-product exist in Belgium and Italy; however, there of overuse is overcrowding of EDs and is no conclusive evidence of any change long waiting times. This is a particular in inappropriate use of ED after their problem where EDs are part of the social introduction. 8 major trauma safety net 4 as these services are often free of charge, whereas patients have to pay The way forward? comprises out-of-pocket to access care elsewhere in the system (e.g. as in the USA, Canada, A 2009 survey among key informants only a part of Cyprus and Bulgaria). In some countries, from 25 countries found that most of the certain population groups, such as countries had plans to reform OOHs care, EDs' workload undocumented migrants, only have access mainly by centralising the provision of to emergency care and not to other forms OOHs care: moving toward larger scale of care. 5 organisations, integrating primary care ‘‘ Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 8 Eurohealth OBSERVER

Table 1: Ease of access to OOHs primary care in selected EU countries

Country Provision of OOHs primary care Ease of access : low Belgium Practice-based services (mainly) and hospital EDs. There are also primary care cooperatives providing OOHs care and rather fewer OOHs primary care centres Bulgaria Urban areas: GPs working in single practices or organised in a group of practices or outsourcing. Rural areas and small towns: hospital EDs Cyprus Telephone consultation with private GPs and private and public hospital emergency rooms France Voluntary GPs in practice-based services, primary care cooperatives known as SOS médecins and hospital emergency units Greece GPs and nurses in their centres Ireland GP cooperatives/OOHs services Latvia Hospital EDs, OOHs primary care centres (occasionally) Luxembourg Hospital EDs and (since December 2008) GP walk-in centres Malta Public primary health care centres Ease of access: medium Austria Urban areas: primary care cooperatives (sponsored by City Councils) and/or hospital departments. Rural areas: GPs within one practice or organised in a group of practices on OOH schedules Estonia Medical emergency service or ambulance service Finland Increasingly organised in conjunction with hospitals; often, a health centre GP provides services from 4 p.m. to 10 p.m. in their own health centre. Some of these services are also outsourced (and provided by specially trained staff) Germany Outpatient emergency services, hospital ED Italy OOHs physicians (special type of physician) usually working in different premises (such as independent ambulatories of local health authorities) Romania Family physicians have to provide medical assistance, including in emergency situations, for all insured persons on their own list Slovakia Walk-in centres and (limited) special deputising services*or hospital EDs Sweden Hospital based acute wards; a few primary health providers have organised OOHs care Ease of access: high Czech Republic OOHs services are organised by local authorities and GPs are obliged to provide these services (it may be on a rotation basis or by finding substitute GPs) Denmark Primary care cooperatives (includes telephone triage and advice, an office for face-to-face contact and house calls) Hungary Usually outsourced to deputising services* Lithuania Hospital EDs Netherlands General practice (usually within large-scale primary care cooperatives) Poland Can be contracted (by the National Health Fund) directly with specialised services or with primary care physicians (the latter can use a rota with the neighbouring practices or subcontract with the deputising service*) Portugal Practice based GPs within one practice or organised in a group of practices available all night when there is no hospital nearby or only in the evening if there is a hospital nearby Spain Primary health centres (open 24 hours a day, 365 days a year in rural areas. In urban areas there is always a primary health care centre on duty within a 30-minute radius; also call-centre triage units, which coordinate and activate the most appropriate health care service for each consultation United Kingdom GPs, walk-in centres, minor injuries units, urgent care centres, NHS 111 or equivalent, local pharmacists, local mental health teams, Accident and Emergency (A&E) departments at general hospitals, and ambulance services

Source: Based on References 9 , 3 and 1 . Notes: Hospital-based provision of OOHs primary care is marked in bold. * This is a form of outsourcing whereby centres/companies employ doctors to take over provision of after-hours care.

with EDs and introducing one national motivated family doctors to provide OOHs Primary care telephone services have telephone number for OOHs calls and care. Other reasons were the overcrowding been developed in some countries in order triage for emergency calls. The major of EDs by primary care patients (self- to reduce the burden on emergency care reasons given for these changes were work referrals), reducing costs and improving and to improve the accessibility of timely dissatisfaction among family doctors, a safety, quality and continuity of care. 10 primary care services (e.g. France, the shortage of family doctors and lack of UK, and Hungary). In Spain, Hungary and

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France such advice lines are essentially has been heavily debated and has raised 3 Kringos DS, Boerma WGW, Hutchinson A, integrated with dispatcher services, as substantial criticism from GPs and the Saltman RB (eds). Building primary care in a changing clinical teams are on hand to advise Danish Medical Association, prompting an Europe. Copenhagen: World Health Organization, 2015 (acting as the host organization for, and patients and make triage decisions to evaluation in August 2014 that has yet to secretariat of, the European Observatory on Health 12 direct them to OOHs care, emergency care be concluded. Systems and Policies). or dispatch an ambulance. In England, 4 WHO. Emergency medical systems in the European NHS Direct (with calls answered by a There is also some evidence that closer Union. Report of an assessment project co-ordinated non-clinical call handler and assessed cooperation of GPs with local nursing by the World Health Organization, 2008. by a nurse either immediately or with a homes in Norway (and the proximity of 5 Paris V, Devaux M and Wei L. Health Systems later call back), established in 2000 was nursing homes to the GP practice) may Institutional Characteristics: A Survey of 29 OECD 13 not found to reduce demand for either contribute to reduced referrals to EDs. Countries. OECD Health Working Papers, No. 50. hospital or primary care; it did, however, A good example of successful cooperation Paris: OECD Publishing, 2010. 2 improve patient satisfaction. NHS Direct with other health care providers is 6 van Ginneken E, Blümel M, Cylus J, et al. Trends was fully replaced in 2014 by NHS 111, a the Capio St Göran (CSt) hospital in and patterns in EU28 health systems and Iceland, more easily recognisable phone number, Stockholm. CSt has developed a good Norway and Switzerland. Copenhagen: European where calls are answered and assessed dialogue and cooperative relationship Observatory on Health Systems and Policies, immediately by a trained non-clinical with several geriatric hospitals, whereby 2016 forthcoming. call handler (preventing waiting or call patients requiring direct admission from 7 Lillebo B, Dyrstad B, Grimsmo A. Avoidable backs) and some calls are then assessed EDs are clearly defined and more elderly emergency admissions? Emergency Medicine Journal by a nurse. In addition, the assessment patients are sent directly to external 2012; doi:10.1136/emermed-2012-201630 system is integrated with some services, geriatric care providers. There is also an 8 KCE. Evaluatie van forfaitaire persoonlijk enabling direct referral and appointments. active dialogue about the opposite flow, bijdrage op het gebruik van spoedgevallendienst. Despite these improvements, NHS 111 did where geriatric hospitals can send patients [Evaluation of the effect of the fixed personal contribution on the use of emergency service]. not deliver the expected system benefits with greater care needs directly to the KCE reports vol.19A, 2005. Federaal Kenniscentrum of reducing calls to the 999 ambulance relevant department at CSt. CSt now has voor de Gezondheidszorg [Belgian Health Care service or shifting patients to urgent rather the largest share of direct admissions to Knowledge Centre]. than emergency care. Studies also found geriatric hospitals of all acute hospitals 9 Kringos DS, Boerma WGW, Hutchinson A, 14 that this type of service had the potential in Stockholm. Saltman RB (eds). Building primary care in a changing to increase overall demand for urgent Europe. Case studies. Copenhagen: World Health Organization, 2015 (acting as the host organization care without reducing the demand for Conclusions emergency care (See the article by Turner for, and secretariat of, the European Observatory on Health Systems and Policies). et al, in this issue). A shift towards developing urgent care and reorganising OOHs primary care 10 Huibers L, Giesen P, Wensing P, Grol R. Out- Coordination of care, in particular for has been taking place in many European of-hours care in western countries: assessment of different organizational models. BMC Health Services chronic conditions and emergency care, countries in order to relieve pressure on Research 2009;9:105. Available at: http://www. remains problematic in most countries. high cost emergency care services. While biomedcentral.com/1472-6963/9/10 Particularly in northern Europe, there is a this shift cannot address the demand- 11 Magnussen J, Vrangbaek K, Saltman RB. trend to reorganise the OOHs primary care side factors which are so closely related Nordic health care systems. Recent reforms and system to better support and cooperate to changes in population health trends, current policy challenges. Maidenhead, England: with EDs (i.e. Denmark, the Netherlands, such as population ageing and increased Open University Press, 2009. Available at: the UK, and Germany). In Denmark, prevalence of chronic conditions and http://www.euro.who.int/__data/assets/pdf_ some past attempts at strengthening improvements in medical technologies, file/0011/98417/E93429.pdf?ua=1 collaboration between primary health it does have the potential to improve 12 Nielsen AJ. New organization of the emergency care and hospitals have not always been efficiency and quality of care. medical services in the Capital Region. Health easy to achieve in practice. 11 The most Systems and Policy Monitor. Published on 17 December 2013. Available at: http://www.hspm. recent solution being implemented in the References org/countries/denmark Capital Region (Hovestsaden) involves 13 the co-location of urgent and emergency 1 Berchet C. Emergency Care Services: Trends, Lappegard Ø, Hjortdahl P. The choice of alternatives to acute hospitalization: a descriptive care services, as well as the integration Drivers and Interventions to Manage the Demand. OECD Health Working Papers, No. 83. Paris: study from Hallingdal, Norway. BMC Family Practice of OOHs primary care with EDs into a OECD Publishing, 2015. 2013;14:87. single entry point, reachable by dialling 2 14 UK Government. International comparisons of a designated telephone number, co- McKee M, Healy J (eds). Hospitals in a changing Europe. European Observatory on Health Systems selected service lines in seven health systems. ANNEX ordination and delivery of urgent and and Policies. Buckingham and Philadelphia: Open 16 – Case studies: Emergency pathway at Capio emergency care, and nurses (rather than University Press, 2002. Available at: http://www. St Goran Hospital. Evidence Report October 27th, doctors) becoming the first point of euro.who.int/__data/assets/pdf_file/0004/98401/ 2014. Available at: https://www.gov.uk/government/ contact for patients; they decide whether E74486.pdf?ua=1 uploads/system/uploads/attachment_data/ file/382842/Annex_16_Capio_St_Goran_ the patient will be re-directed to a doctor Emergency_pathway.pdf on the phone, be attended by a doctor, go to an ED or stay at home. The new scheme

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MANAGING DEMAND FOR URGENT CARE – THE ENGLISH NHS 111 EXPERIENCE

By: Janette Turner, Alicia O’Cathain, Emma Knowles and Jon Nicholl

Summary: NHS 111 is a telephone-based service in England designed to improve access to appropriate care for urgent health problems. Evaluation of four pilot sites revealed that the service was well liked by users but did not change the way people accessed care or produce expected system efficiencies; it also increased emergency ambulance activity. National roll out without results of the evaluation led to significant challenges when the service was introduced. NHS 111 is now firmly embedded in the NHS in England but it is recognised that there is scope for further improvement and a programme of work is in place to enhance the service.

Keywords: NHS 111, Emergency Medical Care, Urgent Care Services, Pilot Evaluation, NHS England

Introduction Over the last twenty years there have been a number of reviews of urgent care, policy Internationally, demand for emergency and recommendations for service changes and urgent care grows every year. In England, service-level innovations, all of which demand for emergency department care were aimed at improving access to and has been reflected in growth in emergency delivery of urgent care. As the range of department attendances, calls to the 999 additional services available to address ambulance service and contacts with other urgent care needs has grown (for example, urgent care services, including primary primary care out-of-hours services, minor care and telephone-based services. injury units, walk-in centres, urgent care Since the 1960s, demand for emergency centres) a central theme has been the department services has doubled, with uncertainty and complexity this presents population utilisation increasing from 138 for the public in making decisions about per 1000 people per year to 267 per 1000 how to access urgent care. Telephone- in 2012/13. Similarly, calls to the 999 Janette Turner is the Director, based services were introduced to try and ambulance service increased by 160% Alicia O’Cathain is a Professor simplify this process, with NHS Direct, between 1994 and 2014. 1 The reasons for of Health Service Research and a nurse-led telephone assessment and Emma Knowles is a Research this relentless rise in demand are only advice service, implemented from 2000 Fellow at the Medical Care Research partly understood but comprise a complex Unit, School of Health and Related in England and followed by similar mix of changing demographic, health and Research (ScHARR), University services in Wales and Scotland. However, of Sheffield, United Kingdom. social factors. 2 Jon Nicholl is the Dean of ScHARR. subsequent consultations with the public Email: [email protected] revealed that confusion about accessing

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services remained a problem and in During the first year of operation, the four response to this a new telephone-based pilot services managed just over 350,000 Box 1: Key features of the service, NHS 111, was developed. calls. All of the services met national NHS 111 service quality standards of less than 5% of calls abandoned and at least 95% of calls The NHS 111 service • Calls to NHS 111 are assessed answered within 60 seconds. On average, by a trained, non-clinical call adviser The objectives of the NHS 111 service across all sites, 11% of calls were sent using the NHS Pathways clinical is to simplify access to non-emergency for an emergency ambulance response, assessment system to determine health care by providing a memorable 6% were advised to go to an emergency both the type of service needed number – 111 – that is free to the caller, department, 56% were directed to primary and the timescale within which help provides consistent clinical assessment at care, 5% to other services and 22% were is required. the first point of contact, and routes callers provided with advice and did not need and patients to the right NHS service, first a service. • The call handling system is time. The service is available 24 hours a electronically linked to a skills-based day, 365 days a year to respond to requests Impact on the emergency and urgent directory of local services so that for health care where the situation is not care system was assessed by measuring callers can be advised about the life-threatening and callers are unsure monthly activity for five key services: appropriate services available at the about what service they need, or if they emergency department attendances; time of their call. need to access care out-of-hours. The urgent care services attendances/ • Where possible, appointments expected benefits of this service are that contacts (e.g. general practice out-of- can be made with the correct service it should improve the user experience by hours, walk-in centres); calls to the at the time of the call. providing a modern entry point to the NHS Direct telephone service; calls to NHS and easy access to more integrated the emergency ambulance service and • Calls that require further clinical services, and improve efficiency in the ambulance service incidents where a assessment can be transferred to emergency and urgent care system by response was needed for two years before a clinician within the same call with matching patient needs to the right service. and one year after implementation of minimal need for a call-back. The key features of the service are given NHS 111 in each pilot site; and a matched • If a call requires an emergency in Box 1. control site. For all sites combined, ambulance response, a vehicle can there was no statistically significant be dispatched without the need for As a first step, the Department of Health change in emergency ambulance calls, further triage. in England identified four pilot sites in emergency department attendances or Durham & Darlington, Nottingham, Luton urgent care contacts/attendances. There Source: Authors. and Lincolnshire to implement NHS 111 was a statistically significant reduction and at the same time commissioned an in calls to NHS Direct of 193 calls independent service evaluation to assess per 1000 NHS 111 triaged calls per month. the impact of the service and provide There was also a statistically significant with 86% indicating they had complied robust evidence on effectiveness to increase in emergency ambulance service with all of the advice given, and 65% inform decisions about any subsequent incidents of 29 additional incidents reporting the advice given had been very national roll-out. These four pilot sites per 1000 NHS 111 triaged calls per helpful. Respondents were also largely became operational between August and month. 4 This equates to a 3% increase clear about when to use NHS 111. 5 December 2010. in ambulance activity or, for a service responding to 500,000 calls per year, an In addition, a population telephone survey Pilot site evaluation additional 15,000 responses. was conducted before and after the introduction of NHS 111 in both the pilot A mixed methods study was designed to A postal survey of users of the new service and control sites to assess use of urgent assess processes, outcomes and costs for in each pilot site found that satisfaction care services. The surveys did not identify the new service. This included a controlled with NHS 111 was very good, with 73% any change in perceptions of urgent care before and after design to measure the of respondents reporting that they were for recent users of emergency and urgent impact of NHS 111 on system activity ‘very satisfied’ and 19% that they were care services or any change in satisfaction and population use of services in the four ‘quite satisfied’ with the new service. with urgent care or the NHS following the pilot and three control sites; qualitative Satisfaction levels were lower for some introduction of NHS 111. The population studies to assess patient experience and aspects of the service than others, in surveys did reveal a high level of satisfaction and to identify the challenges, particular relevance of questions asked awareness about the new service in two barriers and facilitators associated with and advice given. 85% of respondents pilot sites ( > 70% of the population had introducing the service experienced by the indicated that NHS 111 had enabled heard of NHS 111) but lower awareness in pilot sites; and an economic evaluation. 3 them to contact the right place first time the other two sites (< 50%). 6 although this may not have occurred for at least 2% of users. Compliance was high

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a large number of services went live in April 2013 when coverage increased Box 2: Activities associated with successful implementation of NHS 111 sharply to 70% of the population. At the same time, the NHS Direct service began • The strategic, management and operational processes involved in delivering to be discontinued although the impact of the service are complex, difficult and time consuming transferring all calls for urgent care to the • A clear and explicit service specification is needed to support planning NHS 111 service had not been established. and development Introducing a large number of services that • Success is dependent on the committed engagement of relevant agencies and had been rapidly established without the a dedicated project team to manage the process from start to implementation benefit of evaluation information resulted and maintenance in a difficult period for the NHS. Some • There are significant technical issues around licensing, adaptation and services were unable to cope initially in integration of different telephone and IT systems that need to be linked to deliver terms of answering and assessing calls seamless call handling in a timely manner and a substantial amount of negative publicity about the • A robust period of testing to ensure consistency of assessment, alignment of service in the UK media was generated. dispositions to services and system resilience is critical before a service goes live However, as services became established • The Directory of Services linked to dispositions and appropriate referral these problems were resolved and by the is crucial end of 2013 there was almost universal coverage across England. • There needs to be sufficient capacity to support technical implementation and training for the call assessment system used

• 111 is just a telephone number – it is what is behind it that is important and how it operates as part of an integrated 24/7 urgent care system. there

Source: Authors. was a 3% increase in Developing and implementing the new call activity to the new service could not service posed significant challenges be measured and the effects could not emergency within the pilot sites. The key issues be predicted. identified that contribute to successful ambulance implementation are described in National roll-out Box 2. Despite some positive findings, service incidents particularly patient experience and The initial four pilot sites were identified satisfaction, NHS 111 did not have a in 2009, with implementation during 2010 Since the inception of the first pilot significant impact on system efficiency and at the same time the evaluation of sites in ‘‘2010 NHS 111 has, to date, during the first year of operation. This those sites was commissioned with a answered 27.9 million calls and might be explained by the small ‘dose’ publication date of 2012, after a full year triaged 23.6 million. In the year 2014 – 15 of NHS 111 within the wider emergency of operation, followed by decisions about the service dealt with 12.1 million calls and urgent care system or the early stage providing a national service. However, and of the 10.3 million triaged calls, the of development at which it was evaluated during 2010 there was a general election, distribution of dispositions has remained (one year). It takes time for early problems a change of government and an early largely unchanged from that found in to be identified and resolved, for a new decision made in Summer 2010 that the original pilot sites: See https://www. service to become established with users, NHS 111 would be rolled out as a national england.nhs.uk/statistics/statistical- and for reflection on how the service can service by 2013. This meant that across work-areas/nhs-111-minimum-data-set/ be improved. The evaluation highlighted the NHS plans had to be made and (and Figure 1). some issues that needed further services procured and developed without exploration, the most important of which reference to any findings from the pilot Nevertheless, the pressure on emergency were further scrutiny of the relevance of sites evaluation. The final evaluation and urgent care services and managing some questions during the assessment report was published in Autumn 2012 this demand has continued to present a process and the reasons for the increase in but by this time there was little scope for serious problem to the NHS. In 2013, ambulance utilisation. Also importantly, services in development to benefit from NHS England began a wholesale review during the pilot site testing the NHS the findings. By the end of 2012 there of emergency and urgent care provision Direct service was still operating. This were fourteen operational NHS 111 sites and in November 2013 published a meant that the impact of “turning off” this covering just over 20% of the population. strategy for reforming services. 7 NHS 111 service and transferring all of the existing In order to meet the original 2013 deadline remained a cornerstone of the vision for

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Figure 1: Disposition of triaged NHS 111 calls 4 Turner J, O’Cathain A, Knowles E, Nicholl J. Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study. BMJ Open 11% Ambulance dispatches 2013; 3:e003451.doi:10.1136/bmjopen-2013-003451. Available at: http://bmjopen.bmj.com/content/3/11/ 8% Recommended to attend A&E e003451.full.pdf+html?sid=7be850c7-378b-4a24- 62% Recommended to attend primary b915-3a6845fcb976 and community care 5 O’Cathain A, Knowles E, Turner J, Nicholl J. 4% Recommended to attend other service Acceptability of NHS 111, the telephone service for urgent health care: cross sectional postal 15% Not recommended to attend other service survey of users’ views. Family Practice 2013; doi: 10.1093/fampra/cmt078. Available at: http:// fampra.oxfordjournals.org/content/31/2/193. full.pdf+html?sid=f28df9d9-21b1-4096-b2ee- a74e4fefa6b9

6 Knowles E, O’Cathain A, Turner J, Nicholl J. Awareness and use of a new urgent care telephone service, NHS 111: cross-sectional population survey. Journal of Health Services Research Policy 2014; DOI: 10.1177/1355819614535571. Available at: http://hsr. sagepub.com/content/19/4/224.full.pdf+html Source: 3 7 NHS England. High quality care for all, now and for future generations: Transforming urgent and managing emergency care with its central solutions that might resolve it. More emergency care services in England – Urgent and Emergency Care Review End of Phase 1 Report. role in assessing and signposting requests broadly, the limitations of the service Leeds: NHS England, 2013. Available at: http://www. for urgent care to appropriate services. are realised and there is an ongoing nhs.uk/NHSEngland/keogh-review/Documents/ However, the review also recognised programme of work to further develop UECR.Ph1Report.FV.pdf that there was scope to further enhance and enhance NHS 111 so that it might 8 NHS England. Transforming urgent and emergency this service and reduce the burden better assess and direct users through care services in England. Safer, faster, better: good on ambulance services and possibly the complex system of services and practice in delivering urgent and emergency care. emergency departments and provide pathways present in a modern emergency A guide for local health and social care communities, better integration with community-based and urgent care system. Ongoing efforts 2015. Available at: http://www.nhs.uk/NHSEngland/ keogh-review/Documents/safer-faster-better-v28.pdf services by, for example, introducing to evaluate the effects of changes will additional senior clinician assessment in to be needed to assess whether they deliver the triage process. As a result, there is an the intended benefits. The successes, ongoing programme of work with the aim challenges and failures associated with of refining, improving and redesigning introducing NHS 111 highlight the dangers the service specification for the NHS 111 of implementing policy without allowing service so it provides a better fit with sufficient time for evaluation and evidence the aspirations of the broader vision for gathering to inform important decisions emergency and urgent care delivery. 8 about significant change in health care provision. Conclusions References NHS 111 was conceived as a telephone- based service that could both improve 1 NHS Confederation, Emergency Care Forum. patient experience and emergency and Ripping off the sticking plaster: whole system solutions for urgent and emergency care. London: urgent care system efficiency by assessing NHS Confederation, 2014. Available at: and signposting to the right service, http://nhsconfed.org/resources/2014/03/ripping- requests for urgent (not life-threatening) off-the-sticking-plaster-whole-system-solutions-for- health care. Evaluation of pilot sites urgent-and-emergency-care showed there were some benefits for 2 Turner J, Coster J, Chambers D, et al. What the service but not all of those expected evidence is there on the effectiveness of different were realised. In particular, one service models of delivering urgent care. Health Services NHS 111 was expected to decrease Delivery Research 2015 (in press). pressure on, the emergency ambulance 3 Turner J, O’Cathain A, Knowles E, et al. Evaluation service, actually saw additional activity. of NHS 111 Pilot sites. Final Report to the Department This continues to be a substantial problem of Health. Medical Care Research Unit, University of Sheffield, 2012. Available at: https://www.shef.ac.uk/ requiring further research to understand polopoly_fs/1.227404!/file/NHS_111_final_report_ why this happens and to identify potential August_2012.pdf

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WHAT WORKS? WAITING TIME POLICIES IN THE HEALTH SECTOR

By: Luigi Siciliani, Valerie Moran and Michael Borowitz

Summary: Various policy tools have been used across OECD countries to reduce excessive waiting times in the last decade. The most common policy is some form of maximum waiting-time guarantee. Increasingly, such guarantees are backed with targets for providers and sanctions for non-compliance. The guarantees often go hand-in-hand with choice, competition and an increase in supply. These policies have been successful in reducing waiting times. Demand-side policies attempt to define more rigorous clinical thresholds. However, they have proved difficult to implement. A promising policy is to link waiting-time guarantees to different categories of clinical need, a form of prioritisation.

Keywords: Waiting times; Guarantees; Targets; Patients’ choice; OECD countries

Introduction simultaneous reductions in waiting times (to limit subsequent increases in demand). We review various policy tools that Demand-side policies attempt to define OECD countries have used to reduce more rigorous clinical thresholds for excessive waiting times in the last decade. treatment. However, they have proved Compared with an earlier OECD study 1 difficult to implement. A promising policy where supply-side policies predominated, is to link waiting-time guarantees to the most common policy identified in the different categories of clinical need, a form second OECD waiting time project, 2 3 of waiting time prioritisation. This article is some form of maximum waiting-time outlines some of the key country evidence guarantee, which often combines supply- from our OECD study. 2 * side and demand-side measures. Increasingly, such guarantees are backed with targets for providers and sanctions Maximum waiting-time guarantees, for non-compliance. The guarantees targets and sanctions: England and often go hand-in-hand with choice, Finland Luigi Siciliani is Professor of competition and an increase in supply. England and Finland have combined Economics at the Department of These policies have been successful in Economics and Related Studies, waiting-time guarantees with sanctions for reducing waiting times. In contrast, most and Valerie Moran is PhD student failure to fulfil the guarantee. In England, at the Centre for Health Economics, attempts to increase supply temporarily maximum waiting-time guarantees University of York, United Kingdom. in order to decrease waiting times have Michael Borowitz is Chief were set at twelve months in 2002 – 03, met limited success. This suggests the Economist at The Global Fund, and progressively ratcheted down to Geneva, Switzerland. need to work simultaneously on supply Email: [email protected] and demand-side policies; for example, by conditioning increases in supply on * The content of this article draws heavily from Chapter 3 of the report.

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eighteen weeks by 2006, where they targets, but Valvira had to issue 30 orders For the past two decades, Portugal has remained. In 2010, patient entitlements for improvement, including eight threats tried to solve its waiting time problem for waiting times were codified into of fines. 2 with bursts of additional funding under the NHS Constitution, a quasi-legal four initiatives during 1995 – 2009. In all instrument, establishing a maximum The use of waiting-time guarantees raises four cases, waiting times declined initially wait from General Practitioner (GP) concerns over incorrect prioritisation, but subsequently increased. Portugal has referral to treatment of eighteen weeks. gaming or changes in referrals. For found an innovative solution through The Department of Health monitors England, Propper et al. 5 did not find a combination of guarantees coupled the eighteen-week target monthly and evidence for such behavioural changes. with a new integrated system to collect expects 90% of patients to be treated However, Dimakou et al. 6 found that wait information from all public and within target; a breach results in the probability of patients being treated private hospitals, known as Integrated reductions of up to 5% of revenues for increases when the wait approaches the Management System of the Waiting List the relevant specialty in the month of target, and falls when the wait is above for Surgery (SIGIC). One key feature the breach. the target, which may be consistent with of the SIGIC is the use of a treatment incorrect prioritisation: giving priority voucher to operationalise the guarantee. Evidence from England indicates that to lower severity patients approaching When patients on the list reach 75% of the guarantees with sanctions reduce waiting the target and increasing waits for higher maximum guaranteed time, a voucher is times. Waits of over six months have severity patients below the target. issued that allows them to seek treatment virtually disappeared. Targets with at any public or private provider. This penalties were introduced during 2000 – 05, Maximum waiting times linked to creates incentives for public hospitals to with strong political oversight from the choice: Denmark and Portugal treat within the guarantee. The national Prime Ministerial Delivery Unit and waiting list for surgery declined by 39% the Health Care Commission. 4 Senior In some countries, patients can be from 2005 to 2010, even though demand health administrators risked losing their treated by another provider if the waiting increased. The improvement is partly due jobs if targets were not met. Compared time guarantee is not fulfilled or when to better management, the shift from a to Scotland (where no penalties were the patient reaches a threshold level. decentralised to centralised information introduced), Propper et al. 5 found In Denmark, free hospital choice was technology (IT) system, and the use of the that in England the proportion of introduced in 1993 within or outside the IT system to implement the guarantee, patients waiting over six months fell patient’s region. Patients were given an allowing patients to find other providers, by 6 – 9 percentage points. intended maximum wait of three months thus introducing choice and competition. 2 from GP or specialist referral to treatment. Finland also introduced a strong waiting In 2002, this was formulated explicitly Activity-based funding and socially time guarantee combined with targets as as a maximum waiting time guarantee acceptable waiting times: the part of the Health Care Guarantee 2005, (extended free choice) and reduced to two Netherlands subsequently incorporated into the months, and in 2007 to four weeks. If the Finnish Health Care Act of 2010: primary hospital can foresee that the guarantee A common policy to encourage providers care services are provided within three cannot be fulfilled, the patient can to increase the volume of patients treated days; and patients are referred from choose another public or private hospital. is to use activity-based funding (ABF) that primary care to an out-patient specialist If treatment is outside of the region’s pays a price for each additional patient within three weeks. For elective surgery, own hospitals, treatment expenses are treated. The change of hospital payment any evaluation should occur within covered by the originating region. On methods towards ABF and the removal three weeks; diagnostics within three average, the proportion of patients using of a hospital spending cap was the key months; and surgery within six months a private hospital increased from 2% policy that resolved long waits in the of assessment. The introduction of the to 4.2% between 2006 and 2008 and Netherlands. In 2000, the government legal guarantee resulted in the number to 4.8% in 2010 (up to 10% for orthopaedic considered introducing a maximum of patients waiting over six months to surgery). The expected maximum waiting waiting time guarantee for hospital decrease from 126 per 10 000 population time declined significantly after 2002, care, which was motivated by a court in 2002 to 66 per 10 000 in 2005. The and free choice likely played an important decision in 1999 that patients have an National Supervisory Agency (Valvira) role. With free choice, reimbursement enforceable right to timely care. A formal supervised the implementation of the policies also changed. Until 1999, each guarantee was ultimately not introduced guarantee and penalised municipalities county received a low per-diem from other because of concerns about the cost of failing to comply. Valvira provided targets counties. From 2000, counties instead operationalising the policy. However, to municipalities for the number of patients paid the diagnosis-related group (DRG) the national associations of hospitals and waiting over six months, progressively tariff, reflecting average costs, making insurers agreed on a socially acceptable lowered from 15 per 10 000 population it profitable to keep patients within waiting time (known as ‘Treek norms’) of in 2007 to 7.5 in 2009 and 5 in 2010. the county. 2 six weeks for day treatment (80% within Almost all hospital districts met the four weeks), seven weeks for in-patient treatment (80% within five weeks), and

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four weeks for hospital specialist diagnosis where clinicians first ranked conditions it is not only funding, but the wider and medical assessment (80% within three against each other, with each condition institutional setting that determines weeks). In 2001, the fixed budget scheme being allocated a score from 1 to 100. At incentives to increase production. In was replaced by ABF. The government one point, CPAC tools for 29 specialities general, short-term funding targeted at also abolished restrictions on medical were listed on the Ministry of Health waiting lists and waiting times has proved specialist positions in hospitals. Hospital website. One critical implementation issue unsuccessful. This may be because it and specialist incentives were aligned, and was whether to use national or locally fails to address the structural issues production rapidly increased and waiting developed tools. Even when national tools that determine waiting times, leads to times decreased substantially. The Dutch were used, there were still variations in a subsequent increase in demand, or combined a relatively soft guarantee linked scoring and clinical thresholds. There is targeted at a specific waiting list. to choice with competition linked to ABF. were also issues with developing valid and Although it should be possible to spend In 2011, mean waiting times for almost all reliable tools for measuring patient need/ sufficiently to reduce and even eliminate surgical procedures were four weeks or severity and the benefit from surgery. waiting times, this would require massive less. There is an on-going discussion about investment, which is unlikely to be re-introducing hospital budget caps as part With these caveats, the focus on clinical available in a time of fiscal constraint. of a policy to curb spending. 2 prioritisation has resulted in the number of One possible way forward is to fund patients with a commitment to treatment higher supply conditional on reductions in Prioritisation of patients on the (booked or given certainty) waiting waiting times (i.e. funding is not provided waiting list: New Zealand more than six months to decline from if the higher supply does not translate into around 7000 patients in 2002 – 06 to lower waiting times) in order to control A demand-side policy to reduce waiting around 3000 patients in 2007 – 10. 2 potential demand inflows. times involves introducing clinical thresholds below which patients are not Individualised maximum waiting time Conclusions entitled to publicly-funded surgery, thus guarantee: Norway decreasing the “inflow” to the list. New Over the past decade, waiting-time Zealand has been at the forefront of using Given the concern with incorrect guarantees have become the most demand-side policies, where a patient is prioritisation caused by maximum common policy tool to tackle long entitled to elective surgery conditional waiting-time guarantees, Norway has tried waiting times, but are effective only if on need and ability to benefit as assessed to condition the guarantees on the basis enforced. There are two approaches to by the specialist. Patients are referred by of need using criteria such as severity enforcement. The first entails setting their GP, and the specialist assessment and effectiveness of treatment. This is targets and holding providers to account determines whether the patient goes on the essentially an “individualised” guarantee, for achieving them. The second allows list. Patients are classified into: booked; where a maximum wait is determined by patients to choose alternate providers, certainty of treatment; and active care and the patient’s condition, need and severity. including in the private sector, if the wait review. Patients in the first and second It was introduced in 2002, with patients exceeds a maximum time. In England groups are treated within six months. classified into three groups: emergency and Finland, hospitals were penalised for Patients in the third group have the least patients who should receive treatment exceeding targets. As a result, waiting severity and do not enter the waiting list. with no further delay; elective patients times decreased. This method is, however, They are referred back to their GP, who entitled to an individual maximum waiting unpopular with health professionals and treats them and monitors their health time; and less severe elective patients difficult to sustain long-term. Portugal, status. If the condition deteriorates, these not entitled to a maximum wait. If the the Netherlands and Denmark successfully patients can change group. individual guarantee is not fulfilled, introduced choice and competition, and patients can be treated in another hospital this is the direction recently taken by This innovative scheme of demand or abroad. 2 Unfortunately, evidence England. The Portuguese model has been management dates back to the 1990s, suggests that increased prioritisation did effective in decreasing waiting times. The when the country developed clinical not take place. 7 model entails a unified information system prioritisation assessment criteria (CPAC) containing data on waiting times for tools to manage waiting lists. A distinction Dedicated/additional funding has not public and private providers, and vouchers was made between the clinical threshold proved successful that allow free choice issued to patients where patients benefitted from treatment when 75% of the waiting time guarantee and a higher “financial threshold” which One policy commonly used by countries is is reached. The Netherlands successfully the health system could afford. Many some type of targeted-funded programme eliminated waiting times by a combination CPAC tools were multi-dimensional, to reduce waiting times. Despite being of ABF, lifting a cap on hospital spending, integrating objective and subjective the most common approach across OECD allowing choice and competition, and clinical criteria combined into a composite countries, it has invariably failed. These introducing waiting time norms. However, score. Integrated tools were also developed programmes are short-term bursts of these policies tend to be expensive and, in some specialty areas (orthopaedics, funding that are insufficient to raise given the current economic environment, ophthalmology and plastic surgery), capacity significantly. Furthermore, may not be feasible in all countries.

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A complementary approach to reducing HEALTH OWNERSHIP waiting times is to implement demand-side policies by introducing tools to improve clinical prioritisation. They have been OF HEALTH POLICY? used in New Zealand, with some success. Implementation can be difficult, as it is necessary to set a clinical threshold in CHALLENGES AND a valid and reliable manner. In Norway, clinical prioritisation is linked to waiting- time guarantees, with guarantees varying CONCERNS IN THE NEW according to need. This appears to be a promising approach, but requires better tools for clinical prioritisation that reliably ERA OF EU HEALTH measure clinical need and the benefit of the elective procedures. POLICY References

1 Siciliani L, Hurst J. Tackling excessive waiting times for elective surgery: a comparison of policies in 12 OECD countries. Health Policy 2005;72(2):201 – 15. By: Ellie Brooks 2 Siciliani L, Borowitz M, Moran V. (Eds) Waiting Time Policies in the Health Sector. What works? Paris: OECD, 2013.

3 Siciliani L, Moran V, Borowitz M, Measuring and comparing health care waiting times in OECD Summary: In the post-crisis era, EU health policy increasingly risks countries. Health Policy 2014;118:292 – 303.

4 to be overshadowed by a patchwork of competing processes and Bevan G, Hood C. Have targets improved performance in the English NHS? British Medical policies, such as the European Semester and Health System Journal 2006;332:419 – 22.

5 Performance Assessment. This re-focusing poses challenges for the Propper C, Sutton M, Whitnall C, Windmeijer F. Incentives and targets in hospital Care: evidence from collection of necessary health system data and could threaten the a natural experiment. Journal of Public Economics 2010;94:318 35. ownership of health issues by health actors. In the current climate 6 Dimakou S, Parkin D, Devlin N, Appleby J. of fiscal and economic coordination the public health community Identifying the impact of government targets on waiting times in the NHS. Health Care Management must be vigilant in safeguarding EU health policy and protect the Science 2009;12:1 – 10. achievements made in recent decades. 7 Askildsen JE, Holmås TH, Kaarbøe OM. Monitoring prioritization in the public health care sector by use of medical guidelines: The case of Keywords: Economic Governance, Health System Performance Assessment, Norway. Health Economics 2011;20:958 – 70. Better Regulation, Health Systems, Health Data

Background economic stability of the region. The macroeconomic dimension of health Health policy at European Union level catalogues the people, institutions and has entered a new era. The revised resources of the health sector in terms of economic governance framework which their fiscal and economic impact. Though was introduced in the wake of the crises it focuses primarily on expenditure, it Ellie Brooks, PhD candidate, of the late 2000s challenges traditional has prompted debates about financing Lancaster University, United processes and adds a new dimension Kingdom. Former Research models, service delivery and how to to policy-making at European level. 1 Associate, European Public Health ensure universal access to high quality Alliance, Brussels, Belgium. This dimension is macroeconomic – it care. As such, the European Union (EU) Email: [email protected] scrutinises the budgets and financial is increasingly engaged in analysing commitments of national governments The author sincerely thanks Bernard and evaluating health policies, trying to sector by sector, identifying in each the Merkel and Paul Belcher for their identify, quantify and target specific areas policies and developments which present support in the writing of this article. of value or concern. a threat to sustainability and thus to the

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Two early observations can be made about financial crisis has necessitated a shift set the parameters of subsequent policy this ‘new era’ of health policy and the in focus to fiscal sustainability and led, decisions. As one of the largest areas of future development of the field. Firstly, in some countries, in some countries to public expenditure, health is a central monitoring, comparison, guidance and implementation of an austerity agenda, focus of this process and recommendations control require access to comprehensive, further exacerbating anti-European have commonly targeted the cost- coherent and comparable data. This will be sentiment. These challenges have forced efficiency of national spending on the next governance challenge for the EU. the EU to, once again, re-evaluate its pharmaceuticals, the balance between Secondly, the context of the new health approach in health, as embodied in primary and secondary care provision policy mandate risks the potential loss of the Better Regulation agenda and the and health and long-term care sector ownership by health actors. This presents a proliferation of activity which assesses, reform. 4 Though the recommendations are much deeper political question. evaluates and structures health policy. non-binding for most Member States, the issues they identify and the analysis upon Contemporary challenges It might be argued that the EU has which they are based increasingly define gone as far as it can go in health under the parameters of national reforms and Each era of EU health policy is defined the current Treaty – competences have European policy*. by its challenges. In the 1960s and 1970s, been stretched, provisions creatively the free movement of workers exposed interpreted and opportunistic extensions In aid of the Semester process, the new diverging occupational health and safety made into many unforeseen areas. Put less Health Commissioner was charged with practices, forcing the establishment of theatrically, the EU is now engaged in an further developing the EU’s competence common standards and providing the impressive range of health policy activities in health system performance assessment foundation for a series of EU social policy and increasingly faces, with each new (HSPA). This involves establishing measures. In the 1980s, the battle to undertaking, a tougher ‘sell’ with regard methodologies and indicators to assess present a ‘People’s Europe’ and a ‘human to the necessity and appropriateness of its how health systems are performing, which face’ of economic and monetary union was actions. As such, there is some logic to in turn feed into the evaluations and fought using the Europe Against Cancer the new Commission’s notion of ‘being analyses undertaken in the Semester and programme, which offered genuine EU big on the big things and small on the other processes. An expert group has been ‘added value’ and stimulated significant small things’; 2 whilst political will and established to map the national activity activity in the public health field. In public support is lacking, it is perhaps in this area, based on the understanding the 1990s and 2000s, the free movement natural to turn to improving the efficiency that ‘Knowing how health systems work is of services and patients was brought of existing activities rather than seeking the precondition to design effective health to the fore, raising important questions further expansion. For health, this could system reforms for the benefit of citizens’. 6 about the balance between economic and mean that the immediate future would Policy-makers now face the challenge of social priorities in the EU project and be characterised by ongoing processes ‘measuring’ health and assigning value to promoting the recognition of health as an of audit and revision. The risks here are the outcomes that health systems produce, issue inherent in all policies. Furthermore, significant – the Better Regulation agenda whilst ensuring that these outcomes reflect throughout this period health policy has has already labelled important public patient experience and societal wellbeing, responded to and been shaped by sporadic health policies, such as those protecting and not simply clinical or financial crises; scandals involving thalidomide, workers from exposure to dangerous end-points. 7 BSE, blood contamination and breast chemicals, as ‘regulatory burdens’, implant products have each made their whilst limiting new policy initiatives Finally, and also prompted by the post- mark upon the structure and content of and fostering an increasing reliance on crisis focus on financial sustainability, the contemporary EU health policy. soft law. 3 role of the EU in health systems policy has become at least tacitly recognised. EU Health policy in the ‘new era’ Last year DG Santé published an ‘agenda’ for effective, accessible and resilient In addition to turning its attention health systems and, whilst this is far from inwards to improve the efficiency of a coherent, stand-alone policy strand, an ongoing its health policy activity, the EU has it reflects a broader understanding that also redirected its focus in response to addressing sustainability issues and process of audit the political priorities of the post-crisis implementing health reforms efficiently Union. The financial crisis and economic requires some central coordination of and revision recession forced an overhaul of the health systems policy. For the moment, economic governance framework, the activity is centred on issues such as The challenges defining EU health policy most notable innovation of which has been cross-border health care, professional in the current era are two-fold. Firstly, the European Semester. The Semester Euroscepticism amongst the general embraces all policy areas and applies the * The legal character of the recommendations differs for public and national governments has risen same fiscal-sustainability framework to members of the euro area, for states which rely heavily upon sharply in recent years. Secondly, the each, generating recommendations which EU funds and again for those countries subject to economic ‘‘ adjustment programmes. See also (5).

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mobility, patient safety and pricing and renewed focus on HSPA and health the past decades and vocal in supporting reimbursement of medicines but the systems policies target the infrastructure the continued role of the EU in health potential scope for this new avenue of of national health policy and scrutinise protection and promotion. 10 EU policy is substantial. some of its most fundamental elements. This shift is not exclusive to health – References all-encompassing ‘economisation’ Implications for the future 1 introduced by the Semester is forcing most Brooks E. EU governance 3.0 – in search of Two important observations can be made policy areas to engage in some form of a characterisation. Health governance in Europe Blog, Ideas on Europe, 28 January 2015. Available about the implications of these ‘new era’ streamlining. This progression could be at: http://healthgovernance.ideasoneurope. undertakings – the European Semester, read positively; a policy area has to reach eu/2015/01/28/eu-governance-3-0-search- HSPA and the early fragments of an EU a certain level of institutionalisation and characterisation/ health systems policy – for the future of success before it can undertake the kind of 2 European Commission. Press Release ‘A new EU health policy. Firstly, each of them efficiency-drive and internal-stocktaking start’, 16 December 2014. Available at: http://europa. will require consistent, comprehensive which DG Santé is currently unofficially eu/rapid/press-release_IP-14-2703_en.htm and comparable data. This is both the engaged in. This might be interpreted as 3 EuroActiv (2015) Officials accuse Timmermans silver bullet and, arguably, the third rail of an achievement in itself. of delaying EU health, food safety rules. EU health policy; whilst vital to perform Available at: http://www.euractiv.com/sections/ the kind of policy activities which seem health-consumers/officials-accuse-timmermans- likely to characterise health policy in the delaying-eu-health-food-safety-rules-313964 coming years it is notoriously difficult 4 EPHA (2015) Analysis of the 2015 CSRs. Available to acquire. One of the most critical at: http://www.epha.org/spip.php?article6361 elements is the presence of reliable importance of 5 Baeten R, Thomson S. Health care policies: eHealth systems, such as electronic European debate and national reform. In Natali prescriptions and health records, which health has D, Vanhercke B (eds.) Social developments in the can collect vast quantities of data without European Union 2011. Brussels: ETUI, OSE, 2012: 187-211. putting excessive burden upon health become so well care professionals, administrators or 6 Expert group on HSPA web site. Available at: patients. Sufficient systems are in place recognised http://ec.europa.eu/health/systems_performance_ assessment/policy/expert_group/index_en.htm in only a handful of Member States and are particularly weak in the poorer In practice, however, it the importance 7 Porter M. What is value in healthcare? New health systems, immediately creating a of health has become so well recognised England Journal of Medicine 2010; 363:2477-81. data bias. Within those countries which, that it can no longer be entrusted to the 8 Merkel B. Measuring the performance of health via eHealth or other systems, do collect DG Santé. Its role risks being confined systems – a troubled history British Medical Journal ‘‘ Blog, 9 April 2015. Available at: http://blogs.bmj. health system data, there is substantial to a technical and analytic role and com/bmj/2015/04/09/measuring-the-performance- variation in the kind of information ‘in support’ of those colleagues in the of-health-systems-a-troubled-history/ recorded and the methodologies used. Commission responsible for the Semester 9 This makes comparison difficult and often and the policy recommendations it EPHA. Better Regulation for whom? Newsletter, May 2015. Available at: http://blogs.bmj.com/ precludes thorough assessment of specific makes. This is made clear in the mandate bmj/2015/04/09/measuring-the-performance-of- features. Moreover, even where reliable given to the Health Commissioner, health-systems-a-troubled-history/ systems collect the appropriate data, which outlines how he should develop 10 Stein H. The Maastricht Treaty 1992: Taking stock national governments have historically expertise to ‘inform’ national and of the past and looking at future perspectives. South been reluctant to transmit health system EU level policies and contribute to the Eastern European Journal of Public Health 2015;3. data beyond national borders. When the European Semester, leaving leadership World Health Organization published its and substantive development of health World Health Report in 2000, producing systems policy to the economic and for the first time a ranking of health finance officials in DG ECFIN and their systems, a significant backlash was colleagues from the Member States. experienced, particularly from the poorer- The Better Regulation agenda looks set performing countries. 8 Since this episode, to perpetuate this ‘streamlining’ work national governments have remained wary programme, reducing active leadership of international comparison and its power and policy initiatives and instead to impact upon policy agendas. investing resources in implementation of legislation, review of existing A second implication is far more directives and production of technical concerning: if the 'economisation' trend reports. As such, characterisations of continues the latest era of health policy decline seem increasingly apt 9 – the might see a loss of ownership for health EU health community must be vigilant actors. The European Semester, and in safeguarding the progress made over

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WHY HAS THERE BEEN VERY VARIABLE IMPLEMENTATION OF eHEALTH SERVICES WITHIN THE EU?

By: Margaret Ellis, Tony Cornford and Sofia Moreno-Perez

Summary: Published data about eHealth services, both potential and actual, and their introduction within the European Union are observed and reported on. It was found that the levels and speeds of adoption are very variable. Some of the variables can be linked to the education and understanding of eHealth opportunities by some health professionals and policy makers. More readable data dealing with cost-effectiveness and user benefits would be of special value.

Keywords: eHealth, Education, Integrated Approach, Cost Effectiveness

Introduction status of a mature or ‘taken for granted’ component of systems or pathways of eHealth encompasses a growing range care for people living in their own homes. of demonstrably cost-effective policies, One reason may be that, in some EU services and equipment available to Member States, social care and health support greater independence for care are administered separately and European Union (EU) citizens. The telecare pathways, which should link term embraces telecare, telehealth services are impeded by that boundary. (itself embracing telemedicine) and health Technology that facilitates more efficient informatics. As illustrated in Figure 1, procedures needs to be embraced and there are overlaps. Nevertheless, these sub- existing organisational structures adapted divisions are useful, but a problem is they accordingly to achieve cost-effectiveness are not yet sufficiently inter-connected in and better outcomes for service users. the real world of health and social care. Telehealth encompasses those health care Telecare has now been a part of the policy services delivered via telecommunications Margaret Ellis is Lead Academic, dialogue in health and social care for media, over any distance. Service delivery LSE Enterprise, Tony Cornford over two decades. As with many other is Associate Professor in may be done in real time or stored and eHealth innovations, e.g., electronic Information Systems, Department broadcast through media, ranging from of Management, London School of patient records and electronic prescribing, simple telephonic conversations and Economics and Political Science, it is experiencing a particularly slow and United Kingdom. Sofia Moreno- Internet to video conferencing across painful maturation. Perez is an independent consultant, national boundaries. The services could Madrid, Spain. involve consultation, patient monitoring, Email: [email protected] It is hard to argue that telecare has diagnosis, prescription, treatment or even achieved in any substantial sense the

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Figure 1: eHealth and some of its constituent sub-fields sector has shown strong interest in consumer health as a core market. New products and services are continually being delivered. Both providers and the eHealth users need to be competent to appreciate both the capability and the limitations Telehealth of the technology on offer. Education is the key to this, and the lack of it is the most apparent and continuing reason for both variable and slow introduction of Telecare Telemedicine eHealth services.

Better- informed, bolder, Health Information timely decision- making is needed

Currently, the existing supporting infrastructures for user technology, surgery. Real-time telemedicine services Our review has disclosed a wide variation such as the reliability and availability may involve tele-cardiology, tele-dentistry, in levels of adoption of eHealth services of digital‘‘ networks, accessible tele-mental health, tele-neurology, tele- in the EU. This article identifies and constellations of expertise and education, nursing, or tele-rehabilitation. Outwith discusses some of the reasons. and supply chains with which ‘user’ telemedicine, but within telehealth are communities (individuals, families remote keep-fit systems and health apps, We argue that there are three key or local care commissioners and etc. Many telehealth systems encourage components that need to be coordinated in providers) can confidently connect, is self-care and personal responsibility for every eHealth initiative: weaker than the current status of ‘user’ areas of health such as blood pressure and technologies themselves. 1. Suitable technology sugar level measurement which enable people to be treated at home, and so reduce 2. The existing models of care with However, it is encouraging that models hospital attendance and costs. 1 which the technology must integrate or of care and their funding in many EU which must be adapted to increase the countries are moving in directions that Health Informatics facilitates the efficiency enabled by the technology seem increasingly compatible with collection, analysis, and dissemination, eHealth provision. Patient-centred care, 3. The broader institutional settings, and as well as access to health information. which in part may involve the shift of the mobilisation of relevant interests, Thus, access to their medical data by health resources to primary care, and users and workforce personnel, patients, provided for 300,000 people various efforts across Europe to integrate around eHealth in Estonia, 2 improved patient health primary health care with social care are outcomes and decision making, reduced two examples. Innovation in models of health care costs, travel time, redundant Facilitators and Blockers care should be driven both by the reality of diagnostic procedures and tests, waiting demographic change and by the increasing User-friendly technologies are now time and led to improved early diagnostic, proportion of the population living with available in many areas of eHealth administrative and communication multiple chronic conditions. Changes and their conceptual utility has been capabilities. Other EU countries have are, in part, also driven by a growing demonstrated. 3 User’ technology both been slower to adapt their systems and perception that the old ways will soon develops and changes quite rapidly. It thus effect the improved outcomes and become impractical both financially and is generated by an active community efficiency savings. Some media scare organisationally. Provision of eHealth of eHealth innovators who are eager to stories, which attribute a ‘big brother’ or services can offer cost-effective solutions place new technologies, via the “Digital intrusive nature to open access medical which users approve, as shown in Scotland Industry,” literally into peoples’ hands. For records, have discouraged development. and Newham. 4 example, the thriving App development

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Yet policy decision-makers are at times section of TECS emphasises the need Landscape Review with NHS England will still not being presented with a clear, for cost-effective data. In consequence highlight the variability of introduction. balanced case, including the cost- TECS is funding the evaluation of Expansion is expected later in 2015. effectiveness of eHealth services, and stakeholder schemes. so hesitate to agree changes for fear of In Spain, the Andalusian e-Health 10 increasing costs. Of course, an eHealth Some innovative examples Strategy has enhanced the quality of service that is not a better (cheaper, more life of its citizens and the coordination reliable and more user-friendly) way of There are many examples of the effective- of their health and social carers through doing what we do now should not be ness of eHealth services. We set out a few the integration of health information. It is considered. But eHealth services may, of them below. cost-effective: ePrescription enabled early while involving radical or disruptive shifts saving of €6.3 million; hospital admissions away from current procedures, result in In 2010, the Scottish Government launched decreased from an average stay of 7.5 days better services. Initial disruption leading Reshaping Care for Older People, 8 in 2008 to 7.16 in 2012 and consultations to better future outcomes should be including a national Telecare Development in family medicine reduced by 16.11% accepted. Better-informed bolder timely Programme to help people live at home from 2007 to 2012. In Catalonia, the decision-making is needed. longer – Scottish Patient at Risk of Re- government has established integrated admission and Admission (SPARRA) 9 – technology (ICT) services, which are resulting in an estimated gross saving now well known to users and service of €110.6 million (£78.8m) up to the end providers. The main Pulmonary Medicine of the financial year 2013. Scotland is Department reached a significantly lower planning a coordinated system between (10%) rate of early readmissions after integrate health and social work, introducing discharge than those observed in the whole legal requirements for these services to region (15%), in Spain (30 – 35%) or at EU appropriate work together. level (30 – 35%), a pattern that is being repeated elsewhere in Spain. multiple interest In England, the East London Foundation Trust, used an eHealth service which In 2007, the EU Ageing Well in the groups provided for 353 people, with long-term Information Society Action Plan conditions, to be treated at home rather acknowledged the demographic change A large scale project in the than in hospital – ‘a virtual ward’ and in the European Agenda. The focus on United Kingdom, the Whole System reported a total gross saving of £597,940 the ageing population forced a change Demonstrator (WSD) 2011, provided (€839,500) and a total net saving of of vision, from the traditional acute compelling evidence‘‘ that telecare and £162,826 (€228,600) over a twelve month illnesses approach to chronic conditions. telehealth were viable solutions for older period. In an earlier twelve month period, eHealth appears as a necessary enabler and disabled people living independently where 1,000 people were treated at home, of the change from reactive to preventive and taking control of their own health and approximately £500,000 (€702,000) medicine to embrace the integrated ‘care care. Furthermore, the WSD programme was saved. Users not only approved of & cure’ approach. Many initiatives have found that, “if delivered properly, this eHealth service, but they had fewer been launched at European political level telehealth can substantially reduce infections, did not block hospital services, with the aim of fostering a triple win: mortality, reduce the need for admissions did not require transport to and from better quality of life for citizens, improved to hospital, lower the number of bed days hospital, and were able to maintain normal sustainability for public services, and new spent in hospital and reduce the time spent contact with friends and families. opportunities for the European Industry. in Accident and Emergency”. 5 A follow- Another EU report, Excellent innovation up scheme, “3MillionLives”, 6 offered In Sweden, 3 mobile telephones provided for ageing. A European Guide (2013), 11 services to 3 million users, but was then to people with mental health problems includes more than 30 examples from shelved. This is an example of a national enabled them to select services on twelve countries classified from one to government applying the brake to eHealth medication, housing, etc., and have greater four stars, although none has yet achieved service development. In September 2014, direct control of their own health, reducing the highest ranking. NHS England published a new proposal, the need for hospital visits. Technology Enabled Care Services The need for more action (TECS), 7 which asks for Commissioners In England, some general practitioners ‘to support the programme that takes the (GPs) have already established an open EU officials are concerned that despite NHS into a new and exciting technological access system for their patients to acknowledging changes in demography, era that will help empower patients and access and read their own records. The too few Member States have addressed improve health outcomes’. There is a very Royal College of Physicians of London the need to plan and introduce eHealth real danger that different schemes being acknowledges that such access is cost- services. At a March 2015 EU Summit, 12 introduced will not be inter-compatible effective and encourages self-care. Their the EU Digital Commissioner stressed or permit easy transfer of data. One the need for more digital services. “We

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want to continue this program, secure and and the Ambient Assisted Living 13 9 Soto Alba JD. The Andalusian eHealth Strategy. deepen it, and for the quality of life of Forum (AAL) in Ghent. EKTG are now Presentation Norwegian eHealth week, 2014. elder European citizens”. planning for a Symposium in January 2016 Available at: http://grimstad.uia.no/ehelse/ eHelseUKA2014/Presentations/Andalusian%20 in London. eHealth%20Stragegy_Jose_Daniel_Soto.pdf A broader understanding across the EU of 10 what eHealth is, what it can do, and how NHS Scotland. Scottish Patients At Risk References of Readmission and Admission: A report on it serves various interests and generates development work to extend the algorithm’s 1 Padmanabhan R. Newham Model for Integrated value, is urgently needed. While both applicability to patients of all ages, June 2008. Care. Presentation EKTG Symposium, House of technology and models of care matter, Available at: http://www.isdscotland.org/Health- Lords, London, July 2015. eHealth’s future is ultimately most Topics/Health-and-Social-Community-Care/ dependent on its being able to integrate 2 Aaviksoo A. Estonian eHealth experience: SPARRA/2008_06_16_SPARRA_All_Ages_Report. pdf appropriate multiple interest groups. Thus, combining efficiency & trust. Presentation EKTG Symposium, House of Lords, London, July 2015. users and their representatives should 11 European Innovation Partnership on Active and press for greater access, involvement, and 3 Ryden M. Assistive Technology for Persons with Healthy Ageing. Excellent innovation for ageing A European Guide, 2013. Available at: http://www. training themselves. In addition, special Psychiatric Disabilities. Presentation WFOT Congress Japan, 2014. ehealthnews.eu/images/stories/pdf/excellent_ emphasis needs to put on the education of innovation_for_ageing.pdf all health care professionals in computer/ 4 Martin M. Telecare development. Scottish 12 Innovation for Active & Healthy Ageing. Final communications technologies and, Government Supporting People Matters. Issue 24, June 2007. Available at: http://www.gov.scot/ Report, European Summit on Innovation for particularly, on its inclusion in their initial Resource/Doc/179830/0051123.pdf Active and Healthy Ageing, Brussels, 9 –10 March education syllabuses. 2015. Available at: http://ec.europa.eu/research/ 5 Department of Health. Whole system demonstrator innovation-union/pdf/active-healthy-ageing/ageing_ programme – Headline Findings. December 2011. summit_report.pdf#view=fit&pagemode=none Available at: https://www.gov.uk/government/ Conclusion 13 uploads/system/uploads/attachment_data/ Active and Assisted Living Programme web site. Where better education of the workforce, file/215264/dh_131689.pdf Available at: http://www.aal-europe.eu/ policy makers and governments exists, 6 Department of Health. A concordat between the eHealth services have proved highly Department of Health and the telehealth and telecare popular with users and are cost-effective. industry. January 2012. Available at: https://www. We are convinced that faster progress in gov.uk/government/uploads/system/uploads/ the introduction of these services depends attachment_data/file/216757/Concordat-3-million- lives.pdf on placing more emphasis and more resources in appropriate education at 7 Corlett K. Newham Model for Integrated Care. all levels. Presentation EKTG Symposium, LSE, London, 2013. 8 Reshaping care for older people web site. This topic was addressed at European Available at: http://www.jitscotland.org.uk/action- Knowledge Tree Group (EKTG) debates areas/reshaping-care-for-older-people/ in 2015 at the House of Lords in London

New HiT on Switzerland As this new review of Swiss health care makes clear, public satisfaction with the system is high and quality is generally viewed to be good or very good. Despite this positive By: C De Pietro , P Camenzind, I Sturny, L Crivelli, assessment a number of challenges remain. In particular, S Edwards-Garavoglia, A Spranger, F Wittenbecher, improving financial protection and fairness of financing is W Quentin becoming important because rising Copenhagen: WHO Regional Office for Europe premiums and an exceptionally high share of out-of-pocket payments Number of pages: 288, ISSN: 1817-6127 place an increasingly large financial Freely available for download at: http://www.euro.who. burden on households with lower int/__data/assets/pdf_file/0010/293689/Switzerland-HiT. and middle incomes. pdf?ua=1

Life expectancy in Switzerland (82.8 years) is the highest in Europe after Iceland. The Swiss health system offers a high degree of choice and direct access to all levels of care with virtually no waiting times.

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THE MEDICRIME CONVENTION – FIGHTING AGAINST COUNTERFEIT MEDICINE

By: Oscar Alarcón-Jiménez

Summary: The Council of Europe has adopted a criminal law convention on “counterfeiting of medical products and similar crimes involving threats to public health” (MEDICRIME Convention), drafted from a public health perspective. The Convention’s main goals are to criminalise certain acts, protect the rights of victims, and promote national and international co-operation. The counterfeiting of medical products and similar crimes is a growing threat for many countries due to the low level of deterrence within national and international legislation. As the only international legal instrument to fight against falsified medical products, the Convention represents a milestone in tackling transnational organised crime.

Keywords: Public Health, Counterfeiting of Medical Products, Criminal Networks, MEDICRIME Convention, Council of Europe

Introduction be efficiently combated through close international co-operation. The factors Given its lucrative character, the which contribute to this state of affairs counterfeiting of medical products and are corruption, the ineffectiveness of similar crimes is a new global threat systems for monitoring the production facing the international community. and distribution of medical products, and The control by criminal networks of both the lack of a legal framework to prosecute the production and trade of counterfeit such crimes. The criminals are attracted goods facilitates the infiltration of these by the risk-benefit ratio involved. In fact, counterfeit medical products into the legal this activity is more profitable than drug supply chain and their sale as authentic trafficking with a significantly lower level Oscar Alarcón-Jiménez is products. The opacity of these networks of risk, due to the relatively low risk of Co-Secretary of the European makes it difficult to combat these Committee on Crime Problems, prosecution and detection, the potential new crimes. Criminal Law Division at the Council high gains, and the ease of advertising of Europe, Strasbourg, France. and supply around the world through the Email: [email protected] The counterfeiting of medical products Internet. Moreover, it is not an isolated violates basic human rights by effectively Note: The views expressed in this crime: it affects the economies of all denying patients necessary and authentic article are those of the author and states, with organised networks operating medical treatment and constitutes a direct may not under any circumstances at a global level and jeopardises the health be regarded as stating an official threat to individual and public health. It and lives of individuals. position of the Council of Europe. is a trans-border crime which needs to

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Global international response these crimes (Article 1). The scope of the believing that the medical product Convention is expressly limited to medical which the document accompanies is Adoption of the MEDICRIME Convention products by covering both medicines (for legitimate and not a counterfeit. The When facing organised crime, no human and veterinary use), their active MEDICRIME Convention defines the single response can be effective. On substances, excipients, and medical term “document” by covering not only the contrary, the response needs to be devices, parts or materials designated certificates and similar documents global. With a view to tackling this crime, to be used in the production of medical used in trade and commerce, but also international action by states was needed, products, and accessories designated to the packaging and labelling of medical in particular, harmonised international be used together with medical devices products, as well as texts provided on legislation to overcome loopholes, the (Article 3). internet sites which are specifically establishment of sanctions to deter this designed to accompany the product activity, and the promotion of international It is important to stress that intellectual in question. co-operation. The Council of Europe property rights do not fall within the (CoE), the oldest intergovernmental scope of the MEDICRIME Convention. 4) Similar crimes involving threats organisation which has been at the Moreover, the term “counterfeit” is to public health: despite not being forefront of promoting human rights, the defined as a false representation with counterfeited, products intentionally rule of law and democracy in Europe regards to identity and/or source. manufactured, kept in stock for supply, over the last 60 years, sees the eradication Any natural person suffering adverse imported, exported, supplied, offered to of this phenomenon as the common physical or psychological effects as supply, or placed on the market without responsibility of the global community. a result of having used a counterfeit authorisation (medicinal products) or It elected to take on this challenge as medical product or a medical product without being in compliance with the the counterfeiting of medical products manufactured, supplied or placed on the essential conformity requirements violates human rights and undermines market without authorisation or without (medical devices) equally pose a serious the values upon which the CoE is based. being in compliance with the conformity threat to public health (Article 8). Thus, in 2010, the CoE’s Committee of requirements as described in the Therefore, these crimes are considered Ministers adopted the Convention on Convention should be considered a victim. to be similar to the counterfeiting of the counterfeiting of medical products medical products. An example of this and similar crimes involving threats to Criminalising certain acts offence is the existence of a sprawling public health (hereafter MEDICRIME black market for medicinal products for The MEDICRIME Convention introduces Convention) 1 which was opened hormonal treatment produced without four new independent criminal offences for signature on 28 November 2011 authorisation. This Article shall only considered dangerous to public health: in Moscow. apply when the previous Articles (5-7) are not applicable. 1) Intentional manufacturing of counterfeit medical products, their The above criminal offences should be active substances, excipients, parts, made punishable under domestic law materials and accessories (Article 5); by those countries which have ratified related to this offence, the adulteration the MEDICRIME Convention and efficiently of medicines and other listed products is which should foresee and lay down also considered a criminal offence. combated accompanying “effective, proportionate and dissuasive sanctions”. 2) Intentional supplying, offering to through close supply and trafficking in counterfeit Aggravating circumstances medical products’ active substances, international co- excipients, parts, materials and When sentencing offenders, judges accessories (Article 6). This includes the may take into consideration some operation activities of brokering and advertising circumstances (although they are under online or at a distance, such as social no obligation to apply them) in the Harmonised definitions media and through various parts of determination of the sanction for the above The MEDICRIME‘‘ Convention is a the Internet. offences, such as: criminal-law convention 2 with the – the offence caused the death of, or ultimate goal of protecting everyone’s right 3) Intentional falsification of documents damaged the physical or mental health to life by introducing new offences and (Article 7). This can take place either of, the victim; providing for the establishment of penal through the making of a false document and other sanctions that are proportionate from scratch or through unlawfully – the offence was committed by persons and dissuasive for these offences. It aims ammending or changing a document abusing the confidence placed in them to prosecute certain acts, protect the with regard to its content or appearance. in their professional capacity; rights of victims, and promote national In both cases, the aim is to deceive and international co-operation against the person reading the document into

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– the offence was committed by persons of the Convention is that it provides the prevention of illegal supply) are also abusing the confidence placed in them the possibility for third states to join envisaged. Moreover, victims would have as manufacturers and suppliers; (see below). access to information, assistance in their physical, psychological and social recovery – the offences of supplying and offering The legal bases applicable in the context of and have the right to compensation from to supply are committed through the extradition and the principles enunciated the perpetrators. use of large-scale distribution, including there are applicable, mutatis mutandis, in through information technology systems the field of mutual legal assistance, which (the Internet); A global Convention is broader than extradition. Moreover, – the offence involved a criminal given the importance of the victims of The MEDICRIME Convention is organisation; counterfeit medical products and similar not confined to CoE Member States. crimes, whether as a result of their Any state wishing to sign and ratify – the perpetrator has previously been suffering or because of the potential they the Convention is welcome to do so convicted of offences of the same offer as witnesses, special attention is paid (Article 28.1), recognising that the world nature as those established under to them even in the provisions relating to is facing a global problem as a result the Convention. international criminal co-operation. such crimes. Apart from the seventeen CoE Member States that have signed Enhanced co-operation of authorities the MEDICRIME Convention so far, and information exchange Israel and Morocco have also signed the Convention while the Republic of Guinea The MEDICRIME Convention paves special ratified the MEDICRIME Convention the way for solid co-operation and on 24 September 2015, initiating the information exchange at both national and attention paid procedure for its entering into force international level. Networking at national on 1 January 2016. Belarus has also level based on a multidisciplinary and to victims been invited by the CoE’s Committee multisectorial approach is a key element of Ministers to sign this Convention. in the fight against the counterfeiting Prevention and protection measures To date, five countries have ratified of medical products and similar crimes. One innovation introduced by the the Convention: Ukraine (2012), Spain The wide range of authorities (justice, Convention is the inclusion of victims. It (2013), Hungary (2014), Moldova (2014) law-enforcement and health authorities) should be recalled that the protection of, and Guinea (2015). Undeniably, more involved in this new crime usually and assistance to, victims of crime has countries are needed to sign and ratify the requires a strengthening of the existing long been a priority in the work of the MEDICRIME convention in order for it to frameworks for co-operation. The CoE CoE. Taking into account the potential be effective internationally. model based on a network of Single Points ‘‘ grave consequences for victims of of Contact (SPOC model) is a successful counterfeited medical products and similar system already used in other fora Conclusion crimes, the Convention provides for the (i.e. EU, WHO, INTERPOL). protection of such victims (Chapter VI), The MEDICRIME Convention offers ensures that they be kept informed by the a valuable tool for combating the The MEDICRIME Convention clearly competent national authorities on relevant counterfeiting of medical products from provides a legal basis for a platform for developments in their cases, and gives the standpoint of protecting health. co-operation, with a view to avoiding them the possibility to be heard and to Through the harmonisation of criminal any requirement for further bilateral supply evidence. provisions, the Convention lays the agreements. Mutual legal assistance foundation for efficient and effective is a formal process by which states Additionally, the MEDICRIME national and international co-operation grant assistance to one another with Convention provides for some preventive among all competent authorities the purpose of gathering evidence for and protective measures (Article 18) in involved, namely judicial, health and law use in criminal trials. The Convention combating the counterfeiting of medical enforcement authorities, protecting, above encompasses all existing forms of Mutual products and similar crimes, namely the all, the most vulnerable people, patients. Legal Assistance (e.g. rogatory letters*, introduction at national level of quality and transfer of proceedings). For some safety requirements for medical products The counterfeiting of medical products states, the Convention may be the only as well as measures ensuring the safe and similar crimes are crimes that treaty between itself and other states, distribution of such products. Additional ultimately could kill or at the very least particularly since one particular aspect preventive measures (capacity building make people ill or not treat their illnesses. activities for justice, law-enforcement, It is a universal problem that demands health care professionals and providers in strong responses: the MEDICRIME order to better prevent and combat these Convention can provide them.

* A rogatory letter is a formal request from a court to a crimes; awareness-raising campaigns; foreign court for some type of judicial assistance.

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References WORTH THE PAPER

1 Council of Europe. Information on the MEDICRIME Convention. Available at: http:// THEY’RE WRITTEN www.coe.int/medicrime

2 Council of Europe. Convention on the counterfeiting of medical products and ON? THE POTENTIAL similar crimes involving threats to public health. Council of Europe Treaty Series No. 211. Available at: http://www.coe.int/en/ web/conventions/full-list/-/conventions/ ROLE OF NATIONAL treaty/211 MEN’S HEALTH POLICIES

By: Peter Baker

Summary: The Irish government was the first to introduce a national men’s health policy. It ran for five years, from 2008 –2013, and has recently been independently reviewed. The review found, overall, that the policy had a positive impact on men’s health in Ireland. The conclusions of the review suggest that national strategies on men’s health in individual European states, as well as in Europe as a whole, could be beneficial. Existing health policies should also take explicit account of the specific needs of both men and women.

Keywords: Men’s Health, Gender, Health Policy, Ireland

Introduction ‘reflect several factors – greater levels of occupational exposure to physical and Men’s health in Europe is unnecessarily chemical hazards, behaviours associated poor. Life expectancy for women on with male norms of risk-taking and average across European Union (EU) adventure, health behaviour paradigms member states reached 82.2 years in 2012, related to masculinity and the fact that compared with 76.1 years for men. The men are less likely to visit a doctor when gap between the EU member states with they are ill and, when they see a doctor, the highest and lowest life expectancies are less likely to report on the symptoms was 7.6 years for women and 11.5 years of disease or illness.’ 2 Peter Baker is Director, for men. 1 Across all EU member states Global Action on Men’s Health. in 2011, the male mortality rate was Email: [email protected] nearly 60% higher than the female rate. Men’s health policy Note: Peter Baker was Marmot believes that national commissioned by the Health Service Professor Sir Michael Marmot, one of the governments should develop strategies Executive in Ireland to lead the world’s leading authorities on the social independent review of the National that ‘respond to the different ways health determinants of health, has suggested that Men’s Health Policy. and prevention and treatment services are men’s poorer survival rates across Europe

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government in Europe – to have responded it still would have been challenging to to the health problems facing men with a demonstrate a link between the NMHP Box 1: Ireland’s National Men’s dedicated National Men’s Health Policy specifically and any changes in men’s Health Policy 2008 – 2013: Where (NMHP). 4 This set out ten strategic aims – health outcomes. was progress made? and 118 specific action points – for the period 2008 – 2013. Among the problems it The wide range of health professionals, Most progress was made in aimed to tackle were male life expectancy health service and government officials, four areas: five years below that of females, a steep men’s health advocates and others • Increasing the focus on men’s social gradient in male mortality, and the consulted for the review were nevertheless health research second highest suicide rate in young men overwhelmingly of the view that, overall, • Developing health promotion out of the 30 OECD member states. the NMHP made a significant and initiatives that support men to important contribution to making the issue improve their health (see Box 2) As well as being the first comprehensive of men’s health more prominent in Ireland, • Tackling social isolation and attempt to address men’s health at a policy to providing a framework for action, and disadvantage in men through level, it moved beyond the traditional to implementing many important new community development work ‘medical model’ and was based on a social initiatives. However, it was also generally determinants approach. It advocated a acknowledged that its impact had been • Developing men’s health training ‘whole-system’ response, with roles for a stronger in some areas of activity than for health and other professionals wide range of government departments, others and very weak in some (see Box 1). Progress was slower in seven areas: non-governmental organisations, • Establishing structures nationally employers and others. The achievements of the NMHP were and locally to support and in large partly due to its very existence monitor implementation of The focus of the NMHP was on prevention (which validated and encouraged work the policy and the importance of supporting men in a previously overlooked field), the • Increasing the proportion of men through a community development thorough pre-publication consultation working in education, the caring approach. Significantly, it did not seek process (which engaged a wide range professions and community work to blame men for their poor health and, of organisations and individuals), its instead, embraced an understanding holistic approach to men’s health, and • Developing health services of masculinities and the ways men are the commitment of a core group of (especially in preventative health) socialised to behave. It also aimed to individuals from the statutory and non- which take men into account support men to become more active statutory sectors who took responsibility • Developing policies that improve advocates for their own health. The for co-ordinating its implementation. The the health of men at home in their European Commission’s report on the state involvement of several significant non- roles as husbands, partners, of men’s health across Europe called the governmental organisations, including the fathers and carers publication of the NMHP ‘a significant Irish Cancer Society and the Irish Heart • Improving the health and personal landmark’. 5 Foundation, was also important. development of boys through work in schools and colleges Making a difference? The NMHP was, however, published at • Developing men's health initiatives a time of economic crisis. The impact of at workplaces But was the NMHP actually effective? this on implementation cannot be under- What difference did it make to men’s estimated. Although some government • Increasing men's access to sport health in Ireland? And does it provide a money continued to be provided for men’s and recreation facilities. template for the development of men’s health work, including the annual Men’s health in other European countries and Health Week in June, this was not on a perhaps beyond? An independent review scale commensurate with the ambition of experienced by men [and] women … and of the NMHP, commissioned by Ireland’s the NMHP. [ensure] that policies and interventions are Health Service Executive and published responsive to gender.’ 2 In a subsequent in 2015, provides some answers to these Other implementation problems concerned report on health inequalities in the important questions. 6 the large number and scope of specific UK, Marmot highlighted the fact that policy recommendations and actions, the deprivation has a greater negative impact It was not possible for the review to assess lack of clearly-stated priorities, and the on men’s health outcomes than women’s the impact of the NMHP quantitatively. No problem common to many jurisdictions and called for a greater policy focus on clear time-framed performance indicator of securing action across government men’s health to help tackle this. 3 outcomes were established at the start of departments. In Ireland, the latter the NMHP and it was implemented during problem was compounded by significant Ireland: the first to act a period when, because of cuts in public reorganisations within some departments expenditure, there was a dearth of official and the loss of staff who had been closely The Irish government was the first in data on health behaviours and outcomes. involved in the initial development of the world – and to date remains the only Even if good data had been available, the NMHP. There was also a lack of

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cancer and mental health policy, as well as to apply only to men. Women may live for men to be included within the national longer than men but they nevertheless Box 2: Health promotion with men chlamydia screening programme and still have a wide range of unmet health in Ireland for the introduction of abdominal aortic needs that require attention. The value aneurysm (AAA) screening for men. In of national women’s health policies is One area of clear progress in Denmark, the government has recently an issue women’s health advocates may implementation of the NMHP was allocated €1 million to develop initiatives wish to consider and, if there is support the development of new health with unskilled and unemployed men and for this approach, there is potential for promotion initiatives. A wide range additional funding for ‘Men’s Sheds’* in collaborative working between men’s and of male-targeted health information rural areas. Nevertheless, in England, women’s organisations. resources was produced, including Wales and Denmark, as well as Europe by the Men’s Health Forum in Ireland, generally, the principal advocates for How men’s health will be taken forward the Irish Cancer Society, the Irish men’s health still perceive progress to have in Ireland, specifically now that the Heart Foundation, An Post (Ireland’s been patchy and fragile and in need of NMHP has come to an end, is still to be postal service), and Safefood underpinning by clear national strategies. determined. The review found very strong (the statutory body that promotes support for the continuation of a dedicated awareness and knowledge of food Most advocates also consider that progress national policy on men’s health in order to safety and nutrition issues in Ireland). should be made within a broader gender maintain momentum. But it was also felt Evaluated health promotion pilot mainstreaming framework (GMF), and that men’s health should now be addressed, and longer-term programmes that attention must be paid to the health in the form of a dedicated Men’s Health aimed at men included the Men needs of both men and women. But there Action Plan, within the country’s new on the Move initiative (which are concerns that a GMF alone is not overarching public health policy, Healthy engaged men in sociable physical able to drive sufficient action on men’s Ireland. This policy has the high-level activity programmes), The Larkin health. This is primarily because ‘gender’ political support and the governance and Unemployed Centre’s Men’s Health is still widely interpreted to refer to implementation structures that make it and Wellbeing Programme (a ten- women alone and, where GMFs exist (as much more likely that it will successfully week intervention for men aged in Ireland), they have in practice proved make progress through co-ordinated cross- over 30 years in a disadvantaged difficult to implement. Because gender sectoral activity. part of Dublin) and Farmers Have mainstreaming tends to be framed as Hearts (a cardiovascular health a binary issue (male/female), there is References screening programme for rural men). an additional risk that it will overlook lesbian, gay, bisexual, transgender and 1 OECD. Health at a Glance: Europe 2014. Paris: intersex issues. OECD Publishing, 2014. Available at: http:// ec.europa.eu/health/reports/docs/health_ glance_2014_en.pdf sustained high-level government official Where next? 2 or ministerial support which could have UCL Institute of Health Equity. Review of social determinants and the health divide in the helped drive progress on implementation. The conclusions of the review of Ireland’s WHO European Region: final report. Copenhagen: NMHP point to a need for national WHO Europe, 2014. strategies on men’s health in individual Other countries 3 UCL Institute of Health Equity. Marmot Indicators European states, as well as for existing 2014: A preliminary summary with graphs. London: Two other countries, Australia and Brazil, policies, whether on cancer, cardiovascular UCL Institute of Health Equity, 2014. Available at: have also introduced national men’s disease or obesity, to take explicit account http://www.instituteofhealthequity.org/projects/ health policies. Although the evidence of the specific needs of men. There is marmot-indicators-2014/marmot-indicators-2014-a- suggests their outcomes, like those of the also a case for Europe as a whole to preliminary-summary-with-graphs Irish policy, were mixed, many men’s develop a strategy on men’s health which 4 Department of Health and Children. National Men’s health researchers and advocates around takes account of the conclusions of the Health Policy 2008– 2013: Working with men in Ireland the world now believe that dedicated and European Commission’s report on men’s to achieve optimum health and wellbeing. Dublin: 5 Department of Health and Children, 2008. Available comprehensive national men’s health health. This was published in 2011 but at: http://www.mhfi.org/menshealthpolicy.pdf policies represent the best way forward. In has not yet been followed up with any 5 Europe, this view is taken by the Danish recommendations for action. White A. The State of Men’s Health in Europe. Extended Report. Brussels: European Commission, Men’s Health Society, the Men’s Health 2011. Available at: http://ec.europa.eu/health/ Forum (England and Wales) and the There are also obvious implications for population_groups/docs/men_health_extended_ European Men’s Health Forum. women’s health policy, as it would seem en.pdf

anomalous for gender-specific policy 6 Baker P. Review of the National Men’s Health Policy This is despite evidence that progress in and Action Plan 2008 – 13. Final report for the Health men’s health can be made in the absence of * Men’s Sheds are defined as dedicated and friendly meeting Service Executive. Dublin: Health Service Executive/ a specific national men’s health policy. In places where men come together to undertake a variety of Department of Health, 2015. Available at: http://www. England and Wales, for example, the Men’s mutually agreed activities, with the aim of sharing skills, mhfi.org/policyreview2015.pdf Health Forum has successfully argued for learning new ones and generally participating in group projects. The overall objective is to enhance the social connectedness the male perspective to be integrated into and well-being of participating men. Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 30 Eurohealth SYSTEMS AND POLICIES

HOSPITAL REFORMS IN SWITZERLAND

By: Wilm Quentin, Friedrich Wittenbecher, Anne Spranger, Luca Crivelli, Isabelle Sturny, Paul Camenzind and Carlo De Pietro

Summary: The health reform process in Switzerland is complicated and almost always takes a very long time due to the fact that particularly broad consensus of the main stakeholders is required. One important area of reform in recent years has been the acute inpatient sector: Diagnosis Related Group (DRG-) based hospital payment was introduced in 2012 and hospital planning was considerably improved through the adoption of detailed planning criteria and increased coordination across cantons. This article provides an overview of hospital reforms in Switzerland and highlights interesting features of the hospital planning model that was adopted by most Cantons in 2015.

Keywords: Hospital reforms, Hospital planning, Hospital payment, DRGs, Switzerland

Introduction regulation and direct intervention. In fact, in the acute hospital inpatient sector, The Swiss health system is often viewed cantons are by far the most important by outsiders, in particular from the United actors in the system. They own most of the States, as an example of a “consumer- larger hospitals in the country, they plan driven” health system. 1 2 This perception hospital capacity, and they are the largest derives from two important features of payer, financing almost half (about 46% the system. First, residents in Switzerland in 2012) of all expenditures for acute have a lot of choice when purchasing their inpatient care. Consequently, cantonal standard mandatory health insurance planning and investment decisions Wilm Quentin is a Senior Research (MHI) package from one of 59 competing determine the supply of inpatient care Fellow, Friedrich Wittenbecher companies, which offer thousands of and Anne Spranger are Research in the country. Fellows at the Department of Health different insurance plans. Second, patients Care Management, University have a lot of choice when choosing their Over the past two decades, many of Technology Berlin, Germany; physician or hospital, and traditional Luca Crivelli is Director of the European countries have aimed to reduce insurance policies allow direct access Department of Business Economics, inpatient capacity because advances in to all levels of care, including hospital Health and Social Care, and medical technology have allowed faster Carlo De Pietro is Professor at inpatient care, without the need for discharge of patients and treatment in the University of Applied Sciences a referral. and Arts of Southern Switzerland; day care settings. In comparison with Isabelle Sturny is Head of the Client its neighbouring countries, including Center and Paul Camenzind is However, what is often overlooked (at Austria, France and Germany, Switzerland Deputy Director of the Swiss Health least by outsiders) is the strong role of the Observatory (Obsan). has been able to reduce bed capacity federal government and of the 26 cantons Email: [email protected] considerably more strongly since the in shaping the health system through

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Figure 1: Beds in acute hospitals per 1000 population in Switzerland and selected countries, 1990 to 2013

8

7

6

Austria Germany 5

EU members since 2004/2007 4 EU France EU members before 2004 3 Netherlands Switzerland Italy 2 United Kingdom

1 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: 3

year 2000 (see Figure 1). In 2013, there far-reaching consequences on the hospital of insurance coverage for cross-border were 2.91 acute care beds per 1000 sector. It introduced Swiss-DRGs as the inpatient care (i.e. for care provided in population in Switzerland, which was basis for hospital payment; it increased one canton to residents of another canton) almost 20% below the average of countries choice for patients (and competition for which is now systematically covered by that had joined the European Union (EU) hospitals) because patients can now choose MHI. Prior to the reform, out-of-canton before 2004. to be treated in private hospitals and in services were covered by MHI and cantons hospitals outside their canton of residence; only in the case of emergency or if the This article describes the most important and it mandated cantons to improve their services were not available in the insuree’s hospital reforms in Switzerland since planning of hospital inpatient care and canton of residence. Patients wishing to the year 2000. These reforms do not to coordinate planning activities with have choice of provider in other cantons necessarily explain the comparatively other cantons, in particular in the area of had to take out supplementary voluntary faster decline in bed capacity in highly specialised care. Consequently, two health insurance (VHI) or pay directly. Switzerland than in neighbouring of the other three reforms mentioned in countries. However, they have supported Table 1, i.e. the inter-cantonal agreement The new rules for the financing of cross- this trend through changes in financial on highly specialised medical services, border care in Switzerland are interesting incentives and by improving planning and the adoption of the Zurich model for for EU Member States because regulations of inpatient capacity in the country. hospital planning, are directly related to in Switzerland are similar to regulations Furthermore, a recently adopted model for the hospital financing reform. Finally, the that apply to cross-border health care in the planning of inpatient capacity might establishment of the National Association the EU. Swiss residents can choose to be provide inspiration for improved hospital for Quality Improvement in Hospitals treated in any hospital in Switzerland and planning in other countries. and Clinics (ANQ) has promoted the they receive reimbursement up to the level collection of data in order to improve the of costs that would have been paid in the Focus on financing, planning, and quality of care of acute, rehabilitation, and canton of residence for the same service. quality of care psychiatric hospitals. However, the introduction of Swiss-DRGs has solved a problem that still persists in Table 1 summarises the most important Cross-border health care within the EU: in Switzerland, it is now possible reforms and other significant Switzerland to compare costs for a particular service developments in the hospital inpatient across cantons because inpatient services sector since the year 2000. The hospital One part of the hospital financing reform are defined by the Swiss-DRG system. financing reform has had particularly introduced inter-cantonal portability In contrast in the EU, it is not possible

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Table 1: Major reforms and other significant developments in the hospital inpatient sector, 2000 – 2015

Reforms Contents Year passed Year implemented Hospital Financing Reform Adoption of Swiss DRGs for payment of inpatient care. 2007 2012 Inter-cantonal portability of insurance coverage for inpatient care (with limitations). Inter-cantonal hospital planning for highly specialised medicine. Inter-Cantonal Agreement on Highly Specialised Organisation of the inter-cantonal planning of highly 2008 2009 Medical Services specialised medicine. Creation of the National Association for Quality Agreement of hospitals, cantons and insurers to merge – 2009 Improvement in Hospitals and Clinics (ANQ) two previously existing quality initiatives into one national association.

Adoption of the Zurich model of hospital planning The Zurich model defines groups of hospital services and – 2015 by most cantons specifies quality criteria that hospitals have to fulfil in order to be allowed to provide these services.

Source: based on 4

Table 2: Service-specific requirements for hospital planning group GEF2 – estimating future care needs, including Intraabdominal Vascular Surgery numbers of patients and bed days for different areas of acute inpatient care on Specialist qualifications Surgeon with sub-specialisation in vascular surgery the basis of epidemiological extrapolations to the year 2020. 5 In a second step, a Specialist availability 24/7, intervention starts within ≤ 30 min hospital planning model was developed, Emergency department 24/7, during day time a surgeon and a specialist in internal medicine which defines about 140 hospital planning are available within 5 minutes; during nights and weekends, a surgeon is available within 15 minutes, a specialist in internal medicine within groups, which group together similar 30 minutes, in-house availability of an anaesthetist and intensive hospital services. 6 For each of these care specialist groups, certain structural requirements are Intensive Care Unit (ICU) Level 2 ICU according to national standards specified concerning the availability of an Applicability of other GEF2 can be provided only if hospitals fulfil service requirements for emergency department, an intensive care service requirements other hospital planning groups (1) ANG2 - intraabdominal unit (ICU), other specialty departments interventional angiology + (2) RAD1 – interventional radiology + and minimum volume thresholds. (at least in cooperation with another hospital) (3) HER1.1 – cardiac Table 2 provides an example of service- surgery or vascular surgery with heart-lung machine specific requirements for the hospital Minimum volume threshold 10 per year planning group GEF 2 – Intraabdominal Other requirements Interdisciplinary conference for confirmation of indication Vascular Surgery.

Providers have to apply to be included Source: Authors’ own compilation based on 7 in the hospital list. The cantonal department of health then follows a two- to compare costs for inpatient services should be based on quality, efficiency and step procedure for checking if hospitals across borders because different countries geographic accessibility. Cantonal hospital fulfil the requirements. First, general have different DRG systems or do not use lists are important because they determine requirements are evaluated at the level DRGs at all. which hospitals are allowed to provide of the hospital for quality (e.g. having which MHI-reimbursable services. The implemented discharge pathways or Improved cantonal inpatient planning Canton of Zurich has been very influential quality management systems), efficiency supports better purchasing in promoting objective planning criteria (i.e. having case-mix adjusted costs that and in developing a planning model that do not exceed by more than 15% the The hospital financing reform has was adopted by most other cantons in 2015 average costs of cantonal hospitals), and fundamentally changed the planning (see Table 1). This model could potentially geographic availability. Second, service of inpatient capacity in Switzerland. It provide inspiration also for other countries specific requirements are evaluated for specified that cantons should plan hospital that work on improving hospital planning. each of the hospital planning groups, capacity on the basis of objective criteria, using the criteria specified in Table 2. and that the selection of providers for In a first step, the Zurich Department Subsequently, hospitals are included in inclusion in the cantonal hospital list of Health developed a methodology for the hospital list for the specific hospital

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planning group. Because inclusion in the Planning for these areas of medical care 4 De Pietro C, Camenzind P, Sturny I, Crivelli L, hospital list is a prerequisite for providing is now carried out jointly by cantons, Edwards-Garavoglia S, Spranger A, et al. Switzerland: MHI-reimbursable services, hospitals and decisions are binding for all cantons. Health System Review. Health Systems in Transition 2015;17(4). are, in fact, awarded with a contract for Quality requirements have been defined providing the related service. for each area of highly specialised 5 Canton Zurich. Zürcher Spitalplanung 2012: medicine concerning structures and Versorgungsbericht. Zürich: Canton Zurich Department of Health, 2009. processes. Providers have to comply with these requirements if they wish to be 6 Canton Zurich. Spitalplanungs-Leistungsgruppen hospital included in the hospital list for a particular (SPLG) Akutsomatik. Zurich: Canton Zürich, Gesundheitsdirektion, 2014 [11 December 2014]. area of highly specialised medicine. The Available at: http://www.gd.zh.ch/internet/ financing reform result of the planning process is a national gesundheitsdirektion/de/themen/behoerden/ list of hospitals that are allowed to perform spitalplanung_leistungsgruppen.html#a-content

has had far- one or several of these highly specialised 7 Canton Zürich. Anhang zur Zürcher Spitalliste 2012 medical services in Switzerland. Akutsomatik: Leistungsspezifische Anforderungen. reaching Therefore, in addition to the hospital Zurich: Canton Zürich, Gesundheitsdirektion, plans of the 26 cantons, an inter-cantonal 2015 [27 October 2015]. Available at: http:// consequences hospital list exists, specifying for each www.gd.zh.ch/dam/gesundheitsdirektion/ direktion/themen/behoerden/spitalplanung/ field of highly specialised medical care, leistungsgruppen/aktuelle_leistungsgruppen_ In the Canton of Zurich the new rules for where these services can be provided in und_anforderungen/a_leistungsspezifische_ hospital planning have had an important Switzerland. 10 anforderungen_akutsomatik_2015.1_gueltig_ impact on the structure of care provision. ab_01.1.2015.pdf.spooler.download.1417443819941. Since 2012, only the University Hospital pdf/a_leistungsspezifische_anforderungen_ ‘‘ Conclusion akutsomatik_2015.1_gueltig_ab_01.1.2015.pdf of Zurich is allowed to provide services for most of the 140 hospital planning groups. 8 Hospital reforms in Switzerland 8 Canton Zurich. Zürcher Spitalplanung 2012: All other hospitals are allowed to provide since 2000 have focused on financing, Strukturberich – Das wichtigste in Kürze. Zürich: Canton Zurich Department of Health, 2011. only a small proportion of these groups. In planning, and quality of care. The 2007 other cantons, the impact of the hospital hospital financing reform has some 9 GDK/CDS. Koordination und Konzentration der planning reform has often been weaker for important implications for policy-makers, hochspezialisierten Medizin. Bern: GDK/CDS, 2014. various reasons, including the absence of a always bearing in mind the specificities of 10 GDK/CDS. Spitalliste im Bereich der university hospital, greater importance of the Swiss health system: first, it shows that hochspezialisierten Medizin. Bern: GDK/CDS, assuring geographic availability, stronger in the context of cross-border health care, 2015. Available at: http://www.gdk-cds.ch/index. php?id=903&L=1%20AND%201%3D1%97. influence of private hospitals vis-à-vis it would be important to have a common cantonal politics and government, etc. definition of hospital activity in order to determine if costs of care delivered in Highly specialised medical care and one country are higher or lower than in reference centres another country. Second, the Zurich model for the planning of inpatient capacity is Hospital planning has improved not promising and might provide inspiration only within cantons but also across for improved planning and purchasing of cantons. The hospital financing reform inpatient care in other countries. Third, the obliged cantons to coordinate their approach of the GDK/CDS for defining planning activities for highly specialised areas of highly-specialised medicine medical care with the aim of promoting and specifying quality requirements for concentration of highly specialised each of these areas could be useful also care in reference centres. In response for other countries that are working on to this requirement and to avoid federal designating reference centres for highly- regulation in this area, the Conference specialised medical care. of the Cantonal Ministers of Health (GDK/CDS) adopted an inter-cantonal References agreement on highly specialised medical care (IVHSM) in January 2009. 9 Since 1 Okma KG, Crivelli L. Swiss and Dutch "consumer- then, 39 highly specialised medical fields driven health care": ideal model or reality? Health Policy 2013;109(2):105 – 12. have been identified, including stroke, neurosurgery, severe trauma and severe 2 Herzlinger RE, Parsa-Parsi R. Consumer-driven burns, organ transplantations, stem cell health care: lessons from Switzerland. JAMA 2004;292(10):1213 – 20. transplantations, proton therapy, cochlear implants and visceral surgery. 3 European health for all database [Internet]. WHO Regional Office for Europe. 2015 [cited 16 September 2015]. Available at: http://data.euro.who.int/hfadb/

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NEW PUBLICATIONS

Promoting Health, Preventing Disease: How can countries address the efficiency and The economic case equity implications of health professional mobility in Europe? Edited by: D McDaid, F Sassi and S Merkur

Maidenhead: Open University Press, 2015 By: IA Glinos, M Wismar, J Buchan and I Rakovac

Number of pages: 337; ISBN: 978 03 352 6226 7 Copenhagen: World Health Organization, 2015 Observatory Policy Brief 18 Freely available for download at: http://www.euro.who. int/__data/assets/pdf_file/0006/283695/Promoting-Health- Number of pages: 28; ISSN: 1997–8073 Preventing-Disease-Economic-Case.pdf?ua=1 Freely available for download: http://www.euro.who.int/__data/ This book provides an economic perspective on health promotion assets/pdf_file/0008/287666/OBS_PB18_How-can-countries- and chronic disease prevention, and gives a rationale for assessing address-the-efficiency-and-equity-implications-of-health- the economic case for action. It professional-mobility-in-Europe.pdf?ua=1 provides a comprehensive review The health workforce is a key contributor to health system of the evidence base in support performance. Shortages, mal-distribution and skill-mismatches of of a broad range of public health health professionals can have interventions, addressing not immediate consequences for only their effectiveness in

LYSIS the efficiency and equity of improving population health, but HEALTH SYSTEMS AND POLICY ANA health systems. The in- and also their implementation costs, out-flows of health impacts on health expenditures POLICY BRIEF 18 professionals change the and wider economic How can countries address the efficiency and equity implications composition of the health consequences. of health professional mobility in Europe? workforce in both source and Adapting policies in the context of the WHO An economic perspective is Code of Practice and EU freedom of movement destination countries, and

about more than counting Irene A Glinos may improve or aggravate Matthias Wismar the costs associated with James Buchan health workforce problems. poor health. It is about In the European Union, EU understanding how economic health professionals are free incentives can influence healthy lifestyle choices in the to move and seek work in population. The book provides tools for developing effective and any Member State. Intra- efficient policy strategies and addressing trade-offs between the EU mobility is increasing; goals of improving population health, while being mindful of the some countries rely on foreign inflows while other Member need to tackle inequalities in health outcomes across individuals States experience important outflows. At the global level, the WHO and populations. Global Code of Practice on the International Recruitment of Health The book practically illustrates methods and measures of cost and Personnel calls on countries to mitigate the negative effects of outcome used in the evaluation of interventions and covers specific migration and encourage positive ones. risk factor areas. It is designed for health policy makers and all those This brief analyses the impact of free mobility of health professionals working or studying in the areas of public health, health research, for destination countries, source countries and the EU as a medicine or health economics. whole, and presents the policy tools which decision-makers can Contents: Introduction; Supporting effective and efficient policies; use to address its effects on efficiency and equity. While health Measurement; Curbing tobacco smoking; Tackling alcohol-related professional mobility is not in itself “good” or “bad”, targeted well- harms; Promoting physical activity; Improving the quality of nutrition; conceived policy measures can make it work better. Addressing environmental risks for child health; Preventing road- Contents: Key messages; Executive summary; 1. Introducing related injuries; Protecting mental health; Social determinants the Efficiency-Equity Conundrum; 2. Trends in Mobility: of health; Health inequalities; Translating evidence into policy; A New Map of Europe?; 3. Unpacking the Efficiency-Equity Intersectoral action; The way forward. Conundrum: A Matrix; 4. Policy Options: How to make mobility work better; 5. Implementation Considerations; 6. Conclusions; Acknowledgements; References.

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NEWS

International whereby Member States are to co-ordinate Transatlantic Taskforce on Antimicrobial their national responses. Resistance meets in Luxembourg Report: Cross-Border Health Threats The report is available at: http://tinyurl.com/ Decision has improved health security On 22–23 October, nearly 80 international zwl2b3e in the EU experts in antimicrobial resistance came together in Luxembourg for a meeting of The European Commission adopted the Transatlantic Taskforce on Antimicrobial Commission launches new version Decision 1082/2013/EU on serious Resistance (TATFAR). This was created of ECHI data tool cross-border threats to health, following a 2009 US – EU presidential on 22 October 2013. It has now published summit on combating antimicrobial On 11 November at the Expert Group a report that assesses progress with resistance. Intended to fortify relationships on Health Information (EGHI) meeting in implementation over the subsequent two and collaborations on activities relating to Luxembourg, the Commission launched years. The report, in particular, includes an antimicrobial resistance (AMR), the biennial the European Core Health Indicators assessment of the operation of the Early in-person meeting provide members and (ECHI) data tool to replace the existing Warning and Response System (EWRS) the TATFAR partners (Canada, EU, Norway “Heidi” data tool. The new tool presents and of the epidemiological surveillance and the US) the opportunity to plan, relevant and comparable information on network, as well as information on how the coordinate, and comment on technical health at European level in an interactive established mechanisms and structures activities for its next implementation period. way, covering five groups of indicators: complement other alert systems at Union 1) demographic and socio-economic Attendees heard opening remarks from level while not duplicating them. The factors, 2) health status, 3) health the TATFAR co-chairs; the European report concludes that the established determinants (smoking, alcohol, etc.), Union (EU) Commissioner for Health and mechanisms have worked well and that the 4) health interventions / health services, Food Safety, Vytenis Andriukaitis and Decision has improved health security in and 5) health promotion. Luxembourg Minister of Health, Lydia the EU. The EWRS has been instrumental Mutsch, who both emphasised the need to notify alerts as well as measures More information at: http://ec.europa.eu/ to improve antibiotic use in humans and in undertaken by the Member States. The health/indicators/echi/index_en.htm animals, surveillance of resistant infections, epidemiological surveillance network, the and drug development. Commissioner EWRS, the European Centre for Disease Andriukaitis remarked specifically that Prevention and Control (ECDC), and the Tobacco: specifications for health new business models to pique drug Health Security Committee (HSC) have warnings on cigarette packages adopted development, partnerships to harmonise operated effectively, and to the required surveillance, and national actions plans quality level, during serious cross-border An implementing act adopted on 9 October where they have yet to be developed, are threats to health. These systems have lays out specifications for the new needed. Minister Mutsch also pointed to complemented EU rapid alert systems combined health warnings on packages the gains that can be made in reduction of which cover other areas (e.g. food, animal of tobacco products for smoking (in unnecessary antimicrobial use by robust health, etc.), while avoiding any duplication. particular cigarettes and roll-your-own stewardship policies, such as has been tobacco), which are required under the Measures successfully carried out during experienced in Luxembourg. She stressed Tobacco Products Directive (2014/40/EU). the Ebola outbreak include information to the commitment of the presidency to The new health warnings will comprise travellers, guidance to health professionals, supporting international action on AMR, a colour photograph, a text warning and medical evacuation to the EU of including attention to the new proposals on on the harmful effects of smoking and patients and health workers infected or veterinary medicines in the EU legislative smoking cessation information. These suspected to be infected with the Ebola programme. should collectively cover 65% of the front virus. The report notes that while overall and back of packages, in accordance Attendees participated in discussions that communication in the HSC has been with the aforementioned Directive. The produced proposals for joint actions to reasonably effective, some important implementing decision gives technical be taken over the next five years. These lessons have been learned. During specifications for the layout, design and include work to standardise the definition of the peak of the Ebola outbreak there shape of the combined health warnings appropriate antibiotic use for surveillance; was a strong focus on the exchange of taking into account different packet to produce a review of AMR reduction information while the impetus to discuss shapes. These new health warnings will targets; to characterise transmission, and coordinate the response was less appear on packages across the EU from surveillance, and communication related to considerable. A major conclusion from the May 2016. AMR interventions in veterinary medicine; Ebola outbreak is that there is scope for to have policy dialogues on regulatory improving the implementation of provisions

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control and on actions to strengthen come with migrants as in that respect, they problems. Danish Health Minister Sophie surveillance and compliance. These do not pose a greater risk than international Løhde stressed the importance of sharing proposals will be further refined by the travellers; efforts should be directed to the experience of what works across the TATFAR members before adoption. most vulnerable parts of the population Nordic countries in the effort toward e.g. children, women, older people and people with mental disorders, adding that More information at: http://www.cdc.gov/ those in need of mental health care. she hoped that the summit would be the drugresistance/tatfar/ starting point for closer cooperation in this More information at: http://tinyurl.com/ area in the future, pfnplhr High-level meeting on refugee and Materials from the summit are available at: migrant health http://www.xn--nordiskpsykiatritopmde- pjc.dk/ In 2015, nearly two million refugees and Country News migrants have taken shelter in Turkey, while over 700,000 have entered other Refugees: Commissioner Andriukaitis Ireland: Original plans for universal countries in the World Health Organization presents the Personal Health Record health insurance will not go ahead (WHO) European Region. It was in this in Greece context that a WHO high-level meeting on On 18 November Minister for Health Leo refugee and migrant health, hosted by the On 19 November during a visit in Varadkar definitively ruled out pressing Italian Government, took place in Rome Greece, Health and Food Safety DG ahead with the Government’s original plans on 23 and 24 November. Commissioner Andriukaitis presented for universal health insurance. The decision the “Personal Health Record” (PHR) to comes after publication of a new study Opening the meeting, Beatrice Lorenzin, Greek authorities in Athens and to non- from the Economic and Social Research Minister of Health of Italy, emphasised that governmental organisations on the island Unit (ESRI) which reports that the proposed the Region must not renounce its values of of Lesbos, where he visited a centre for model of Universal Health Insurance (UHI) solidarity and called on countries to come refugees. This document prepared by the would increase overall health spending by together to provide leadership and offer Commission, together with the International up to 11%, or as much as €2 billion a year. refuge and health care to those seeking Organisation for Migration, will be made The proposals would have made health greater security. “We cannot turn away our available at hotspots, to evaluate migrants’ insurance mandatory with every individual eyes”, she said. medical needs and help reconstruct their having equal access to a standard package Dr Zsuzsanna Jakab, WHO Regional medical history. The PHR is accompanied of primary and acute hospital services, Director for Europe said that the objective by a handbook to be used by health including acute mental health services. The of the conference was to start to prepare a professionals. system would have had open enrolment, framework for long-term action on refugee lifetime cover and community rating, with The personal health record is available at: and migrant health that could be discussed a choice between competing insurers http://tinyurl.com/nerzug5 and agreed by the Regional Committee who would have been obliged to offer the and the handbook at: in September 2016. She noted that “the same package of services to all. Lead- http://tinyurl.com/nhy2hkl European public health community must author of the ESRI report, ‘An examination do what we can to respond to the needs of the Potential Costs of Universal Health of those fleeing, to see that they are cared Insurance in Ireland’, Dr Maeve-Ann Nordic Summit on Mental Health for in both the short and longer terms, and Wren, stated that competition law would that our health systems are able to deal have limited the government’s ability to The Danish Ministry of Health hosted the effectively and humanely with these extra control pricing and insurers’ margins. The first Nordic Summit on Mental Health in demands, whilst continuing to offer full report recommends further research into cooperation with The Nordic Council, services to resident populations.” alternative UHI models. The Danish foundation Trygfonden and the Key points in an outcome document Social Network on 6th November 2015. The report is available at: http://tinyurl.com/ developed at the meeting included The Summit was opened by Crown hxuwbbx integrating the needs of refugees and Princess Mary of Denmark who is also migrants into existing health structures as Patron of the Danish Mental Health Fund. quickly as possible. Systems collecting It focused on improving services for people Additional materials supplied by: data on migrant health also need to with mental disorders, and creating the EuroHealthNet Office be reinforced and be available to other framework for knowledge and experience 67 rue de la Loi, B-1040 Brussels countries as an individual moves around. It exchange between the Nordic countries. Tel: + 32 2 235 03 20 was also stressed that health assessment Danish, Swedish, Norwegian, Icelandic Fax: + 32 2 235 03 39 and mandatory screening should not be and Finnish researchers, specialists, Email: [email protected] seen as a solution, as migrants do not pose experts, users, relatives, politicians and a threat to public health. Participants also ministers came together in Copenhagen noted that it was important to demystify the to discuss how to overcome the stigma perception that communicable diseases surrounding people with mental health

Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015

The Gastein Health Outcomes 2015

Securing health in Europe – Balancing priorities, sharing responsibilities The 18th edition of the European Health Forum Gastein (EHFG) explored how to respond in an age when “crisis is the new normal”. In an ever-changing political and social environment for health, how can we safeguard past gains to our health systems while responding to new threats and opportunities?

Key Outcomes of the EHFG 2015 • We need “more Europe” – deeper cooperation – to develop a comprehensive, sustainable and collective strategy to respond to the challenges and opportunities presented by key societal challenges. The costs and consequences of non-Europe should be considered. • This is not a refugee crisis, this is a reception crisis. Human mobility is the new norm in our increasingly globalised world. • A paradigm change is needed in the way we finance, organise and operate our health systems; particularly to take into account demographic changes, rising healthcare costs, new patterns of disease and a shortage of skilled health workers. Strengthened primary healthcare, a better workforce skills-mix and technological innovations, amongst other things, can play a major role here. • We need to build-in mechanisms to ensure joint accountability for Health in All Policies (HiAP) across government ministries and European institutions. Improved inter-sectoral collaboration is a pre-condition for health security.

For full details, see the Gastein Health Outcomes 2015.

Available at: http://www.ehfg.org/fileadmin/ehfg/Programm/2015/EHFG_ Gastein_Health_Outcomes_2015.pdf

Save the Date: 19th EHFG th th European 28 – 30 September 2016 Health Bad Hofgastein, Austria Forum www.ehfg.org GASTEIN