Analysing Health Targets in Europe

Volume 5 Number 3, Autumn 1999 eurohealth

The European Parliament and public health

Measuring the appropriateness of health care

Cost sharing in health care

Health policy in the UK On behalf of the editorial team I am very pleased to wel- eurohealth come Mike Sedgley as the new editor of eurohealth. He arrives at an exiting time of change for the European LSE Health, London School of Economics and Political Science, p Union. Many important developments in European Houghton Street, London WC2A 2AE, politics have and will continue to take place over the United Kingdom Tel: +44 171 955 6840 coming year, with a new Commission and Parliament, Fax: +44 171 955 6803 the bringing together of health and consumer policy Web Site: www.lse.ac.uk\department\lse health issues into a single Directorate General within the – r Commission, and, importantly, the publication of pro- EDITORIAL posals early next year for a future EU health policy. It EDITOR: Mike Sedgley: +44 171 955 6194 has been a pleasure to work with Mike on his first issue email: [email protected] of eurohealth and I look forward to working with him SENIOR EDITORIAL ADVISER: Paul Belcher: +44 171 955 6377 on many issues to come. email: [email protected] e EDITORIAL TEAM: Paul Belcher Johan Calltorp Julian Le Grand Senior Editorial Adviser Walter Holland Elias Mossialos

SUBSCRIPTIONS It is an exciting time for eurohealth, as a forum for debate Janice Isaac: +44 171 955 6840 f between policy makers and academics, to have a new email: [email protected] generation of decision-makers in Europe’s institutions, Published by LSE Health and the and I hope that many of them, over the coming months, European Health Policy Research will be contributing to discussion about the place of the Network (EHPRN) with the financial support of LSE Health and Merck and a Union in the health policy field. We are making a good Co Inc. start in this issue, in which Caroline Jackson, the new eurohealth is a quarterly publication Chair of the European Parliament committee responsible which provides a forum for policy- makers and experts to express their views for public health, outlines her views of the role of the on health policy issues and so contribute European Union and the Parliamentary Committee in to a constructive debate on public health policy in Europe. c this field. The views expressed in eurohealth are The new Directorate General for Health and Consumer those of the authors alone and not necessarily those of LSE Health and EHPRN. Protection to some extent reflects the nature of the EU’s primary role in public health and also the connection ADVISORY BOARD e between these two policy areas. It remains to be seen, Dr Anders Anell; Professor David Banta; Mr Michael Brown; Dr Reinhard Busse; however, whether important areas of health policy are Professor Correia de Campos; Mr Graham Chambers; Professor Marie eclipsed by food safety issues. There are worrying signs Christine Closon; Dr Giovanni Fattore; that the public perception of the new DG is as one Dr Josep Figueras; Dr Livio Garattini; Dr Unto Häkkinen; Professor Chris Ham; primarily concerned with this important but narrow Mr Strachan Heppel; Professor David aspect of health. Hunter; Professor Claude Jasmin; Professor Egon Jonsson; Dr Jim Kahan; Professor Felix Lobo; Professor Guillem There are further challenges ahead for health policy- Lopez-Casasnovas; Mr Martin Lund; makers in Europe, as member-state populations age and Professor Martin McKee; Dr Bernard Merkel; Dr Stipe Oreskovic; technologies advance. eurohealth will continue to have an Professor Alain Pompidou MEP; Dr Alexander Preker; Dr André Prost; important part to play in the exchange of ideas and opin- Dr Tessa Richards; Professor Richard ions about the future of Europe’s public health and Saltman; Dr B Serdar Savas; Mr Gisbert Selke; Professor Igor Sheiman; health care systems into the next century. This issue con- Professor JJ Sixma; Professor Aris tains several articles discussing many of these problems Sissouras; Dr Hans Stein; Dr Miriam Wiley

and providing some options for action. © LSE Health 1999. No part of this publication may be copied, reproduced, stored in a I hope readers will be able to continue to rely on retrieval system or transmitted in any form eurohealth as a source of the very best discussion, debate without prior permission from LSE Health. and information about all that is happening in European Design and Production: Westminster European, email: [email protected] health. Reprographics: FMT Colour Limited Printing: Seven Corners Press Ltd Mike Sedgley ISSN 1356-1030 Contents Autumn 1999 Volume 5 Number 3

“Giving health the priority it deserves” CONTRIBUTORS TO THIS ISSUE ANDERS ANELL is Managing Director at the 1 The role of the European Parliament and its Committee on the Swedish Institute for Health Economics, Environment, Public Health and Consumer Policy in health issues Sweden Caroline Jackson MEP BERNARD BURNAND is a Senior Lecturer at the Institut de Médecine Sociale et Préventive, University of Lausanne, Switzerland

Health targets, health care and health policy in the EU REINHARD BUSSE is Senior Research Fellow at the European Observatory on Health Care 3 Health targets, care and Systems, Head of the Madrid Hub based at policy in the EU: Setting the agenda Escuela Nacional de Sanidad, Spain Matthias Wismar, Reinhard Busse and Friedrich Wilhelm Schwartz DIANE DAWSON is a Senior Research Fellow at the Centre for Health Economics, University of York, UK

KATHRYN FITCH is Senior Researcher at the Instituto de Salud Carlos III, Madrid, Spain

Cost sharing in health care DAVID J HUNTER is Professor of Health Policy and Management at the Nuffield Institute for 24 Perspectives on cost sharing Health, University of Leeds, UK Ray Robinson CAROLINE JACKSON MEP is Chair of the Euro- 5 Defining health targets pean Parliament Committee on the Environ- 25 User charges in health care: ment, Public Health and Consumer Policy Loes van Herten the Swedish case JAMES P KAHAN is a Practice Director at RAND Anders Anell and Marianne 7 Health targets: policies, Europe, Leiden, the Netherlands polity and politics Svensson PABLO LAZARO is Director of the Health Services Matthias Wismar 27 Could charging patients fill Unit, Instituto de Salud Carlos III 9 Implementing health targets the cash gap in Europe’s JULIAN LE GRAND is Richard Titmuss Professor in health care health care systems? of Social Policy, Department of Social Policy David J Hunter Adrian Towse and Administration, and Chairman of LSE Health, London School of Economics and 12 Evaluation and outcomes of 29 Why charge patients if Political Science, UK health targets there are better ways to DONALD REID is Joint Chief Executive of the UK Reinhard Busse contain costs, encourage Public Health Association efficiency and reach for ANNA RITSATAKIS is Head of the WHO 14 Setting targets for health: the equity? European Centre for Health Policy WHO European experience Diane Dawson RAY ROBINSON is Professor of Health Policy at Anna Ritsatakis LSE Health, London School of Economics, UK

FRIEDRICH WILHELM SCHWARTZ is Director of the Department of Epidemiology, Social Medicine Health policy and reform in and Health System Research, Medical School Appropriateness as a tool the UK Hannover, Germany for quality assurance MARIANNE SVENSSON is Senior Project Manager 32 Reform of the NHS under at the Swedish Institute for Health Economics, 16 Defining appropriate health New Labour Sweden care Julian Le Grand ADRIAN TOWSE is Director of the Office of James P Kahan and Mirjam Health Economics, London, UK 34 The new Health van het Loo JOHN-PAUL VADER is Senior Researcher at the Development Agency for Institute of Social and Preventive Medicine, 19 Using appropriateness England. What will it do? University of Lausanne, Switzerland criteria to improve health Donald Reid LOES VAN HERTEN is an epidemiologist at the care Public Health Division, TNO Prevention and Kathryn Fitch and Pablo Health, Leiden, the Netherlands Lázaro MIRJAM VAN HET LOO is a Policy Analyst at 21 Prospective assessment of 36 European Union news RAND Europe, Leiden, the Netherlands the appropriateness of by the European Network of MATTHIAS WISMAR is Head of Working Focus on health care Health Promotion Agencies European Health Policy Research, Department of Epidemiology, Social Medicine and Health John-Paul Vader and and the Health Education Bernard Burnand System Research, Medical School Hannover, Authority, England Germany THE EUROPEAN PARLIAMENT

Following the European Parliamentary elections of last summer, Caroline Jackson has been nominated as the new Chair of the European Parliament Committee on the Environment, Public Health and Consumer Policy. Dr Jackson here elaborates on the role of the Union in the public health field and on the role of the Committee in the development of health-related policies and initiatives. She also comments on the major successes and failures of EU health programmes and on how the EU role in health policy fields is likely to and ought to develop in confronting challenges common to all Member States. “Giving health the priority it deserves”

The role of the European Parliament and its Committee on the Environment, Public Health and Consumer Policy in health issues

tosanitary fields which have as their Commission is responsible for direct objective the protection of putting forward proposals for public health, and incentive mea- actions, the actual decision-making sures designed to protect and power is shared equally between the Caroline Jackson MEP improve human health. The empha- Council on the one hand and the sis throughout is on complementing European Parliament on the other. the policies of the Member States and encouraging cooperation. The detailed scrutiny of any propos- While the EU has long been active in als coming from the Commission contributing to health protection in Clearly, the EU is particularly well placed to do this, helping Member relating to public health is the job of a variety of ways, public health as the European Parliament's such is a relatively new policy area States to act more effectively togeth- Committee on Environment, Public for the EU. It was not until 1993, er than would be possible separately Health and Consumer Policy, of with the Treaty on European Union, in certain areas – in other words, which I am Chairman. This means that the health dimension was finally providing what has become known that we deal with a wide range of given full formal recognition in the as ‘Community added value’. But it issues. Towards the end of the last European context, with the intro- is not in a position, and nor should it legislature, for example, we had been duction among other things of a spe- be – as the Amsterdam Treaty makes looking at matters as diverse as cific legal base for EU action. The clear – to intervene in the running or Amsterdam Treaty, which came into funding of our respective national orphan drugs, exposure to electro- force on 1 May 1999, develops the health services or their programmes magnetic fields and BSE. Our new health dimension still further. and policies. There are however responsibilities mean that in future numerous areas where the EU can we will most certainly be giving still Community action, according to the and should make a major contribu- more attention to areas such as food Treaty, should be aimed at improv- tion and where it, and the European safety, animal foodstuff and veteri- ing public health, preventing illness Parliament in particular, has an nary health issues, as well as the and disease, and obviating sources of important role to play. more conventional health questions. danger to human health. It should cover research into the major health European decision-making in the Once the committee has adopted its scourges, as well as health informa- health area is based on the co-deci- report on the Commission proposal, tion and education activities. Specific sion procedure. This implies the full it goes to Parliament's plenary for reference is also made in the Treaty and equal participation of further discussion and final adoption to quality and safety standards for Parliament in the decision-making as Parliament's formal position on organs and substances of human ori- process. It represents one of the question. When the co-decision Parliament's most powerful tools. It gin, blood and blood derivatives; procedure applies, as it now does in means that while the European measures in the veterinary and phy- the vast majority of cases, if

1 eurohealth Vol 5 No 3 Autumn 1999 THE EUROPEAN PARLIAMENT

Parliament is not satisfied with the central to the EU's activities on concerned – patients, consumers, the way in which Council goes on to health, for example by encouraging medical profession, industry, and deal with the question, it can insist and assisting with publicising certain government. Cooperation and open- on conciliation. In the rare event that initiatives. Last year's report on ness is crucial if we are to manage no compromise is possible, osteoporosis in the EC – “Action for the fast pace of change. This was the Parliament could if necessary reject Prevention” is just one example of conclusion of the Parliament's the entire proposal. this. Finally, it has significant power report on the Communication at the to intervene directly in the drawing end of the last legislature and I am It is rare for matters to reach that up of the EU budget for the areas it confident that the new committee point – but it provides a valuable and covers, in order to ensure that and Parliament will adopt a similar so far extremely effective stimulus resources are directed where they are stance. for all sides to find a solution. It was needed most. at the beginning of 1996 that the first In the public health field, perhaps health legislation was adopted by the Given that public health is a relative- more than in many other areas, there Council of Ministers and the EP ly new policy area for the EU, much is no place for complacency. Hardly after a successful conciliation has already been achieved, but there a day goes by without some new process. As a result, the EU now has is always scope for improvement. concern being raised about the safety a long-term action plan (1996-2000) This is true not only with regard to of the food we eat or the air we on health promotion, information, specific programmes or actions but breathe. BSE, the dioxin crisis, education and training. Since then a also, and especially, with regard to uncertainty over the development number of other measures and pro- the extent to which public health and use of GMOs – these are just grammes, including plans to combat concerns are being integrated into some of the most recent issues which cancer and AIDS, as well as pro- other policy areas. The health have brought home to us all the grammes to combat rare and pollu- dimension cannot be viewed in isola- nature and extent of the new chal- tion-related diseases, have been suc- tion. It must be integrated at an early lenges which exist and which must cessfully adopted under this proce- stage into all policy areas and initia- be met at national, European and dure. In these and many other cases, tives – not least at EU level – and international level if the health and the fact that Parliament enjoys the this is something which I feel sure safety of the consumer and the citi- power of co-decision has meant that my committee will be giving particu- zen are to be guaranteed. Consumers it has been able to influence the lar attention to during the coming need clear, unambiguous, factual direction and budget of these pro- legislature. information to assist them in the grammes and to bring additional choices they make – not only with pressure to bear in order to achieve regard to the food they eat, but also important concessions in the inter- “The health dimension can- with regard to the lifestyles they ests of citizens. The environment, choose to adopt. And most impor- public health and consumer policy not be viewed in isolation. It tantly of all, they need to be able to committee will closely scrutinise any trust the products they buy and the subsequent proposals coming from must be integrated at an information they receive about the Commission, as well as any early stage into all policy them. It is part of our task to help to assessment of what has been bring this about and, by entering and achieved to date, with a view to areas and initiatives - not shaping the debate, to cool any hys- ensuring that the Community really teria, and bring forward the facts. is providing added value to the least at EU level.” The European Parliament's role, in actions of the Member States. this and all areas, is first and fore- While participation in the formal The Commission's Communication most to reflect and defend the inter- decision-making process is one of on the development of public health ests and concerns of the citizens, our most powerful activities, the policy in the EU provides a good whom we as MEPs have been elect- committee has other means at its dis- starting point for re-defining the ed to represent. Our aim, and espe- posal which allow it to intervene in future shape of this crucial policy. It cially that of the committee on the issues falling under its responsibility identifies the importance of better environment, public health and con- and to ensure that appropriate action information; a rapid response to sumer policy, is to ensure that the is taken. For example, it can draw up health threats, health promotion and health, rights, and expectations of reports and resolutions on its own the development of disease preven- those citizens – the patients and the initiative in order to highlight issues tion. All excellent aims. But they are consumers of the EU – are given the of particular concern and to stimu- meaningless if they are not backed priority they deserve. As Chairman late new actions. It can also organise up by concrete action. In particular of that committee, I intend to do my public hearings with a view to gath- the Commission will need to come best to ensure that this is indeed the ering knowledge and expertise on forward with specific, realistic pro- case and that the EU makes a gen- specific issues or on the direction of posals based on clearly defined tar- uine contribution to ensuring the health policy in general. It can con- gets, timescales, methods and strate- highest possible standards of health tribute to the information and gies. There must also be a solid protection for all our citizens as we awareness-raising actions that are so framework for dialogue between all enter the new millennium.

eurohealth Vol 5 No 3 Autumn 1999 2 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU Health targets, care and policy in the EU: Setting the agenda

Matthias Wismar, Reinhard Busse and Friedrich Wilhelm Schwartz

To achieve better health outcomes with scarce resources is a health policy leitmotif for policy makers, administrators and scientists across all Member States of the European Union. Nevertheless, health care policies in most countries remain dominated by been sobering. An evaluation of the US campaign ‘Healthy People 2000’ was not economic considerations and cost-containment policies. encouraging. Out of the 319 strictly quantifiable targets set in 1990 only eight per cent were achieved by 1996. For 40 per cent there was at least a noticeable movement in The World Health Organization’s ‘Health the right direction. For eight per cent of the For All’ (HFA) policy agenda aims to pri- targets no change could be reported and 18 oritise health through an increasing number per cent developed in the wrong direction. of health target programmes – formulated For the remaining 26 per cent no data were and (partly) implemented at national, available. The health service related targets regional and local levels.1 Although they like clinical preventive services, immunisa- address a wide range of intervention areas tion and infectious diseases, maternal and 4 from health promotion via environment to infant health scored even worse. education, health care is often only a minor Similarly, the analysis of the impact of the area or is even neglected. HFA strategy in the Netherlands comes to Is there a potential to include health care in the conclusion that “the health targets for health target programmes to counter-bal- the year 2000 are too ambitious: not one ance the economic orientation of health target will be fully achieved, 10 targets will policies? This issue has rarely been be achieved partially and in five cases some addressed in a systematic way. Equally, the of the target levels had already been challenges of implementing and evaluating achieved before the start of the HFA cam- health targets for health care management paign; 11 targets will not be achieved and have rarely been discussed. Quite to the no conclusion could be reached about the 5 contrary, there is little European compari- 17 other targets”. son, information exchange and cooperation The British "Health of the Nation" cam- in this area even though the Commission of paign which started in 1992 was assessed by the European Communities has called for two reports published in 1998. They con- such measures in its communication “on clude that the campaign, although wel- the development of public health policy in comed by local authorities, healthcare insti- the European Community,”2 which was tutions and health professionals had little endorsed by the European Parliament.3 impact in terms of readjusting priorities on 6 In the light of the growing support for the national, regional or local level. health target programmes we need to Despite fundamental criticism, the research address a simple question: is there evidence teams from the Netherlands and the UK of a need for health targets within health especially have concluded from their services? Do they produce benefits in terms research that the health target programmes of redirecting health policies, improving need a new start, rather than to be abol- medical outcomes, improving resource ished all together. allocation and expanding citizen participation? To assess the scope, feasibility, impact and political options of health targets with a Empirical evidence of the effectiveness of special focus on health policy and health ambitious health target programmes has care was the purpose of an international

3 eurohealth Vol 5 No 3 Autumn 1999 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU workshop that took place in April 1999 in Sharp & Dohme GmbH and the support of Celle, near Hannover, Germany. Under the the German Ministry of Health. auspices of the German Council presidency, the workshop aimed at agenda setting for a Europe-wide discussion on health tar- REFERENCES get programmes. Four major themes were 1. Water HPA, Herten LM. Health Policies discussed: on Target? Review of Health Target and – defining health targets; Priority Setting in 18 European Countries. Leiden: TNO, 1998. – health targets and health policy; 2. Commission of the European Communi- – implementing health targets in health ties. Communication from the Commission care; on the development of public health policy in “Empirical evidence – evaluation and outcomes of health tar- the European Community. COM(1998) gets. 0230 final. 15-4-1998. of the effectiveness of Invited to discuss these issues were policy 3. European Parliament. Resolution on the ambitious health makers, administrators and scientists active communication from the Commission on the in this field. The participants’ backgrounds development of public health policy in the target programmes European Community. COM(98)0230. R4- were either national or regional and com- has been sobering.” prised Finland, Germany, Northrhine- 0082/99. 10-3-1999. Westphalia (Germany), Spain, Portugal, 4. Sondik E. Healthy People 2000: meshing Hungary, the UK, Cracow (Poland), Italy national and local health objectives. Public and The Netherlands. To complement this Health Reports 1996;111:518–20. focus the European Public Health Alliance 5. Water HPA, Herten LM. Bull's Eye of (EPHA) participated to introduce the citi- Achilles' Heel; WHO's European Health for zens and patient perspective. Additionally All Targets Evaluated in the Netherlands. there were representatives from the Leiden: TNO, 1996. German Federal Ministry of Health, the 6. Universities of Leeds and Glamorgan, European Commission, WHO Regional London School of Hygiene and Tropical Office for Europe and from the industry. Medicine. The Health of the Nation – a poli- The international workshop was organised cy assessed. Two reports commission for the by Medical School Hannover. We grateful- Department of Health. London: The ly acknowledge the sponsorship by MSD Stationery Office, 1998.

Preliminary Notice Follow-up Conference on Health Targets, Autumn 2000

The Debate on health targets is rapidly receiving more attention both in terms of regulating healthcare and improving quality and outcomes. This year’s workshop in Celle (as reported in this issue of eurohealth) and the international conference Targets for Health – Shifting the Debate in Paris, September 1999, sponsored by the European Public Health Association (EuPHA), the European Health Management Association (EHMA) and Merck, Sharp & Dohme have con- tributed to this development.

Different programme profiles and initiatives have been identified and discussed by a broad audience. To move forward it is necessary to understand the outcomes of health target programmes. Three outcome parameters have been suggested that may provide ground for further discussion: • discursive outcome: segmented and segregated health services may profit from health targets because they re-focus healthcare on health related issues; • political efficiency: conflict management in health politics may profit from health targets, since actors will more easily agree on measures in relation to established common objectives; • improving health outcomes: implemented health targets may improve population health, efficiency and quality.

Scientific evidence and the international comparison of experience with existing programmes are limited. To bridge this gap will be the purpose of the upcoming conference. eurohealth will provide details when they become available.

eurohealth Vol 5 No 3 Autumn 1999 4 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU Defining health targets

“The target setting approach is seen as a step by step approach with increasing specificity: principles and values, goals, objectives, qualitative targets, quantitative targets, tives > qualitative targets > quantitative tar- indicators for monitoring progress.” gets > indicators for monitoring progress. The participants agreed with those definitions, although some saw difficulties in translating these terms into their own language. As one of them remarked: “We know the term ‘goal’ only in football”. In The discussion in the first session of the addition, remarks were made about the workshop ‘Health targets, health care and conditions related to targets such as real- health policy in the European Union’ ism, achievability within a given time focused on the definition of health targets, frame, and so on. The targets should also the process of health target setting and the preferably be defined in quantified mea- scope and focus of health targets. As could sures, so that conclusions can be drawn be expected at the beginning of a workshop about their attainability. that was intended as a brainstorming exercise many questions were raised. During Which level and what kind of health the session, even more questions arose and targets? some of them were answered. The discussion then moved on to the level of target setting. Two types of levels were Loes van Herten What is a health target? distinguished. The first one is based on What is a health target and what are targets geographical parameters, i.e. the European, in relation to goals and objectives? In national, regional and local levels. The sec- attempting to clarify these matters, two ref- ond one is related to the aggregation level, erences were made to the literature. The i.e. the macro, meso and micro levels. The World Health Organization formulates a participants agreed that both types of levels target as ‘an intermediate result towards the could be used in combination. achievement of goals and objectives; it is During the discussion, four types of targets more specific, has a time horizon and is fre- were mentioned. Distinctions were made quently, though not always, quantified’. In between health outcome targets, intermedi- the same chapter, WHO states ‘A goal ate targets, input targets and process tar- refers to the long-range aims of society and gets. In addition, three types of target use is usually expressed in rather general terms. were mentioned. Health targets were con- In international literature and in many sidered to be a source of inspiration and national policy documents it is frequently motivation, but they were also seen as tech- used interchangeably with the term objec- nical tools for making policy decisions with tive, although according to United Nations an optimal balance between effect (health usage, an objective is rather more specific gain) and the allocation of the available than a goal and it is an aim which can be resources. Furthermore, health targets were partly achieved during the planning peri- seen as a management tool for guiding the od’.1 complicated team work that characterises The other reference was to the report present-day health policy and health care. ‘Health policies on target?’.2 In this report These various opinions are of course com- “health targets a health target is defined as ‘an explicit end- plementary and compatible. point of public health or health care, can only help to make expressed in terms of population health and Why health targets? its determinants, to be pursued within a During the discussion, the question ‘Why health policy given time with systematic monitoring of health targets?’ was raised. Most partici- transparent … they progress towards achievement’. Here also, pants agreed that health targets could be the target setting approach is seen as a step used to rationalise health policy. Since soci- will not reduce costs.” by step approach with increasing specifici- ety is becoming increasingly complex, the ty: principles and values > goals > objec- decision-making process is also becoming

5 eurohealth Vol 5 No 3 Autumn 1999 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU more complex. Furthermore, at a time zens, researchers, politicians, councils, “the crux lies in when most countries are revising their institutions, other sectors, the media, etc. health policy due to the ageing of the pop- However, the answer to the question of democracy and ulation and the increasing prevalence of who should be involved also depends on chronic diseases, together with the increase the question ‘Where is the focus of health empowerment … in technical possibilities and limited finan- targets?’ there should be some cial resources, health targets can also help to establish the ‘big picture’. However, as Where is the focus of health targets? kind of involvement.” one of the participants pointed out, health The diversity in health targets can be targets can only help to make health policy explained by differences in interests, differ- transparent and they will not reduce costs. ences in priorities, differences in target Another argument mentioned in favour of groups, and so on. Until now, most health using health targets was that they can also targets have focused on intervention areas underline the shared commitment between like health promotion, while health care the partners involved in the health target received less attention. The targets will also process. differ according to the levels chosen. Is a health target set at the national level or at Who should set health targets? the local level? Furthermore, does it focus Another point in the discussion was related on the macro or the micro level? to the process of health target setting. Depending on the focus chosen, different Questions asked were: Who initiates the expertise will be needed to start the process process? Who should be involved in the of health target setting. All participants target setting process? Who is responsible? agreed that the health target process is an etc. In reply to the question ‘Who is the ongoing one requiring an interdisciplinary target group?’ the participants preferred the approach. It is also a process that requires term ‘citizen’ to the word ‘population’. commitment and consensus. Such an They considered the word ‘population’ to approach will therefore take time. It is also be too abstract. The population cannot get more than an academic exercise. The setting involved in a health target process; citizens of health targets stands or falls with politi- can. Other terms for referring to the target cal will. Nor does the process stop with the group, such as ‘patients’ or ‘consumers’, formulation of the targets. The definition were rejected. of targets is not the end; it is only the beginning. However, should citizens be involved in the target setting process? Some of the par- In addition, during the course of the dis- “The setting of health ticipants said that citizens expect leadership cussions, more and more questions arose and that they therefore prefer a top-down about the implementation and evaluation of targets stands or falls approach. Others argued that you need health targets. However, these subjects commitment and consensus when setting were discussed in sessions three and four of with political will. health targets, and they therefore advocated the workshop. a bottom-up approach. Some saw difficul- Nor does the process ties in the involvement of citizens, especial- Conclusion stop with the formula- ly when citizens in large areas are asked to During the first session of the workshop, a give their opinion. However, the example lot of questions were raised and some tion of the targets. The of the health facilitators in Sweden made it answers were given. All participants agreed clear that it is not impossible to involve the that it would be impossible to define an definition of targets is public. Other difficulties were seen in the ideal target. However, although most of the power of interest groups and patient organ- questions had more than one answer, the not the end; it is only first session – like the others – was very isations, because setting targets and priori- the beginning.” ties also means giving less priority to other helpful in establishing a common language areas. about health targets. So what is the answer, bottom-up or top- down? The participants came to the conclusion that this depends on the focus and REFERENCES the level of the health targets. A combination of bottom-up and top-down was con- 1. WHO Regional Office for Europe/ European Centre for Health Policy. sidered necessary when defining a complete Setting targets for health. Definitions and experience in Europe. Handout for framework of health targets. All agreed that participants at the workshop: Health targets, health care and health policy in the crux lies in democracy and empower- the European Union, Hannover, 28–29 April 1999. ment and that there should be some kind of 2. Water HPA van de, Herten LM van. Health Policies on Target?: Review of involvement. This involvement in the Health Target and Priority Setting in 18 European Countries. Leiden. TNO health target process can come from citi- Prevention and Health, 1998.

eurohealth Vol 5 No 3 Autumn 1999 6 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU Health targets: policies, polity and

The political dimension of setting and move towards selective contracting in the politics implementing health targets is a much Netherlands, the growing relevance of user neglected issue, both in terms of analytical charges in many countries. Although mar- understanding and strategic options for kets promise to raise efficiency they are in policy planning. No doubt the political principle indifferent if not contradictory to process shapes health target programmes. equity. A change in process will produce different The relation of health target programmes targets and different implementation strate- with national or regional health service gies. This in turn will determine the focus policies or other social sector policies is and success of a given programme. Therefore, it is crucial to understand the also complicated. Although health target political dimension of health target pro- programmes in general are welcomed or grammes and what shapes the policy even initiated by health service departments process. on the national level or competent authorities on the regional level, they do not nec- There is a large body of political experience essarily succeed in integrating different with health target programmes. This is departments or sub-departments. Other Matthias Wismar unsurprising since The World Health social sector policies seem to be too far Organization’s Health For All campaign detached from health policies in terms of was initiated more than 20 years ago. The organisational structure, policy arenas and first lesson we can learn from this experi- policy objectives. Even within health ser- ence is that political will is a necessary but vice departments a split between the strate- not sufficient prerequisite. Three other fac- gic and management units can be observed, tors are highly relevant: which constitutes a barrier that is difficult _ proactive management of policy context to overcome. relation – the policy factor; Health service policies are highly relevant _ the impact of institutional settings – the for economic and industrial policy. polity factor; Although throughout the 1980s major con- _ vertical and horizontal consensus build- cerns related to the share of health care ing – the politics factor. expenditure of GDP and the tax or contribution level, today there is a growing Proactive management of policy awareness that health services are a source context relations of employment and an important market How do health target programmes relate to for high value-added ‘sunrise’ industries, their context? Are health target pro- such as the pharmaceutical, medical devices grammes in conflict with their contexts or and telematics industries. It was therefore are they complementing or even supporting surprising that neither the negative nor the other policies, and existing social values positive potential economic consequences and ethics? of health target programmes were addressed. It is assumed that health target programmes enjoy perfect context relations in regard to A general conclusion that could be drawn is that health target programmes have “a market driven dominant social values and ethics. All health target programmes are strong in rather complex, if not contradictory, rela- health service will face supporting equity in terms of access, health tions to their context. But this is true for outcomes and choices. Many of them focus almost all health care policies. Health target even more difficulties on sub-populations with special health initiatives should take this into account risks. Although this is in line with the prin- from the very beginning in order to specify in developing the ciple orientation of most health services the context relation of a programme in a across the European Union and the acces- proactive way. This would stimulate sup- relevant institutions sion states, these values are in conflict with port for a policy and dampen conflicts that would otherwise hinder the programme. and organisation in market ethics that exist at the same time. Market mechanisms – different in degree – order to achieve a have been introduced or reinforced in The impact of institutional settings many countries since the early 80s. Do institutions matter? This simple ques- coherent and feasible Examples are the internal market in the tion is a key issue in political science and British NHS, the enforced competition policy research. It addresses key factors policy.” among sickness funds in Germany, the that co-determine policies and politics. In

7 eurohealth Vol 5 No 3 Autumn 1999 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU regard to health care institutions it became “Other social sector policies seem to be too far detached clear that the political process and the management of health targets requires the from health policies … even within health service depart- implementation of new institutions that are in principle complementary to existing ments a split between the strategic and management units health care institutions. A good example of can be observed, which constitutes a barrier that is difficult this is the state health conference in Northrhine-Westphalia, which meets regu- to overcome.” larly and serves as a means of consensus building and policy setting. Since health target programmes often focus on the do play a role, but political will can con- interface between health services and other tribute to adjust them to the needs of a policy sectors it is almost inevitable to health target programme. introduce new institutional settings. Even if health targets are set in a very narrow fash- Vertical and horizontal consensus ion, for example indication specific targets, building new institutions for coordinating and mon- To distinguish and analyse the various itoring are required. political strategies and conflicts in the process of defining and implementing General institutional factors such as a health target programmes we have designed health service model or regional/national a model (see figure 1), which is based on polity do have an impact too. In a national the assumption that feasible programmes health service the department of health rely on a social and political compromise. provides a focal point that facilitates plan- This compromise is established between ning processes. Many social insurance four poles. based health services do not have such a focal point. Power, control, accountability The poles of the horizontal axis, which rep- and sources of information are dispersed resents the process of defining target pro- over various institutions. In this respect a grammes, have been termed ‘technocratic’ market driven health service will face even and ‘participative’. The vertical axis signi- more difficulties in developing the relevant fies the relation between the policy makers institutions and organisation in order to and those who are responsible for imple- achieve a coherent and feasible policy. On menting, executing and running a pro- the other hand, as soon as it comes to put gramme in a given health care setting. In policies into practice, social insurance terms of implementing a programme it is schemes do have an advantage because the possible to distinguish between a top/down relations between purchasers and providers and a bottom/up strategy. While the first is are often organised by a legally enforceable carried out on behalf of the policy makers contractual arrangement. Contracts that (top) the latter is at least initiated by those working in the health care settings or by specify prices, quality and volume may the patients. The relation between the two serve as a vehicle to make target achievement obligatory for providers. Contracts within a national health service are in this respect of limited use because purchasers Figure 1: The political coordinates of health target programmes and providers belong to the same institutional body. These contracts are not top / up enforceable by court action or sanctions. political decision makers transmission optimal legislative support essential balance to national Besides the health service model, more gen- political level eral constitutional factors do play a role too technocratic participative – namely centralism, federalism, regional autonomy and the process of devolution. ¥ scientific enlightenment ¥ democratic legitimacy ¥ analysis of needs, ¥ value-community Health target initiatives at the regional level } problems and deficiencies ¥ setting up alliances will find a greater political and administra- ¥ development of ¥ health unrelated strategies tive support than those at a national level, instruments ¥ distanced from the policy ¥ lack of information because the competent authorities will process ¥ single interest relate more easily to the people involved at ¥ no democratic legitimacy } ¥ manipulation the grassroots level. bottom / down Therefore it is essential that in countries sub-national political health care professional level as moderator with centralised political and administrative values and incentives essential structures the necessary competencies be delegated to the regional level. Institutions Modified from Wismar, Busse, Schwartz, 1998.

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“Any health target ini- poles on the vertical axis is crucial in regard dox’. Health target programmes do not to the success of implementing a health tar- necessarily serve the achievement of a tiative has to be sup- get programme. It is necessary to build a health objective. In some instances, they political alliance or consensus for a given are rather employed to introduce a strategy ported both on the health target programme. debate, to support consensus building or to process conflicts between different actors Any health target initiative has to be sup- regional level and in the health policy arena that could not ported both on regional and national levels otherwise be solved. This follows the well- national level – an – an important role is played by competent known saying ‘the way is the destination’. political or administrative bodies at the This approach is in stark contrast with the important role is played regional level. However, any regional pro- original purpose of health targets to con- gramme that does not have the support of by competent political tribute to the improvement of public the national government will have a narrow health. From the perspective of ‘outcome- room for manoeuvre. Therefore one neces- or administrative bod- orientation’ and in the light of evidence sary task of a regional political or adminis- based health policy making the ‘destination trative body is to ensure the transmission ies at the regional is the destination’. between the regional and the national level. level.” At the same time, these bodies have an The ‘health target paradox’ does play a role important role to play in regard to provid- in most regional health target initiatives ing a platform for the initiative, either as a that were introduced in the absence of a moderator or by leadership. coherent or sufficient national health strategy. It could be argued that the debate An optimal balance in terms of managing serves to provide grounds for the introduc- the tension between the poles is to arrange tion of health targets in the future. But it a compromise and build a political alliance remains unclear whether policy-makers as indicated with the dotted oval. will embark on a health policy concept that An important issue that emerged during was once unsuccessful in achieving its own the discussion was the ‘health target para- goals.

Implementing health targets in health care

Putting policy into practice and translating of clinical interventions. The aim is to objectives into action represents a particu- ensure that scarce finite resources in health lar challenge for health care reformers. care are allocated only to those procedures Implementation is a difficult and underval- and interventions displaying evidence of ued area for governments and one that is either clinical or cost effectiveness. So far, often neglected and not well understood. most of the effort and resources have been Governments may prefer to shape policy, devoted to acquiring the evidence rather leaving others responsible for its subse- than on using or accessing the evidence that quent implementation. But implementation already exists to inform policy and practice. often takes time, especially if complex But when it comes to acting on the evi- changes in organisational and/or profes- dence, there continues to be something of a sional culture and behaviour are sought. vacuum. Not surprisingly in view of the short-ter- Evidence-based implementation has yet to mism which is a feature of most modern receive serious attention, although the issue governments, policy-makers invariably lose is now recognised as one in need of better interest in implementation whatever their understanding and attention and is firmly David J Hunter intentions at the outset. on the policy agenda in many countries. Although many countries are developing Evidence based medicine R&D strategies, for the most part the In health care systems across Europe, as emphasis is on research rather than on elsewhere, there is increasing attention development. There is a sound case for being given to evidence based medicine putting development first since in many (EBM) and on the acquisition of evidence cases the knowledge base is sufficiently testifying to the effectiveness or otherwise robust to recommend a change in policy or

9 eurohealth Vol 5 No 3 Autumn 1999 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU practice, or both. The problem has been “Putting policy into practice and translating objectives into securing change in the face of powerful professional resistance or other obstacles. action represents a particular challenge for health care While EBM is becoming increasingly reformers. Implementation is a difficult and undervalued accepted in primary and secondary care, effective support for healthy public policy, area for governments and one that is often neglected and and for establishing what works and does not work in this complex area, is needed. not well understood.” This demands institutional capacity building in public health where the infrastruc- ture in terms of skills and resources needs strengthening. There is a risk that focusing at other agencies and their contribution to on EBM directs attention towards acute improved health. As a consequence, the care at the expense of preventive care or commitment of these other agencies to the wider public health interventions. There is health strategy was considerably weaker a case for evidence-based health policy. than it might otherwise have been. If there was some strength seen in having The importance of prevention and the national targets as a vehicle to encourage role of targets organisational coalescence, there was a gen- There is an important role for the health eral criticism at the failure to encourage care sector in promotion and prevention local target setting. National targets on but the attitudes and understanding of their own, regardless of their appropriate- health professionals need to be changed if ness, were not seen to be sufficient to effect they are to appreciate and realise their full change at local level unless those at that potential. Incentives need to be identified level ‘owned’ them and believed in them. to achieve change in organisational and The actual targets themselves and their professional behaviour in order to meet technical and scientific basis were also the targets. Financial incentives may, paradoxi- subject of considerable criticism. Many did cally, be too successful, resulting in distor- not consider them to be sufficiently chal- tions or manipulation of the data in order lenging and maintained that they would to meet the target regardless of whether or have been achieved anyway without the not it is appropriate. The waiting-list target NHS or other agencies having to do any- in the British National Health Service is a thing at all. As a result, the value of the tar- good example. ‘Creative accounting’ is not gets set was not seen to amount to much. uncommon in order to be sure that targets This, in turn, led to suspicion concerning are met. Incentives of a managerial and the government’s intentions and a feeling administrative nature also need to be iden- that perhaps its commitment to the health tified. What is required is that resource flows should be linked to policy streams. If strategy left something to be desired. integrated care means anything at all, it is Target-setting and related managerial to achieve such linkage across the care devices are seen as central to government spectrum in a seamless fashion. efforts to modernise public services. Yet In the UK, an evaluation of the health this is increasingly viewed as a rather old- strategy that existed from 1992 to 1997, fashioned agenda as we are now in the The Health of the Nation, reported that, by postmodern age where the certainties of and large, it had been an implementation failure because there was an absence of sus- tained political commitment to it.1 Nor was Health Policy: Paradoxes and Puzzles there an appropriate performance management system in place to ensure progress. Health Health care Views were mixed both on the subject of the value of targeting and on the quality of Health services Disease, sickness services the targets themselves. Some viewed targets as the centrepiece of the strategy, while Joined up government Departmentalitis others saw them as representing a distrac- tion from the main agenda and as focusing Whole systems approach Vertical, fragmented, compartmentalised too narrowly on medical issues rather than on the key determinants of people’s health, Loose-tight (means-ends) Tight-loose (means-ends) which might include housing, employment and so on. The targets were seen to be Hierarchies Markets directed at health care services rather than

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rational, linear policy-making are being has tended to prevail. For example, the questioned, since they have demonstrably ‘whole systems’ approach being pursued in failed to reflect the realities of achieving the UK by the modernising Labour gov- policy change. Postmodernism places a ernment is an attempt to overcome the tra- greater stress on chaos theory and com- ditional compartmentalised nature of gov- plexity and accepts the inevitability of ernment. paradox, ambiguity and messiness. Rather From being concerned primarily with than seek to eradicate such dysfunctional means, there is a trend among governments elements, there is an acceptance of them to place a greater emphasis on ends. In part with efforts directed towards managing this reflects the ‘cult of managerialism’ them more effectively. which has swept through governments in Health policy is riddled with paradoxes recent years, much of it borrowed from the and puzzles. Some of the more common private sector. A key component of this ones are listed in the table below. These are style of management - often referred to as not necessarily all to be found in all coun- ‘new public management’ - is the stress tries but it is likely that at least some will given to outcomes and to the setting of tar- be found everywhere at some point in time. gets.2 Under this approach, the theory is Foremost is the persistent tension between that governments should be tight about ends – that is, objectives and goals – but loose about how they are achieved, therefore allowing maximum freedom and space “There is an important role for the health care sector in to local managers and professionals to find their own solutions to complex problems. promotion and prevention but the attitudes and under- In this way governments steer more and row less. But in practice what happens is standing of health professionals need to be changed if they the precise opposite of this. Because gov- are to appreciate and realise their full potential.” ernments often find it difficult to define with clarity and precision the outcomes of their actions in health care, or to be able to be sure that they are working within a rea- health and health care. They need not be sonable timescale, it is far easier to specify one and the same thing. Yet governments means and to become tight about these and the public invariably see them as indi- while being loose about ends. A truly cen- visible. European health care systems are all tralising government may of course attempt good examples of what might be termed to be tight about both means and ends.3 the ‘medical capture’ of health policy and Finally, many of the left-of-centre reform- health where the professional interests of ing governments in Europe are experiment- those seeking to provide cure are the prin- ing with the idea of finding a third way cipal drivers of policy in those countries. In between hierarchies and command and fact, it is not so much health care services control systems of government on the one that are provided, but sickness or ill-health hand, and highly devolved market systems services. Efforts to improve health in the on the other. The notion of the ‘third way’ broader sense have always been margin- is linked to the ‘loose-tight’ distinction. alised both in terms of the attention of pol- Just as it is not proving easy to maintain an icy makers and in terms of the resources appropriate ‘loose-tight’ separation, so invested. So health care systems continue to finding a ‘third way’ between hierarchies focus on disease or ‘dis-ease’. and markets may prove equally illusive. A holistic approach to health care Recently, there has been an attempt to REFERENCES move away from this fragmented model of 1. Department of Health. The Health of the health and emphasise the ‘whole’ person Nation - A Policy Assessed. London: The and the integrated nature of need for care Stationery Office, 1998. ranging from prevention, through primary, to secondary and possibly tertiary care. 2. Hood C. A public management for all Notions of ‘joined up’ policy and of find- seasons? Public Administration 1991;69(1): ing connected solutions to tackle complex 3–19 problems which are themselves intercon- 3. Hunter DJ. Managing for Health: nected are now finding favour with Implementing the New Health Agenda. reformist governments anxious to over- London: Institute for Public Policy come the narrow ‘departmentalism’ which Research, 1999.

11 eurohealth Vol 5 No 3 Autumn 1999 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU Evaluation and outcomes of health targets

“If Russia in 1990 had passed a target to keep life expectancy constant until the year 2000, it would have been accused of passing a target that would be reached anyway. If this target had resulted in halving the actual achieved. We usually concentrate on the latter, that is, when the target is to lower decline, it would have been a success even though most the mortality or the incidence of a given evaluation strategies would label it a failure.” problem by 10 per cent within 10 years, we evaluate whether the mortality or the incidence is actually 10 per cent lower 10 years later. However, does this really tell us much about the success of the target, let alone the programme in which this target is The technocratic approach to embedded? evaluation To some, the issue of evaluating health tar- Two common reproaches are worth men- gets is straightforward: since health targets tioning in this context. If a target is not are specific, quantifiable and measurable achieved it is easily dismissed as too ambi- objectives to improve health, they provide tious, as in the Netherlands; if a target is a natural instrument for evaluation and achieved it is sometimes dismissed as one adjustment. According to this view – which that would have been reached anyway, as in is the technocratic one in the framework the coronary heart disease death rate target provided earlier (see Matthias Wismar) – in the UK. These statements deserve a clos- qualitative targets also have a concrete er examination. The first statement requires deadline and are in their most explicit form a thorough knowledge of potential effect quantified. Evaluation of all targets should sizes – ‘efficacy’ – of various intervention Reinhard Busse be based on the collection of necessary strategies – and possible combinations of data, an appropriate timeframe and the interventions. The second assumes that lon- margins of successes and failures. The gitudinal trends remain constant over time. equation used in measuring progress in tar- This is not the case, however, since external get achievement is as follows: factors exercise large influences as well.

Current status — baseline x 100 = percentage of target achieved Year X target — baseline

This is the approach used for evaluation in Take the example of life expectancy in the USA and the Netherlands. But what do Central and Eastern Europe. If Russia in the results obtained mean? Two important 1990 had passed a target to keep life questions have to be addressed in this con- expectancy constant until the year 2000, it text. First, what should we evaluate and, would have been accused of passing a target second, what are the desired outcomes of that would be reached anyway. If this tar- health targets. Concerning the first ques- get had resulted in halving the actual tion, at least three foci are possible: the suc- decline, it would have been a success even cess – however measured – of whole health though most evaluation strategies would target programmes; the impact of individ- label it a failure. ual targets on the achievement of the The same holds true the other way around. desired outcomes; or whether the epidemi- If a target – judged by ‘experts’ to be nei- ological data set in the targets has been ther over ambitious nor trivial – has been

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reached successfully, attributing this to the ly? Health targets may be quantifiable and strategy itself is rather difficult. It is usually measurable – their appropriate evaluation, not possible to differentiate the contribu- however, requires qualitative methods as tion of the different elements to the well as quantitative methods. “political or economic measured outcome and we will probably outcomes may be just never be able to control for all factors The art of health target evaluation attributing to good or ill health. This leads Evaluation is a necessary component of as important as the to the second question: What are the health target setting. It should reflect both desired outcomes of health targets? the multiple purposes of the evaluation and health outcomes the multiple outcomes of health targets. Outcomes of health targets Evaluation is a continuous process that themselves.” In the technocratic-epidemiological view, starts even before the target setting is the fundamental purpose of health targets finalised. Evaluation should be in the minds is to improve the public’s health. While of the persons setting targets and designing health outcomes are the most important strategies to achieve targets. Necessary pre- outcomes of health targets, at least two conditions include a vision of the future, other categories of health target outcomes epidemiological knowledge, insight into have to be mentioned: First, the intermedi- intervention efficacy, as well as an articula- ate and process outcomes and second, other tion of what outcomes are desired other outcomes. Paying attention to other than health outcomes. Correct indicators categories of outcomes can in part be a should be chosen to measure progress response to the difficulty of reliably towards each target. Indicators for monitor- measuring health outcomes alone, which ing progress are inherent in the process of are often extremely small and slow – be achieving a target. they defined in terms of length of life or Indicators for measuring outcomes will mortality, or in terms of quality of life, or depend on the kind of outcomes under both. Intermediate and process outcomes – evaluation and should be chosen in a prag- that is, improved and/or equitable access to matic way. Measuring progress is assumed services or a reduction in risk factor to be inherent in the target setting, which profiles, therefore have their own rele- also facilitates rational adjustment. For vance. They often change faster and are those responsible for managing the imple- easier to detect. For example, to evaluate mentation, the range of success in achieving the success of an anti-smoking strategy to the set targets should be a major impetus. achieve the target of lowering lung cancer To be able to do this continuously in order incidence, we would not rely on lung can- to provide feedback is another reason why cer trends alone but would also count num- evaluation should comprise all processes bers of smokers and ex-smokers. contributing to the achievement of a target and not only concentrate on final health outcomes. “Indicators for measuring outcomes will depend on the The best evaluation, however, is useless if it is not followed up. For this purpose, health kind of outcomes under evaluation and should be chosen target achievement may be translated into financial consequences for those responsi- in a pragmatic way.” ble. Health target achievement will also form the basis for a realistic re-definition of health targets and their desired outcomes. The ‘other’ outcomes are easily overlooked, In this respect, evaluation of health target especially if health targets are viewed from programmes is not the end of the pro- a purely epidemiological point of view. grammes but the beginning of new ones. However, political or economic outcomes These may likewise be on the national level, may be just as important as the health out- or on regional or local levels, or even on the comes themselves. To create a climate for European level. health improvement, to stimulate the creation of alliances for achieving better health or to facilitate economic growth should be viewed as reasonable goals for health target programmes. If these are explicit – or more often implicit – goals, then they must be taken into account when the targets are evaluated. But how do we measure a climate for health improvement quantitative-

13 eurohealth Vol 5 No 3 Autumn 1999 HEALTH TARGETS, HEALTH CARE AND HEALTH POLICY IN THE EU Setting targets for health: the WHO European experience

It is already twenty years since the decision tored and evaluated on a regular basis using was taken to set targets for health in a wide range of indicators. One of the valu- Europe. Following the adoption by the able results of this process has been the World Health Assembly of a global strate- establishment of the HFA database, now gy and targets for Health For All (HFA) in available on the internet. A number of 1981, it was clear that the more economi- countries include reports on their progress cally developed countries in the European towards the European targets in their regu- Region needed their own targets because lar public health reports or in reports to many of the broad global targets had parliament. already been reached. These targets were to highlight a limited number of important On a country level, well over half the mem- areas for development, give practical exam- ber states have formulated their own tar- ples of the meaning of the HFA strategy, gets for health on national and/or regional making it more easily understandable to and city levels. In 1989, just before the fall Anna Ritsatakis authorities, special interest groups and the of the Berlin wall, top decision makers public. By defining and monitoring rele- from 19 of the then 32 WHO member vant indicators it was hoped that the targets states in Europe that had formulated would act as a mirror in which countries national HFA policy documents met to could see the trends in health in the region, discuss their progress and experiences. the possibilities for health gains and the They agreed that on the whole, most had consequences of failing to act. tried to set too many targets. They felt that the 38 European targets should act as a Developing targets for Europe check list, from which each country The development of the European targets depending on its own national situation, was a major undertaking, with more than could select a smaller number of strategic 250 experts from across Europe working targets.6 together and going through more than twenty drafts over a period of about three years.1 When in 1984 the 38 targets were unanimously approved by the Regional “Europe had for the first time a common health policy – a Committee,2 Europe had for the first time a common health policy – a considerable considerable achievement, particularly in view of the fact achievement, particularly in view of the fact that at that time there was no political cooperation across that at that time there was no political cooperation across the region. the region.” The sceptic might question the value of the target setting process in an organisation which, unlike the European Union, wields Of the 51 countries which now make up no financial or legal incentives to ensure the WHO European Region, again more that such joint decisions are actually carried than half have already formulated HFA out. Despite the fact that for many it repre- type policies, most of which include targets sented a quite new way of working and for health. These range from policy docu- others still felt rather uncomfortable with ments which focus on only four or five tar- the notion of planning for health in plural- get areas, usually related to the reduction of istic systems,3 considerable evidence indi- the major diseases, to those that, contrary cates the seriousness with which most to the advice from the 1989 meeting, adopt countries faced this challenge. the full range of the European targets. A On a European level, the Regional number of countries such as Bulgaria, Committee reaffirmed this approach in Finland and the Netherlands, which 1991 when the 38 targets were revised4 and embarked on this process in the early again in 1998 when a new set of 21 targets 1980s, are already going through third or were approved.5 Progress towards the fourth revisions of their national policies achievement of the targets has been moni- and targets.

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“The targets must appear feasible but also politically Even in countries that have persevered in this approach for many years and despite challenging, and be relevant to both the experts and the changing governments, the process of formulating and implementing targets for public” health has not been without problems. Politicians may be reluctant to embrace targets that cannot be fulfilled within their Developing targets through actions short span in power. Other problems relate Over the years, partly in response to their to the level at which targets are to be set so sometimes disappointing progress towards that they are scientifically credible, but still intended health outcomes, a number of go beyond the extension of existing trends. countries have set targets related to actions The targets must appear feasible but also which must be taken to achieve the desired politically challenging, and be relevant to outcomes. In these cases, outcome or pri- both the experts and the public. A project mary targets (for example reducing deaths has recently been initiated by the WHO from specific diseases) are linked to inter- European Centre for Health Policy mediate targets, related to risk factors, (ECHP) to clarify some of these challenges which must be achieved in order to reach and to provide a forum for policy makers the primary targets, (for example, targets to exchange their experiences. related to changes in the prevalence of health conditions or symptoms, exposure Implementing targets to hazards, and changes in behaviour); and Formulating and monitoring targets for to input/output targets defining the health is only part of the story however. necessary input of resources and output of What will make the difference are the mea- services; or to process targets dealing with sures taken to implement the targets. A specific actions to be taken, such as legal recent study of the process of HFA policy 7 measures or standard setting. In Catalonia development indicates that on the whole, for example, this method has led to the countries are still not taking action to get to setting of more than 200 targets, most of the root causes, particularly of inequities in which relate to inputs/outputs and process. health.7 Although the need for partnerships across all sectors of the economy is widely recognised as essential to achieving many

REFERENCES of the health targets set, such change is not easy to achieve. The results of the study 1. Kaprio LA. Forty Years of WHO in Europe. The Development of a show that in most cases, the health sector is Common Health Policy. WHO Regional Publications, European Series 40, still working largely with familiar partners, World Health Organization, Regional Office for Europe, Copenhagen, 1991. and in familiar ways. There are very few 2. Targets for Health For All: Targets in Support of the European Regional examples where tackling the determinants Strategy for Health for All. World Health Organization, Regional Office for of health such as poverty, unemployment Europe, Copenhagen, 1985. or poor housing are seen to be among the 3. Planning and Management for Health. Report on a European Conference, main ways of achieving health targets. The Hague 27 August–1 September 1984. EURO Reports and Studies 102, Among the exceptions are the recent mea- World Health Organization, Regional Office for Europe, Copenhagen, 1986. sures initiated in the United Kingdom where England, Northern Ireland, Scotland 4. Health For All Targets. The Health Policy for Europe. European Health and Wales provide interesting examples of for All series 4, World Health Organization, Regional Office for Europe, trying to link health and development in Copenhagen, 1993. order to achieve health targets. 5. Health 21 – Health For All in the 21st Century. European Health for All Series, No.6, World Health Organization, Regional Office for Europe, With only two exceptions, all the EU Copenhagen, 1999. countries have now formulated targets for health at national or local levels. The devel- 6. Consultation of countries with national health for all policy documents. opment of a public health policy for the Report on a WHO meeting, Sofia, 12–13 December 1989. EUR/ICP/MPN European Union,8 and the provisions of 040 World Health Organization, Regional Office for Europe, Copenhagen, article 152 of the recently ratified 1990. Amsterdam Treaty, offer exciting possibili- 7. Ritsatakis A, Barnes R, Dekker E, Harrington P, Kokko S, Makara P. ties for also setting targets for health in Exploring Health Policy Development in Europe. World Health areas where EU level policy is particularly Organization, Regional Office for Europe, Copenhagen, 1999. influential. Fortunately there is now a 8. Communication from the Commission to the Council, the European wealth of experience in the Region and Parliament, the Economic and Social Committee and the Committee of the modern means of communication are mak- Regions, on the development of public health policy in the European ing this easier to share. The ECHP intends Community. Commission of the European Communities, Brussels, to make much of the information available 15.04.1998 COM(1998) 230 final. on the internet by the end of the year.

15 eurohealth Vol 5 No 3 Autumn 1999 APPROPRIATENESS AS A TOOL FOR QUALITY ASSURANCE Defining appropriate health care

The work discussed in this and the following two articles has been conducted as part of a concerted action – “A Method to Integrate Scientific and Clinical Knowledge to Achieve the Appropriate Utilisation of Major Medical and Surgical Procedures,” sponsored by Directorate General XII of the European Commission under the BIOMED II programme (Contract No. BMH4-CT96-1202).

Contemporary developed nations of the determination of quality. are confronted with the problem of The RAM was rapidly disseminated managing their health care systems from North America to Europe, and to assure that patients receive high by the mid-1990s, there was a core quality health care. We define high of investigators throughout Europe quality health care as the consistent using the method. This core formed and reliable delivery of cost effective the basis of a BIOMED concerted care, whose benefits outweigh its action to promulgate and further risks, which is faithful to the values develop the RAM. In this paper, we of the society where the care takes briefly describe the RAM and then place, is feasible given the resources summarise the efforts of the concert- available to the society, and is as ed action. The following two articles responsive as possible to the individ- in this issue (Fitch and Lázaro; James P Kahan ual needs and values of the care Vader and Burnand) explore the recipients. development, dissemination and pol- A signal of possible low quality icy uses of the method. health care is the observation of different utilisation rates for a medical Description of the RAM or surgical procedure in different The following presents an overview geographical areas, where there is no of the different steps involved in reason to believe that the popula- studies using the RAM. When a tions in those areas differ in their topic has been selected, the first step need for that procedure.1 In such sit- of a study using the RAM is to per- uations, there is the suspicion that form a detailed literature review to either one area is over-using the pro- synthesise the latest available scien- cedure, another area is under-using tific evidence on the procedure to be the procedure, or both. Worse, a sin- rated. At the same time, a list of gle area may be over-using and indications is produced in the form under-using simultaneously.2,3 of a matrix, which categorises patients who might present for the Mirjam van het Loo To assess the quality of health care, procedure in question in terms of different analytic techniques are their symptoms, past medical histo- required to determine the cost effec- ry, and the results of relevant diag- tiveness, benefit/harm ratio, adher- nostic tests. ence to values, implementability and responsiveness of care.4 To address The literature review and the list of the benefit/harm component of qual- indications are sent to the members ity of care, a team of researchers at of an expert panel. These panel RAND and UCLA developed what members individually rate the has come to be termed the RAND appropriateness of using the proce- Appropriateness Method (RAM) to dures for each indication on a nine determine ‘appropriate’ care.5,6 A point scale, ranging from extremely “A signal of possible low quality procedure was used appropriately if inappropriate (one) to extremely health care is the observation of its application—to a particular appropriate (nine) for the patient patient—provided the expectation of described in the indication. The different utilisation rates for a more benefit than harm. Benefits and panel members assess the benefit/ harms were defined in terms of the risk ratio for the ‘typical patient medical or surgical procedure in patient's physical, functional, and with specific characteristics receiving subjective well being; costs were care delivered by the typical surgeon different geographical areas” explicitly not included at this stage in the typical hospital.’

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After this first round of ratings, the European Health Policy Forum to lists is too great, that the linkages panel members meet for one or two disseminate its findings to the health, between the scientific evidence and days under the leadership of a mod- scientific and policy communities. panel ratings are vague, and that the erator. During this meeting, the pan- The three categories of activity of method has difficulty when consid- ellists discuss their previous ratings, the concerted action were: (1) mak- ering multiple possible treatments focusing on areas of disagreement, ing the access to the method easier, for a single condition (for example, and are given the opportunity to (2) improving and expanding the surgery, angioplasty, or medical modify the original list of indica- method, and (3) examining the feasi- management for coronary artery tions and/or definitions. After dis- bility of multinational panels. disease). Each of these problems and cussing each chapter of the list of others were addressed by the con- indications, they re-rate each indica- Access certed action. The number of indication individually. The two-round We considered three aspects of tions to be rated was reduced by process is focused on detecting con- access to the method. First, we con- focusing on those indications that sensus among the panel members. solidated the experience of the group are actually seen in clinical practice No attempt is made to force the to write a ‘how to do it’ manual for and that are subject to some debate. panel to consensus. In examining the people considering using the RAM. Indications that never occur in prac- potential use of the procedure for This manual – Fitch et al., which is tice, or indications that are unequiv- these indications, the method can in preparation7 – will be available by ocally either appropriate or inappro- determine situations when the pro- request to the members of the group priate, were excluded from the rat- cedure is inappropriate (that is, the risks outweigh the benefits) or necessary (that is, the procedure is the “The number of indications to be rated was reduced by only possible means of providing substantial benefit for the patient). focusing on those indications that are actually seen in clinical

The Concerted Action practice and that are subject to some debate.” The BIOMED II concerted action to promulgate and further develop the RAM consisted of eleven research within a few months of this writing. ings. In a study on coronary artery organisations in seven different It takes the reader step by step from disease, a 66 per cent reduction in countries: conceptualisation through analysis indications was accomplished. In of the RAM. this same study, panellists were – RAND Europe, Leiden, NL asked not only to rate the appropri- Second, we explored the possibility (Coordinator) ateness of the indication, but the of providing standardised software extent to which their rating was – European Health Policy Forum, for the method. We discovered, based on their understanding of the Leuven, BE however, that progress in the world scientific evidence, using a four of computers had outstripped our – Institute of Social and Preventive point scale ranging from sound sci- knowledge. Several of our research Medicine, Lausanne, CH entific evidence to the rater's own groups independently developed experience and belief. In two panels – Institute of Social and Preventive their own software, and all of the conducted under the auspices of the Medicine, Zürich, CH programmes worked admirably. concerted action, multiple treatment Thus, instead of one standard pack- – Galdakao Hospital, Galdakao, ES options were explored, using differ- age, there are a number of packages ent ways of comparing treatments. – Carlos III Health Institute, available. Madrid, ES In addition to these advances in the Third, we developed new methods method, refinements of the statisti- – Valme University Hospital, to make available the results of cal analyses of panel results were Sevilla, ES RAM studies. Two websites are explored. Reports of all of these – University Hospital, Clermont- being established where physicians efforts are being prepared for jour- Ferrand, FR or researchers can view the results of nal publication. RAM panels for specific patients; – Mario Negri Institute, Milano, IT other programmes for graphical pre- Multinational panels – Institute for Health Care Policy sentation of panel results, and work A major investment of the effort of and Management, Erasmus is underway to more easily translate the concerted action went into the University, Rotterdam, NL panel results into guidelines imple- conduct of three multinational pan- mentable at the local level. els. Before this effort, all previous – Swedish Council on Technology RAM studies had been confined to Assessment in Health Care, Improvement one country; comparisons across Stockholm, SE The RAM has been criticised for a nations were only possible if two or The concerted action began in the number of reasons, some fair and more countries studied the same autumn of 1996 and culminated in some unfair. Among the former are procedure, and even then the varia- March 1999 with a meeting of the that the burden of effort on panel- tions in definitions, indications, and

17 eurohealth Vol 5 No 3 Autumn 1999 APPROPRIATENESS AS A TOOL FOR QUALITY ASSURANCE time made the comparisons prob- consensus. tion into local guidelines that take lematic. By conducting panels com- into account the resources and val- The third multinational panel was posed of experts from different ues of the patient and caregiver com- for treatment of benign prostatic nations, it could be determined munities. Building on the network hyperplasic, and was conducted in that created and nurtured the con- whether agreement could be reached March 1999 in Amsterdam. Again, certed action, the research groups on the definitions of indications to experts from five countries partici- are together considering ways of be rated, and the extent of consensus pated. The panellists compared addressing these issues. across countries could be assessed. If surgery, two pharmaceutical inter- this is possible, then there are poten- ventions, and watchful waiting for tial economies of scale to be gained over 1100 indications. This multina- REFERENCES by having single multinational pan- tional panel replicated a Dutch panel els instead of multiple national pan- conducted in June 1998; interest 1. Wennberg JE. Presidential guest els. here was in whether or not the two speaker: Practice variation and the challenge to leadership. Spine The first multinational panel was of panels yielded the same ratings. 1995;21:910–16. upper and lower gastrointestinal Although the final results of the endoscopy, and was conducted in three multinational panels await fur- 2. Fröhlich F, Burnand B, Pache I, November 1998 in Lausanne. ther analyses, the process and early Vader JP, Fried M, Schneider C, Experts from nine countries partici- outcomes indicate that multinational Kosecoff J, Kolodny M, Dubois RW, pated. The panel not only rated panels are an efficient way of Brook RH, Gonvers JJ. Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy – a prospective study in primary care. “appropriateness ratings are not guidelines in and of Gastrointestinal Endoscopy 1997a;45 themselves. Further work needs to be done in developing ways (1):13-–19. 3. Fröhlich F, Pache I, Burnand B, to make the RAM more amenable to translation into local Vader JP, Fried M, Kosecoff J, Kolodny M, Dubois RW, Brook guidelines that take into account the resources and values of RH,Gonvers JJ. Underutilization of the patient and caregiver communities.” upper gastrointestinal endoscopy. Gastroenterology 1997b;112(3): 690–97. indications for the procedure, but obtaining appropriateness ratings. 4. Kahan JP. Health care assessment also explored the consequences of The panels were all able to agree studies: a rethink. Eurohealth relative costs on their estimates of upon definitions, reported satisfac- 1996;2(4):15–17. appropriateness. This study has tion with the panel process and 5. Brook RH, Chassin MR, Fink A, been extended over time; the panel reported confidence that the ratings Solomon DH, Kosecoff J, Park RE. A is on call to reconsider indications accurately reflected the state of the method for the detailed assessment of should there be scientific or clinical art with regard to the procedures the appropriateness of medical tech- developments that could affect the examined. nologies. International Journal of appropriateness of endoscopy. Technology Assessment in Health Care 1986;2(1):53–63. The second multinational panel was Need for further research for treatment of coronary artery dis- The work of the concerted action 6. Park RE, Fink A, Brook RH, ease, and was conducted in led, as is inevitable, to the need for Chassin MR, Kahn KL, Merrick NJ, December 1998 in Madrid. Experts further research. Participants note Kosecoff J, Solomon DH. Physician from five countries participated. In that the method is time-bound in ratings of appropriate indications for each of these five countries, a previ- the sense that the panel ratings are six medical and surgical procedures. ous RAM study of the appropriate- fixed by when they are obtained. It American Journal of Public Health ness of treatment for coronary is not efficient to conduct repeated 1986;76(7):766–72. panels every year, yet progress in artery disease had been conducted, 7. Fitch K. et al. The RAND clinical medicine must be tracked. between two and seven years previ- Appropriateness Method: A User's ously. To the extent possible (11 out Research is needed on how to make Manual. Leiden: RAND Europe of 15), panellists who had served on the RAM an ongoing process; as Report RE-99.009, 1999. their own national study were indicated, the Lausanne multina- recruited. In this study, particular tional panel is beginning work in 8. Fitch K, Lázaro P. Using appropri- attention was paid to whether a set this direction. Also, we have long ateness criteria to improve health of definitions of indications accept- recognised that the appropriateness care. Eurohealth 1999, this issue. able to all panellists could be devel- ratings are not guidelines in and of 9. Vader JP, Burnand B. Prospective oped, and whether the panellists' themselves. Further work needs to assessment of the appropriateness of ratings of the evidence base for their be done in developing ways to make health care. Eurohealth 1999, this judgements affected the degree of the RAM more amenable to transla- issue.

eurohealth Vol 5 No 3 Autumn 1999 18 APPROPRIATENESS AS A TOOL FOR QUALITY ASSURANCE Using appropriateness criteria to improve health care

“only around 15 per cent of medical decisions are based on scientific evidence about their outcomes”

The basic mission of health services is to intensity of services.”2 To curtail the vol- Kathryn Fitch improve the health of both the individual ume of services without negative effects on and society. As is well known, however, the health status of the population, we need health services in recent decades have been to find ways to assure that our health faced with enormous challenges, making it expenditures are used for effective services ever more costly to fulfill this mission. – that is, those that have demonstrated These include the introduction of increas- value. Yet it has been estimated that only ingly complex services, the rapid innovation around 15 per cent of medical decisions are and diffusion of medical technologies and based on scientific evidence about their out- procedures, and pressures on the demand comes.3 If this proportion is even approxi- for services from both patients and health mately correct, it is not surprising that such professionals. These phenomena are part of wide variations have consistently been the reason health spending has grown so shown to exist in the rates of use of medical quickly in the industrialised nations over procedures – differences that cannot be recent decades. In 1965 European Union explained by patient characteristics. For countries spent on average 4.3 per cent of example, a graph of carotid endarterectomy Pablo Lázaro their gross domestic product on health care, rates plotted as a function of the number of a proportion that rose to 6.3 per cent in surgeons in three areas of the United States 1975, 7.0 per cent in 1985 and 7.7 per cent (Figure 1) shows that the site with the high- in 1995.1 Clearly, this proportion cannot est number of surgeons performed more continue to grow indefinitely. than three times the number of surgical What is driving this growth in health care interventions as the site with the lowest 4 expenditures? Studies have shown that it is number. Does this mean that the area with mostly due to increases in the “volume and more surgeons is performing procedures that are inappropriate, or that the one with a lower number is not completely meeting Figure 1: Number of carotid endarterectomies by number of surgeons in the needs of the population? Based on these three US sites statistics alone, we cannot know. It may even be that both overuse and under-use are occurring simultaneously in any or all of Operations per 100,000 the areas. Medicare enrollees 200 Site 1 The RAND appropriateness method 175 In an attempt to answer these kinds of questions, researchers from RAND and the 150 University of California in Los Angeles 125 Site 2 developed in the mid 1980s what has come 100 to be called the ‘RAND appropriateness method’. The concept of appropriateness, in 75 the RAND method, refers to the relative 50 Site 3 weight of the benefits and harms of a medical intervention. An appropriate procedure 25 is one in which the expected benefits out- 0 weigh the expected risks by a sufficient margin that the procedure is worth doing. 0 5 10 15 20 25 The rationale behind the method is that Number of surgeons who performed carotid endarterectomy randomised clinical trials – the ‘gold stan- per 100,000 Medicare enrollees dard’ for evidence-based medicine – often either are not available or cannot provide Source: Leape LL, et al.1989.4 evidence at a level of detail sufficient to

19 eurohealth Vol 5 No 3 Autumn 1999 APPROPRIATENESS AS A TOOL FOR QUALITY ASSURANCE apply to the wide range of patients upper GI endoscopies,5 and 16 per portion of them did not receive a seen in everyday clinical practice. cent of hysterectomies.6 revascularisation procedure that the Although robust scientific evidence panel considered necessary for their Of particular interest in these U.S. about the benefits of many proce- clinical situation. studies was the finding that the vol- dures is lacking, physicians must ume of procedures was generally not nonetheless make decisions every related with levels of appropriate- Using appropriateness criteria day about when to apply them. ness. That is, areas where relatively as clinical decision aids Consequently, it was believed a few procedures were performed did Appropriateness criteria can also be method was needed that would com- not necessarily have lower rates of used prospectively, as the basis for bine the best available scientific evi- inappropriate use than those where developing different types of aids to dence with the collective judgment intensity of use was higher. For clinical decision making. These of experts to yield a statement example, the proportion of inappro- might be in the form of guidelines regarding the appropriateness of priate use of coronary angiography or flowcharts, which summarise the performing a procedure at the level was approximately the same in three criteria in a more ‘user-friendly’ of patient-specific symptoms, med- U.S. areas (ranging from 15 to 18 per way than the tables of indications ical history and test results. cent), even though the rate of utilisa- with their appropriateness classifica- The basic steps in the RAND tion of the procedure in one area was tions. Such summary formats can be method are described in the accom- more than double that of the other time consuming to develop, howev- panying article by Kahan and van two.5 In one area of the United er, and may run the risk of losing het Loo in this issue. The final prod- Kingdom – a country where physi- the specificity provided by the com- uct of the two-round ‘modified cians perform only about one-sev- plete indications list. The tables Delphi’ process is a list of highly enth the number of cardiac proce- themselves can also be disseminated specific clinical scenarios or ‘indica- dures as in the United States – 21 per in different ways – through publications’, each of which is classified as cent of coronary angiographies were tion in a medical journal, distribu- ‘appropriate’, ‘uncertain’ or ‘inap- found to be performed for inappro- tion of a special report by the rele- propriate’ for the procedure in ques- priate reasons, in accordance with vant medical society, for example – tion based on the median panel rat- the criteria developed by a U.K. so that physicians can consult the 7 ing and the level of agreement panel. These figures suggest that recommendation of the expert panel among panelists. This set of indica- just reducing the number of proce- when confronted with a particular tions – which may number from hundreds to thousands – with the corresponding appropriateness rat- “In one area of the United Kingdom … 21 per cent of coronary ings constitutes what are called the angiographies were found to be performed for inappropriate ‘appropriateness criteria’. reasons” Using appropriateness criteria to measure performance Appropriateness criteria have most dures performed will not necessarily patient. The challenge is to make the often been used as a tool to measure reduce the rate of inappropriate use. criteria available to physicians in an easy-to-use format, while also devis- performance retrospectively. This is The RAND method can also be ing a system to ensure that the done by reviewing the medical applied to measure the possible appropriateness classifications are charts of a representative sample of underuse of procedures. Some pan- updated as new scientific evidence patients who have undergone the els carry out a third round of ratings becomes available. procedure. A specially developed to determine which of the appropri- ‘abstraction form’ is used to collect ate indications are also necessary. One possible solution being tested sufficient data on each patient to Necessity is a more stringent criteri- by the Swiss members of the con- permit assignment of an appropri- on than appropriateness and refers certed action group is to make the ateness rating in accordance with the to procedures which must be criteria available through a web- list of indications. The proportion of offered to a patient fitting a particu- based page on the Internet. This has patients who have received proce- lar clinical description. Necessity the advantage of allowing physicians dures done for ‘appropriate’, ‘uncer- can be more difficult to measure to view the criteria in whatever way tain’ and ‘inappropriate’ reasons can than appropriateness, however, they prefer: in some cases they may then be calculated. Procedures done because it involves identifying a only want to see the appropriateness for inappropriate reasons are consid- group of patients who might have classification, while in others they ered overuse of the procedure. Early benefited from the procedure, but may be interested to see the com- studies in the United States showed did not receive it. For example, to plete panel ratings for a particular that a substantial number of proce- measure the underuse of coronary indication. Using an Internet-based dures were judged to be inappropri- revascularisation, data could be col- system, it would also be possible to ate: 17 per cent of coronary lected from the medical charts of provide hyperlinks to the relevant angiographies, 32 per cent of carotid patients who received coronary publications supporting a particular endarterectomies, 17 per cent of angiography to determine what pro- appropriateness classification, and to

eurohealth Vol 5 No 3 Autumn 1999 20 APPROPRIATENESS AS A TOOL FOR QUALITY ASSURANCE quickly modify criteria that have Conclusions 3. Black N. Research, audit and edu- become outdated. Wide variations exist in clinical prac- cation. British Medical Journal tice, and a substantial proportion of 1992;304:698–700. Gaining physician acceptance health interventions are thought to 4. Leape LL, Park RE, Solomon DH, Enlisting the support of the relevant be performed for inappropriate rea- Chassin MR, Kosecoff J, Brook RH. medical societies early on is an sons. Bureaucratic, administrative or Relation between surgeons’ practice important step in obtaining physi- economic solutions to rising costs volumes and geographic variation in cian acceptance of the appropriate- may limit the quantity of health care the rate of carotid endarterectomy. ness criteria. Specialist societies are provided, but will not necessarily New England Journal of Medicine usually asked to provide nomina- improve the appropriateness and 1989;321:653–57. tions of panel members and may quality of care. The selective elimi- 5. Chassin MR, Kosecoff J, Park RE, sponsor dissemination of the final nation of inappropriate care would Winslow CM, Kahn KL, Merrick NJ, ratings. Physicians need to be free resources to deliver effective Keesey J, Fink A, Solomon DH, assured that the criteria are not dog- care to those who need it. One way Brook RH. Does inappropriate use matic rules to be followed reflexive- to do this is by developing high explain geographic variations in the ly, but rather carefully considered quality, flexible appropriateness cri- use of health care services? A study of recommendations that will usually teria, which can be used both to three procedures. Journal of the apply to a patient fitting the clinical measure past performance and to American Medical Association 1987; indication, in the absence of other guide clinical decision making. 258:2533–37. unusual circumstances. If they do not agree with the recommendation 6. Bernstein SJ, McGlynn EA, Sui AL, Roth CP, Sherwood MJ, Keesey JW, for a particular case, they may be REFERENCES asked to justify why it constitutes an Kosecoff J, Hicks NR, Brook RH. exception. Providing feedback to 1. OECD Health Data 97. A Software The appropriateness of hysterectomy. physicians on their own perfor- for the Comparative Analysis of 29 Journal of the American Medical mance as measured by the appropri- Health Systems. Paris: OECD, 1997. Association 1993;269:2398– 402. ateness criteria can be a helpful way 2. Eddy DM. Broadening the respon- 7. Gray D, Hampton JR, Bernstein SJ, of motivating them to consider the sibilities of practitioners. The team Kosecoff J, Brook RH. Audit of coro- appropriateness criteria when mak- approach. Journal of the American nary angiography and bypass surgery. ing clinical decisions. Medical Association 1993;269:1849–55. The Lancet 1990;335:1317–20.

Prospective assessment of the appropriateness of health care

“retrospective evaluation of care that has been provided is of little use to the patient who has received inappropriate care”

John-Paul Vader Within the framework of the challenges of appropriate use of low-back surgery and improving quality of care, in general, and gastrointestinal endoscopy. It concludes using the RAND appropriateness method with a call for collaboration for the testing in particular, this article will point out and improvement of these instruments. some of the limits and pitfalls of retrospective evaluation of care and argue that Background improvement of care requires prospective Quality and cost of care are dependent on decision support. Given the complexity of the provision of appropriate care. How to the RAND appropriateness method – provide quality care within available bud- which is an explicit evidence and expert gets is a growing concern of all actors in based method to develop specific clinical the healthcare drama, whether providers, scenarios for the appropriate use of med- patients, payers or politicians. This con- ical procedures – this article will describe cern is motivated by observed variations in the development of a computer-assisted, clinical practice, by increasing financial world wide web-based tool which incor- pressure, in some cases by newly intro- Bernard Burnand porates data from recent expert panels on duced legal constraints and most impor-

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patient to access criteria for the Figure 1: Examples of proportion of procedures examined that are inappropriate or uncertain.1,2 appropriateness of care, prospectively, during the decision making 70 process about care that is to be provided or received. 60 50 This is particularly so regarding the guidelines for the appropriateness of 40 care that are developed according to 30 the RAND method, because of the 20 clinical detail contained in such guidelines. This clinical detail is at 10 once a reason for their attractiveness 0 for practicing physicians and an Coronary Carotid Upper GI Coronary artery obstacle to their actual use in a angiography endarterectomy endoscopy by-pass prospective fashion by them. The output from RAND expert panels Inappropriate Uncertain that have examined the appropriateness of different procedures general- tantly by the significant levels of has been shown that the medical ly presents itself as hundreds and at inappropriate care that have been record is not always precise enough times thousands of different clinical observed in widely divergent health- to evaluate the appropriateness of scenarios. 3 care systems throughout the world. what was done. Secondly, if the Table 1 shows a small sample of the For many, clinical practice guide- evaluator is aware of the outcome of 600 sum scenarios that were evaluat- lines are put forth as a response to care, s/he may be biased in his/her ed recently by the European Panel this concern. assessment of the appropriateness of on the Appropriateness of care, a positive outcome for an indi- Although great effort has been and is Gastrointestinal Endoscopy vidual patient being more often asso- being invested in the development of (EPAGE) – which was part of the ciated with appropriate care.4 clinical practice guidelines, they still EU concerted action described in the Because numerous elements, besides present a number of unanswered article by Kahan and van het Loo in the appropriateness and quality of questions, in particular about the this issue of Eurohealth (see that care provided, affect patient out- validity and implementation of such article also for a description of the come, such a reasoning can be falla- 5 guidelines and the degree to which method). In each cell of this Table cious. Thirdly, retrospective evalua- patients should participate in their the numbers above the one to nine tion of care that has been provided is development and use. This article appropriateness scale indicate the of little use to the patient who has will examine a new approach of votes of the 14 experts of the received inappropriate care and implementation of medical practice EPAGE panel. Below the one to probably also to the physician who guidelines for the appropriateness of nine appropriateness scale the medi- provided it. Therefore, a key an vote is indicated, followed by the care, developed using the RAND approach to going from evaluation absolute deviation around the medi- method. of the appropriateness of care to the an and the degree of agreement improvement of the appropriateness between panelists (A = agreement, From evaluation to of care is to allow physician and D = disagreement). improvement Figure 1 is an example of an evaluation of the appropriateness of care Table 1: Example of the scenario matrix, votes and results of European Panel on that shows a substantial proportion the Appropriateness of Gastrointestinal Endoscopy (EPAGE), in certain of care being provided that is inap- indications involving atypical chest pain propriate or the appropriateness of No GERD GERD treatment GERD treatment which is open to question – a com- No known coronary treatment without response with positive response mon occurrence in such evaluations. artery disease Although the figures in the illustra- 1. No cardiac 8 2 1 2 1 7 2 3 1 1 4 6 1 1 2 tion reflect the situation some 15 work-up done 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 years ago, with few exceptions, the (1.0 1.36 A) (2.0 1.14 A) (2.0 1.36 A) proportion of care that is inappropriate generally exceeds 15 per cent of care examined. Also, however – 2. Cardiac 2 3 1 3 3 2 2 5 3 4 3 2 3 1 3 2 and again with few exceptions – such work-up normal 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 (5.0 2.36 D) (8.0 1.07 A) (3.0 2.36 D) studies have been carried out retrospectively, using a review of medical Appropriateness scale: records. There are several problems 1 = extremely inappropriate, 5 = uncertain, 9 = extremely appropriate. with such an approach. First of all, it

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“This clinical detail [of RAND guidelines] is at once a reason approach, innovative ways must be found to assist those on the front for their attractiveness for practicing physicians and an obstacle line in identifying and providing appropriate care. Such approaches to their actual use in a prospective fashion by them” will allow us to move from evaluation to improvement of the appropriateness of care. The world wide web offers great potential in this It can readily be understood that a trated at points seven and eight. The respect, but, as with the introduction practicing physician will find it quite web page therefore shows in a sim- of any new technology in medicine, impracticable to wade through pages ple and accessible format the assess- its use still needs to be tested. Those and pages, with hundreds and hun- ments of physicians of the appropri- interested in such testing are invited dreds of such tables, in order to find ateness of surgery for a category of to contact the authors. a clinical scenario that corresponds patient. Elsewhere on the same web to the patient, seeking assistance in page, access is provided to sum- Dr John-Paul Vader (john- deciding whether it would be appro- maries of articles from the medical [email protected]) priate to request or perform a gas- literature concerning the efficacy, Dr Bernard Burnand (bernard.bur- troscopy to elucidate the nature of outcomes and complications of low- [email protected]) the patient's symptoms. back surgery. IUMSP, Rue du Bugnon 17, CH- As with all guidelines, the conclu- 1005 Lausanne Towards a WWW-based sions concerning the appropriateness approach of an intervention using the results REFERENCES Given the pitfalls and drawbacks of from an expert panel are intended to 1. Chassin MR, Kosecoff J, Park RE, retrospective evaluation of the be a recommendation – rather than a appropriateness of care, the authors Winslow CM, Kahn KL, Merrick NJ, hard and fast rule – to assist patient Keesey J, Fink A, Solomon DH, have been actively involved in the and physician to determine the development of web-based technol- Brook RH. Does inappropriate use appropriate strategy of care given explain geographic variations in the ogy to make the appropriateness cri- the particular circumstances. It use of health care services? A study of teria available for physicians, and would be wrong and in some cases three procedures. Journal of the indeed patients. The work is being even harmful to base the decision to American Medical Association done in collaboration with the operate or not to operate solely on 1987;258(18):2533-7. Laboratory for Theoretical Com- the basis of such a recommendation. 2. Winslow CM, Kosecoff J, Chassin puting at the Federal Institute of It is felt however that if such infor- MR, Kanouse DE, Brook RH. The Technology in Lausanne. mation could be made available to appropriateness of performing coro- physician and patient, via the world One version exists already, integrat- nary artery bypass surgery. Journal of ing criteria from an expert panel wide web, for example, it would the American Medical Association convened in Switzerland in 1995 to provide valuable assistance in the 1988;260:505–9. examine the appropriateness of indi- decision that both need to make to 3. Jeannot JG, Vader J-P, Porchet F, cations for low-back surgery.6,7 By determine appropriate care and opti- Larequi-Lauber T, Burnand B. Can responding to six questions, the mise the desired outcome. the decision to operate be judged ret- physician is immediately pointed to In addition to the pilot version rospectively? A study of medical the results of the experts' evaluation described here for low-back surgery, records. European Journal of Surgery of the appropriateness of performing a similar version is being prepared to 1999;165:516–21. low-back surgery for patients with incorporate criteria from the recent similar characteristics. 4. Caplan RA, Posner KL, Cheney European Panel on the Appropriate- FW. Effect of outcome on physician For example, the web site will show ness of Gastrointestinal Endoscopy. judgments of appropriateness of care. the results that one would obtain for These instruments are still in the Journal of the American Medical a particular individual with a partic- developmental stage and will require Association 1991;265:1957–60. ular presentation: for example, a testing, as to their acceptability for 5. Kahan JP, van het Loo M. Defining patient with sub-acute sciatica (last- physician and patient, their feasibili- Appropriate Health Care. Eurohealth ing for less than six weeks), with ty of use and their validity in terms 1999; this issue. major muscular weakness and a her- of providing more appropriate care niated disk on radiological imaging, and optimising patient outcome. 6. Porchet F, Vader JP, Larequi- who has already been treated with Lauber T, Costanza M, Dubois RW, one non-operative treatment regi- Conclusion Burnand B. The assessment of appro- men, and is severely disabled. The We conclude by repeating that quali- priate indications for laminectomy. results will indicate that for such a ty and cost of care depend on appro- Journal of Bone Joint Surgery [Br] patient, low-back surgery would be priateness of care. Given that, and 1999;81-8:234–39. considered appropriate, with votes given the rather complex nature of 7. Jeannot JG, Vader J-P, Porchet F, of the experts ranging from five to the guidelines on appropriate care Burnand B. Information électronique. nine on a nine point scale, concen- stemming from the RAND Medicine et Hygiène 1999; 57:712–20.

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countries, user charges have been applied increasingly in Sweden during the 1990s in Perspectives on order to deter excessive use of health services. Set against this approach, neither Dawson nor Towse chooses to make a case cost sharing for the extension of charges on the grounds that they would combat moral hazard and reduce unnecessary utilisation. As Dawson argues, if unnecessary over-utilisation is the The uncertain demand and often high cost problem it is probably more to do with the of health care has meant that out-of-pocket supply-side – that is, moral hazard on the payments represent only a small proportion part of doctors who recommend excessive of total health care expenditures in most treatments to individuals with insurance – OECD countries. Instead, risk-pooling and would be more effectively countered insurance arrangements have been devel- through direct attempts to change their oped in order to cushion individuals from practice style, e.g. through financial incen- the financial consequences of ill health. tives, guidelines and protocols. These arrangements take a number of On the second argument, that cost sharing forms. In some countries, such as the is a potential means of raising revenue, United States, there is a flourishing private Towse is more open-minded. He points out insurance market. In most European coun- that cost sharing is used more vigorously in tries, on the other hand, heavy reliance is Central and Eastern Europe where the Ray Robinson placed upon publicly financed schemes, scope for raising extra revenue through tax- either involving social insurance contribu- ation is limited. Even in Western Europe, tions or general tax payments. In public political opposition to increases in public schemes, contributions are related to ability spending in the future might, as he points to pay rather than personal or group risk out, lead to a choice between cost sharing status. In all insurance schemes, however, and cost containment. If, however, greater individuals are not faced with the full finan- reliance is placed upon cost sharing for this cial costs of the services that they receive at purpose it has to be conceded that increases the time of consumption, i.e. there are zero, in health spending would be met by the or only nominal, user charges. Rather there sick. It would also be necessary to devise is a third party payer, either public or pri- elaborate and possibly costly systems of vate, that picks up most of the bill. exemptions to preserve equity objectives. Although there are good reasons for a third Looked at overall, it seems that the eco- party payer system – both in terms of equi- nomic case for an extension of cost sharing ty and efficiency – the absence of user either for reducing unnecessary demands or charges is periodically criticised on the raising extra revenues is weak. In the first grounds that it encourages excessive case, it is a blunt instrument that is unlikely demand and thereby contributes towards to increase efficiency and will tend to have escalating health care costs. This is general- undesirable equity consequences. In the ly referred to as the problem of moral haz- second case, even if additional expenditure ard. By introducing a greater element of on health care is justified on efficiency user charging, it is argued, individuals will grounds, it is not clear why an earmarked be made more aware of the costs of health tax related to health service use – which care services and will have an incentive to could be labelled a ‘tax on the sick’ – is forgo those services that are not really nec- preferable to a more broadly-based ear- essary. Another, more recent, argument is marked tax. But at a time when most that current attitudes towards public European governments are keen to control expenditure mean that governments will no rising public expenditures it may be that “if unnecessary over- longer be able to rely on the growth in the political case for extensions of cost public spending to meet the growing utilisation is the sharing will continue to be pressed, espe- demands for health care as they have done cially in established areas such as pharma- in the past. According to this view, user problem it is probably ceutical reimbursement. If this happens, charges also represent a promising source Anell and Svensson raise an interesting of extra revenue. more to do with the future possibility whereby a distinction is supply-side – that is, The pros and cons of these arguments are made between services of proven cost- examined in the articles by Dawson, Towse effectiveness – for which only nominal moral hazard on the and Anell and Svensson in this issue. Anell charges would apply – and full cost charg- and Svensson explain how, contrary to the ing for other services which do not meet part of doctors” experience of most Northern European this criterion.

eurohealth Vol 5 No 3 Autumn 1999 24 COST SHARING IN HEALTH CARE User charges in health care: the Swedish case

Contrary to the situation in many other the costs of care, and that the elderly are countries in northern Europe, patients in guaranteed a subsistence income level (SEK Sweden pay a flat-rate fee per practitioner 3,380 in 1997) after charges have been paid. or hospital visit, and they are required to Following a rapid increase in expenditures pay 100% of their prescriptions up to a for medicines, user charges for prescrip- specified limit. Swedish health-care deci- tions were changed in 1997. Under the old sion-makers defend the charges as neces- system, patients paid a flat-rate fee for each sary to contain excessive care seeking, not prescription and a second fee for each addi- least at hospital outpatient departments and tional item on the prescription (SEK 170 + for prescription drugs. SEK 30 in 1996). Several patient groups, During the 1990s, several important e.g. diabetics and asthma patients, were changes have been made and new roles for provided medicines free of charge. For user charges have been developed. In par- other patients, the maximum payment dur- ticular, following government decisions to ing a 12 month period was SEK 1,800 increase charges for prescriptions and den- (1996). Since June 1998, patients have been tist services, user charges have gradually required to pay 100% of the first SEK 900 increased in importance from an overall of their prescriptions, 50% of the cost financing perspective. As a result of a gov- between SEK 900 and 1,700, 25% of the Anders Anell ernment decision to allow more local cost between SEK 1,700 and 3,300, and choice in charges for health services and 10% of the cost between SEK 3,300 and nursing home care, changes have been 4,300. Thereafter, prescriptions are free, introduced at the county council and which limits the maximum payment for an municipality levels as well. individual during a 12 month period to SEK 1,800. In principle, this new scheme Charges for health services, nursing applies to all patients. homes and prescription drugs A standard payment for a visit to a general High-cost protection practitioner is approximately SEK 100. A That public health services should be specialist consultation at a hospital or clinic entirely free at the point of service for equi- will cost between SEK 200 and 250, though ty considerations has not gained support the SEK 100 already paid will be deducted from Swedish health care decision-makers. if the patient was referred from primary Physicians, for example, have complained care. Children under the age of 20 years about the recent suspension of charges for have had free access to dental care, however, services used by children under 20, since Marianne and have recently been granted free health this decision has increased demand and Svensson services in most of the county councils. hence required the reallocation of resources to the detriment of other patients. The responsibility for nursing home care was transferred from the 26 county coun- The Swedish model has instead focused on cils to the 289 municipalities in 1992, as protecting the sick from high costs associ- part of the so-called ÄDEL-reform. ated with health services and prescription Following this transfer, new systems of drugs through the high-cost protection user charges were established at the munic- scheme (högkostnadsskydd). Currently, ipality level. Primarily, the changes were two such schemes are in place, one for intended to create neutral charges paid by health services and one for drugs. These residents of old-peoples homes and nursing schemes guarantee that no individual pays homes, and special housing and recipients more than SEK 900 for health services and of home help services, respectively. As a no more than SEK 1,800 for prescription result of these new policies, charges for drugs during a 12 month period. Many nursing home care vary considerably elderly and chronically ill reach those limits among the municipalities and depend heav- quickly, however, and thus receive care free ily on individual income. The only limita- of user charges for the rest of the 12 month tions are that user charges must not exceed period.

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The high-cost protection has no role, how- in which they do not bear the full conse- ever, in preventing user charges from quences of their actions. In simplified form, reducing initial demand for services rela- the argument goes like this: patients who tively more for people with low income. pay nothing for services will demand large The high-cost protection only causes quantities of services that offer only mar- healthy individuals to subsidise the not-so- ginal benefits, to the detriment of taxpay- healthy, but no redistribution occurs ers. User charges then are a steering mecha- between different income groups. With low nism that can enforce, at least to some flat rate charges this is a small problem, but degree, responsible behaviour among increased charges have the potential to patients in the seeking of care. greatly affect the distribution of services across income groups. Given the magni- tude of the changes, and the potential “… user charges should be used selectively, rather than as a impact from an equity point of view, surprisingly little research has been conducted tool for rationing among basic needs across the board..” in the area of equity.

User charges and equity The rationale behind user charges rests on Surveys conducted by the Stockholm coun- several assumptions regarding the demand ty council in 1993, 1995 and 1996 show that for health services, however.4 One such between 20 and 25% of the population important assumption is that patients are refrained from seeking care at least once in able to make decisions about demand for a given 12 month period for financial rea- care that are in their best interests. This 1 sons. This is consistent with the argument assumption has been challenged. Studies that cost sharing is needed to contain have for example shown that cost sharing unnecessary care seeking. The same studies reduces demand for effective services just also show that the unemployed, students, as much as it reduces demand for services immigrants and single individuals, i.e. indi- of little medical value.5 This suggests that viduals that usually have low incomes, user charges should be used selectively, refrained from seeking care for financial rather than as a tool for rationing among reasons to a higher extent than high- basic needs across the board. income earners, which raises questions about overall equity. One possibility for the future that takes this into account would be to charge nomi- There is not much research on the impact nal fees for services that are cost-effective of the new prescription charges. According or important by some social criteria, but to a survey commissioned by the National introduce lower subsidies or full cost Board of Health and Welfare (NBHW), charges for services that do not meet such about 8% of all households who had a pre- basic requirements. With such a more scription in 1997 refrained from collecting selective use of charges it would also be the drug at the pharmacy at least once for possible to link the need for priority setting 2 financial reasons. The study could not from a social point of view with the rising with certainty point to any differences demand for individual patient participation caused by socioeconomic factors. Further, in medical decision-making. It remains to little is known about the effects of the user be seen if such a policy can be accepted by charges that prevailed before 1997. Swedish decision-makers, and the general According to the NBHW the demand for public. services in elderly care has declined in connection with the higher user charges.3 Moreover, the difference in user charges across municipalities has also led to pro- REFERENCES posals to implement a nationally regulated 1. Elofsson S, Undén A-L, Krakau I. Patientavgifter. Ett hinder att söka system. The present system is deemed so vård? Stockholm: Allmänmedicinska enheten NVSO, 1996. complicated that even the municipalities 2. Socialstyrelsen. Är läkemedlen för dyra för hushållen? Resultat från enkä- have problems understanding the total tundersökning i oktober 1997. effect on individuals. 3. Socialstyrelsen, Äldreuppdraget årsrapport 1997. Socialstyrelsen följer upp och utvärderar. Stockholm, 1997. A new role for user charges? The usual theoretical rationale for user 4. Rice T. The Economics of Health Reconsidered. Chicago: Health charges starts with the concept of moral Administration Press, 1998. hazard, i.e. the risk that economic agents 5. Lohr KN, et al. Effect of cost sharing on use of medically effective and less maximise their own utilities in a situation effective care. Medical Care. 1986;24(Supplement): 31–38.

eurohealth Vol 5 No 3 Autumn 1999 26 COST SHARING IN HEALTH CARE Could charging disposable income they have. Hence those on low incomes will be less likely to seek patients fill the cash treatment for a given condition than those on higher incomes, with a consequent gap in Europe’s impact on their health.2 Second, charging patients will raise money for the health care system. Cost sharing payments provide an additional source of health care systems? finance for health care services over and above that of social insurance premiums and taxation.

One solution often proposed to relieve the Charges as a source of revenue financial strain on Europe’s various health This article discusses the second conse- care systems is to ask patients to pay more quence of patient charging – namely, the ‘out of pocket’ towards the cost of their case for using out of pocket contributions health care treatment. Not surprisingly this from patients to increase the resources is a controversial issue because of concern available to Europe’s tax and social insur- that it will lead to patients not seeking or ance funded health care systems. We need not receiving the treatment they need to note that these two objectives of charg- because they cannot afford the direct cash ing are not mutually compatible. This is contribution. However, raising money because to the extent that charging patients from patients may serve two quite different reduces the utilisation of services it will not purposes. raise revenue. Extra revenue will only be raised if patients continue to use the ser- Adrian Towse First, it may make patients take some vices and to pay the direct contribution. Of responsibility for their health care. This is course, both roles for cost sharing can be the ‘moral hazard’ problem associated with regarded as of benefit to those in charge of all forms of insurance. If health care is free balancing the books of the publicly at the point of use then people have less financed system. Both deterrence to utilisa- incentive to take care of themselves than if tion and bringing extra cash into the system they had to pay out of pocket for the con- reduce pressure to put more tax or social sequences. Once a patient, they have an insurance revenues into the health care incentive to over consume health care, i.e. budget. Yet the policy implications are as long as treatment yields some benefit quite different. they will demand it irrespective of whether the cost of providing it exceeds the benefit. If the objective is to raise revenue then There are a number of issues related to this patient initiated care – such as the initial argument, which are considered in the arti- decision to visit the doctor with a symptom cle by Dawson. Two are relevant here: or health worry – should not be targetted, because the impact on utilisation will be (1) Most decisions on the use of health care much higher than where a doctor has initi- resources are made by doctors not patients, ated the treatment – for example by refer- hence incentives to be responsible – that is, ring a patient for hospital in-patient treat- to use resources cost effectively – should be ment. Low income exemptions are also 1 aimed at doctors not patients. essential, not only on equity grounds but (2) Asking patients to pay directly for care because no additional income will be raised requires them to put a monetary value on from those who cannot afford to pay. the care they will receive. Yet any such val- uations will be constrained by how much Charging to reduce demand Europe currently has a patchwork of cost sharing arrangements which have been summarised for the World Health “charging patients reduces the utilisation of services [and] Organisation by Kutzin and Kincses.3 it will not raise revenue. Extra revenue will only be raised They conclude that, broadly, in Western Europe the main purpose of cost sharing if patients continue to use the services and to pay the direct has been to reduce utilisation, whereas in Central and Eastern Europe, it has been to contribution” raise revenue. Central and East European

27 eurohealth Vol 5 No 3 Autumn 1999 COST SHARING IN HEALTH CARE countries have not been able to raise the tax First, if we assume that achieving health revenues to sustain their health care sys- gain is the main objective of providing tems and hence have used direct charges to health care, then at the macro level the help fill the gap. The implication is that question to ask is whether expenditure is once the fiscal base is improved or a com- currently too low, so denying efficient – prehensive social insurance scheme estab- that is, cost effective – treatment to some lished, the role for patient charges will patients.6 diminish. However, the evidence from Second, if so would the revenue raised Western Europe does not suggest that such from cost sharing be used to provide these a straightforward progression will neces- services? Evans et al argue that the extra sarily occur: cash is more likely to go in higher prices – six out of the 15 EU member states have and incomes for providers and could even some patient payment for first contact reduce the pressure to improve the cost “it is not clear that with the system – usually a visit to a pri- effectiveness of health care delivery.7 patients have much mary care doctor; Third, if extra resources would deliver cost – nine member states have cost sharing for effective care, is patient charging the right choice over their in patient stays; source? Charging users meets the benefit consumption of – all have cost sharing for pharmaceuti- criterion,8 but it is not clear that patients cals. have much choice over their consumption health care.” of health care. Moreover there are impor- Patient charges are low as a proportion of tant equity concerns. Given that health is total cost in comparison with Central and linked to income, charging patients will be East European countries and there are usu- a relatively regressive way of raising money ally extensive income or disease related unless there are substantial income related exemptions. If the objective is to reduce exemptions. utilisation it would make most sense to make patients contribute towards the first We must be realistic in assessing the three contact with the system, which is patient hurdles. There are many examples of peo- initiated. Yet this is the area of least cost ple failing to get cost effective treatment in sharing, suggesting that revenue raising is, most European Union countries. Debates perhaps, the more important consideration. about rationing health care are occurring in a number of member states. Whilst the effi- Pharmaceutical use is the area of greatest ciency of health care systems can and is cost sharing. Although this has an element being improved – notably through the use of patient initiation in that patients can of contracts and health technology assess- choose whether or not to present a pre- ment – it is unrealistic to argue that no scription at the pharmacy, “the objectives more resources should be put in until opti- of such policies are rarely stated explicitly, mal efficiency has been achieved. their main purpose appears to be to shift Improving performance is a dynamic much of the cost of drugs to the users.”3 process not a one-off leap. This has certainly been the case in Italy, which has seen some of the biggest increas- Where extra revenue comes from however es in cost sharing for pharmaceuticals over is ultimately a political issue. If politicians the last few years – although there have do not believe the public will support been important consequences for utilisa- increases in taxes or social insurance premi- tion.4 In the UK, which has one of the low- ums to fund health care then the question is est levels of patient charging, the flat rate whether extra revenue from patients will be prescription charge exceeds the cost of put to good use such that there is a net gain most pharmaceuticals that are dispensed to in welfare. The trade off in some EU mem- NHS patients and is therefore a user tax for ber states may be cost containment versus the 50 per cent of the population that is not cost sharing. In this context patient charg- exempt.5 ing, structured to minimise the effects on the health of those on low incomes and in Problems to be overcome poor health – as discussed in Rubin et al9 – Could – and should – cost sharing in the may have a useful though ultimately limit- ‘mature’ health care systems of the ed role to play. This is because, however European Union be increased and used well designed the scheme, it is hard not to explicitly to raise more money for the pro- share the conclusions of Kutzin and vision of health care services? Would it be Kincses:3 “As a means of mobilising rev- efficient to do this? The question of effi- enue for the health services, direct charges ciency is important and there are three hur- to patients are not likely to generate sub- dles to jump. stantial amounts without causing adverse

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consequences in terms of equity.” University of Pennsylvania, 1997. 5. OHE Compendium of Health Statistics. REFERENCES 10th Edition. London: Office of Health Economics, 1997. 1. Culyer AJ. Chisels or screwdrivers? A cri- tique of the NERA proposals for the reform 6. Chalkley M, Robinson R. Theory and of the NHS. In: Towse A (ed). Financing Evidence on Cost Sharing in Health Care: Health Care in the UK: A Discussion of An Economic Perspective. London: Office of Nera’s Prototype Model to Replace the NHS. Health Economics, 1997. London: Office of Health Economics, 1995. 7. Evans R, Barer M, Stoddart G. User fees 2. Keeler EB, Sloss EM, Brook RH, for health care: why a bad idea keeps coming Operskalski BH, Goldberg GA, Newhouse back (or what’s health got to do with it?). JP. Effects of cost sharing on physiological Canadian Journal on Ageing 1995; health, health practices, and worry. Health 14:360–90. Services Research 1987;22:3. 8. Jones A, Duncan A. Hypothecated Health 3. Saltman RB, Figueras J (eds). European Taxes: An Evaluation of Recent Proposals. Health Care Reform. Analysis of Current London: Office of Health Economics, 1995. Strategies. World Health Organisation 1997; 9. Rubin RJ, Mendelson DN. A framework 83–100. for cost sharing policy analysis. In: Mattison 4. Anessi E. The Effect of User Charges on N (ed). Sharing the Costs of Health: A the Utilisation of Prescription Medicines in Multi-Country Perspective. Pharmaceutical the Italian Health Service. Dissertation. Partners for Better Health Care, 1995

Why charge patients? if there are better ways to contain costs, encourage efficiency and reach for equity

There has only been one economic efficien- some of the costs directly; cy argument for charging patients a pro- (3) clinicians who know patients are portion of the cost of their health care and insured will provide more, or more expen- that is ‘moral hazard’. The problem is that sive, treatment than if the patient is paying where the costs of health care are covered and especially if they expect the patient by private or social insurance, incentives would find payment very difficult; for the inefficient use of resources will operate at four levels: (4) firms producing medical equipment and pharmaceuticals have incentives to innovate (1) individuals will take less care of them- in areas covered by insurance as introduc- selves and take greater risks than they tion of a new product likely to be covered would if they had to bear the full costs of by insurance will have a much larger mar- any adverse effects (illness or accident); ket than if patients must pay directly.1 Diane Dawson (2) once an adverse event occurs, the Moral hazard is a problem because it con- patient will demand more medical care if all tributes to the escalation of costs of the costs are paid by a third party than they insured activity – in this case, health care. would demand if they had to pay all or The traditional solution has been to impose deductibles or co-payments high enough to “It only takes brief consideration of how charging patients deter demands for excessive consumption by patients (levels one and two above). … is likely to affect behaviour … to realise that the policy There is some hope that knowledge of a financial burden on the patient will deter is unlikely to be very effective in deterring excessive use clinicians from ‘excessive’ treatment (level three) but no one has suggested cost shar- and is likely to result in defeating other important objec- ing is likely to have any impact on level tives of social health insurance and care.” four moral hazard: the incentives to pro-

29 eurohealth Vol 5 No 3 Autumn 1999 COST SHARING IN HEALTH CARE duce new products irrespective of their cost other medical services.2,3,4 However, effectiveness. charges are a blunt instrument. They are as likely to reduce clinically ‘appropriate’ or It only takes brief consideration of how ‘necessary’ care as they are to reduce charging patients part of the cost of their ‘excessive’ or ‘unnecessary’ care. It is treatment is likely to affect behaviour at important to remember that it is the clini- each of the four levels listed above to cian, not the patient who ordinarily decides realise that the policy is unlikely to be very what medical services the patient requires effective in deterring excessive use and is likely to result in defeating other important and prescribes what s/he considers appro- objectives of social health insurance and priate for the patient’s condition. The care. patient can only decline to act on the clinician’s advice by refusing to pay the charge. The effect of charges on lifestyle Most countries have adopted systems of social insurance for health care in order to With respect to level one moral hazard, ensure that necessary health care is avail- there is virtually no evidence that individuals adopt less risky life styles because they able to the entire population. To impose a anticipate having to pay a proportion of system of co-payment that undermines their health care costs should they become achievement of that objective diminishes ill or suffer an accident. We do not have the efficiency of the system and can only be research evidence on whether people are justified if there is no other set of feasible less likely to smoke if their insurance policies to reduce the extent to which requires co-payment than if their insurance resources are wasted on inappropriate or covers all costs. In theory work could be unnecessary care. Fortunately, there are “charges are a blunt alternatives to charging. done on the extent to which the prospect of instrument. They are as having to pay part of the costs of treatment would discourage individuals from playing Clinicians and patient charges likely to reduce clini- football or going mountain climbing. At As it is the clinician who ultimately decides present however, there is no evidence that what care to offer, most policies for reduc- cally ‘appropriate’ or cost sharing would reduce level one moral ing inappropriate treatment focus on the hazard. clinician. These policies include capitation ‘necessary’ care as they payments for primary care, prospective Charges and demand for medical payment for hospitalisation, prescribing are to reduce ‘excessive’ budgets, utilisation review, treatment pro- treatment or ‘unnecessary’ care.” Most cost sharing relates to level two and tocols and treatment guidelines. All the attempts to deter patients – individuals above are mechanisms to force clinicians to already ill – from demanding excessive ser- use their specialist knowledge to distin- vices. The theory is that, like any other guish between necessary and marginal use consumer purchase, paying for a medical of scarce health care resources. The patient treatment or drug competes with other uses is rarely in a position to know whether a of the patient’s income. If at the margin large dose of a drug would be wasteful and paying, say, an electricity bill is more a smaller dose adequate to produce the important to the patient than obtaining the desired therapeutic outcome. Why use an medical service, the patient will choose not instrument (co-payment) that requires the to consume the medical service. In this case person with the least relevant information the charge has been effective in holding to make an important decision? The devel- down consumption of health care. In prac- opment of treatment guidelines and proto- tice it is difficult to separately identify the cols reflects the fact that there is often dis- effectiveness of co-payments in discourag- agreement between specialist clinicians ing the patient from using services (level over what is appropriate or inappropriate two moral hazard) as opposed to discour- care. Why expect that by confronting a aging clinicians from recommending ser- patient with the requirement to pay part of vices or prescribing drugs when they know the cost of treatment, the patient will be the patient will have difficulty paying (level able to single out the ‘inappropriate’ treat- three). The research evidence therefore ments suggested by his/her doctor and combines the two in measures of the extent hence, by not paying for them, reduce con- of reduction in medical care consumption sumption? If the objective is to reduce the in the presence of cost sharing. use of unnecessary health care services, any, or preferably all of the policies direct- The research evidence here is unambigu- ed at clinicians are to be preferred to charg- ous. Cost sharing does reduce consumption ing patients. of health care. Most of the evidence relates to pharmaceuticals but some applies to The most frequent form of cost sharing in

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Europe relates to pharmaceuticals (see services. If they do reduce consumption, Towse article) and according to the argu- they indiscriminately reduce necessary care ment above, it is the least effective way of and the reduction is greater in the lower reducing excessive or inappropriate con- income groups. If pushed, most supporters sumption. It is the clinician, not the patient, of cost sharing ultimately see it as a way of who is in the best position to discriminate raising revenue rather than a means of between necessary or excessive consump- reducing moral hazard. We can still ask if tion of drugs. The second most common this revenue raising role for charges makes type of cost sharing is for in-patient days. sense on efficiency grounds. All taxes other What kinds of excessive consumption are than poll taxes have efficiency costs. Might these charges intended to discourage? The raising revenue through charging patients patient has no influence over length of stay have lower efficiency costs than raising rev- – clinicians determine this. The patient has enue through some other form of taxation? no influence over the tests administered or What would be the characteristics of an whether s/he receives intensive rather than efficient tax on patients? It must have no ordinary nursing care. The only costs of an substitution effects – that is, there must be in-patient stay over which the patient may no action an individual can take that would have some control are ‘hotel’ costs – choice reduce his/her tax liability. Therefore the of a single room or presence of a television basis for taxation could not be that a per- set or a choice of menu. In order to reduce son reveals him/herself to be ill by present- ‘excessive’ consumption of hotel services, it ing for treatment. The tax could be avoid- might be useful to have some charges that ed, as the evidence suggests, by not seeking may influence a patient’s choice of these treatment. The tax would have to be levied services while in hospital. on some characteristic of the individual So far the argument of this article has that he or she could not control but that focused on efficiency: the efficiency prob- would predict that individual would lem is to reduce excessive or unnecessary become ill. Advocates of taxing patients on consumption of health care services. The ‘efficiency’ grounds may have found a evidence is that policies directed at clini- future role for genetic screening in the tax cians can do this more effectively than system! charges on patients. It so happens that in An efficient tax on patients is clearly this case the most efficient policy is also the impracticable and choosing to tax the sick most equitable! This rare event in econom- more heavily than the well represents a ics arises from the fact that we would not rather odd principle of taxation on equity expect the treatments avoided or curtailed grounds. It flies in the face of the principles through an instrument such as a treatment of national health insurance that have led protocol to have an income bias whereas European countries to pool the costs of ill- we know the impact of charges on curtail- ness across the entire population. The effi- ing consumption is highly income sensitive. ciency costs of existing systems of co-pay- It is sometimes argued that as long as ment and patient charges could be estimat- exemptions are given for the very poor ed as the additional costs of treatment there is no equity problem in using charges, through late diagnoses and failure to pur- but this is untrue. The evidence available chase prescribed medication. The efficiency suggests that even with exemptions, costs would also include lost output reduced consumption is income related.4 through illness that would have been reduced if charging had not discouraged Towards an efficient patient tax? treatment. These are the efficiency costs to It is very difficult to see how anyone can be compared with the efficiency costs of make a case for co-payments for medical raising the same amount of revenue through income taxes or indirect taxes. REFERENCES It is sometimes argued that a tax assigned 1. Weisbrod B. The health care quadrilemma: an essay on technological to health care is more acceptable to people change, insurance, quality of care, and cost containment. Journal of Economic than a tax that goes into general govern- Literature 1991;29: 523–52. ment coffers – and therefore an assigned tax should have lower efficiency costs. If this is 2. Hurley J, Johnson N. The effects of co-payments within drug reimbursement programs. Canadian Public Policy 1991;17: 473–89. true, it is an argument for earmarking some tax that lacks the incentives for inefficient 3. Smith S, Watson S. Modelling the effect of prescription charge rises. Fiscal behaviour and inequity of existing systems Studies 1990; 11:75–95. of co-payment. The need to raise revenue 4. Mossialos E, Le Grand J (eds). Health Care and Cost Containment in the in a relatively efficient manner is not an European Union MPG Books Ltd, 1999. pp 75–83. argument for charging patients.

31 eurohealth Vol 5 No 3 Autumn 1999 HEALTH POLICY AND REFORM IN THE UK Reform of the NHS under New Labour

As most readers of eurohealth will be health services strategies, have to be agreed aware, in the early 1990s the British with all relevant parties, including local National Health Service underwent a mas- governments as well as commissioners and sive organisational change. The old state trusts. However, an element of competition bureaucracy, where health care was provid- remains: as a last resort, commissioners can ed by a command-and-control system and resort to other providers if they are unable resources were allocated by managerial or to reach a satisfactory service agreement professional fiat, was replaced by an inter- with their current provider. nal or 'quasi' market. This split the pur- The principal commissioners under the chaser from the provider, encouraged the new system are Primary Care Groups providers – now called trusts – to compete (PCGs), led by GPs. PCGs include up to with one another for contracts from pur- 50 GPs and cover populations of varying chasers, and set up two kinds of purchaser: sizes (from around 30,000 to around Julian Le Grand the Health Authority that purchased ser- 250,000). PCGs hold budgets; they will be vices for a particular city or district and the able to retain surpluses, which can be spent General Practice (GP) Fundholder, a pri- on services or facilities of benefit to mary care practice that was given a budget patients. All GPs are required to join for purchasing secondary care on behalf of PCGs. PCGs can operate simply in an the patients registered with the practice. advisory capacity to the health authority The internal market was highly controver- (Level 1), before graduating to the control sial, and the Labour Government elected in of their own budgets and to merging their 1997 was pledged to abolish it. In line with commissioning and primary care provider this pledge, in December of that year it roles in new Primary Care Trusts (Level 4). published a White Paper (Department of The current secondary care trusts remain; Health 1997) that proposed a further re- they are also to retain surpluses. organisation of the system, proposals that GP Fundholders have been absorbed into are currently in the process of implementa- PCGs. Health Authorities are losing their tion. But these have fuelled further contro- purchasing role, except for certain highly versy. Do they really constitute a change specialised services. But they are generally from the internal market? Alternatively, are the lead for HimPs; they are also the body they simply a return to the old command- to whom PCGs are accountable for their and-control system? Or are they neither of spending of public funds. A new perfor- these, but rather something quite different: mance 'framework', with performance a genuine Third Way? indicators emphasising effectiveness and outcomes, is being put in place. There are New Labour Reforms two new national bodies being set up: one – The principal changes are these. The pur- National Institute for Clinical Effectiveness chaser/provider split remains. But the rela- or NICE – to set quality standards; the tionship between purchaser and provider is other – the Commission for Health to be cooperative, and not competitive or Improvement or CHI – to enforce them. adversarial. Purchasers are relabelled as commissioners, contracts as service agree- A Third Way? ments. More generally, throughout the service, competition is to be replaced by col- The first striking point about these propos- laboration. Health Improvement als is that, despite the rhetoric to the con- Programmes (HimPs), local health and trary, key elements of the internal market have been retained. There is still a purchaser/provider split. The new GP-led commissioning organisations hold budgets, and in “A review of the evidence concerning the internal market's that respect are similar to GP Fundholders. effectiveness … concluded that the purchaser/ provider Trusts and PCGs are both to be allowed to retain their surpluses. And purchasers will split had worked. It also found that GPs with budgets be able to switch to other providers if they are dissatisfied with their existing ones: so tended to be the most effective purchasers.” competition – or at least contestability (the

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“The atmosphere has changed … there is an openness and groups did better, largely because they had less need to invest in inter-practice organi- cooperative spirit around the Service which is really rather sational development. different from the commercial suspiciousness which used to There is also another concern relating to the size of PCGs. The bigger the commis- characterise some of the relationships in the market.” sioning authority, the greater the danger that their purchasing constitutes too large a portion of local trusts' income, thereby potential in extremis for competition) – restricting their ability to shift business will remain. elsewhere, if necessary. This problem was particularly acute for the old health author- Overall, these continuities are a good thing. ities, which often found their attempts to A review of the evidence concerning the alter significantly their pattern of purchas- internal market's effectiveness (Le Grand, ing stymied by the threat of collapse (either Mays and Mulligan 1998) concluded that genuine or synthetic) from the trusts losing the purchaser/provider split had worked. It business. also found that GPs with budgets tended to be the most effective purchasers. Under the Finally there is the role of the centre. The internal market, health authorities and new institutions NICE and CHI have an trusts could not retain any surpluses they important job to do in ensuring that quality might generate – which severely limited is improved and that there is consistency their incentives. And it would be impossi- across the country. However, they will ble to retain the purchaser/provider split have to operate with a light touch so as not without some possibility of competition. to stifle innovation and legitimate diversity. Also they must demonstrate their indepen- But there are differences from the internal dence, both from government and from the market as well. These have both positive various interest groups within and outside and negative aspects. On the positive side, the Service. In many ways running these the atmosphere has changed, at least for the will be the most challenging task for the moment; there is an openness and coopera- new NHS. tive spirit around the Service which is really rather different from the commercial suspi- Conclusion ciousness which used to characterise some The NHS is now well into the new world of the relationships in the market. It of the Labour reforms. Important elements remains to be seen whether this new spirit of the internal market remain including the will survive when real conflicts of interest most successful ones such as the purchas- begin to emerge. There is also a danger that er/provider split and GP-led purchasing too great a cosiness between purchaser and and commissioning. However, in other provider, or between providers themselves, respects there have been significant may not always operate in the public inter- changes, some of them with echoes of a est; after all, it was the fear that the NHS return to command-and-control, but by no was being run too much in the interests of means all. So the reforms do not really con- the providers, especially the acute hospitals, stitute either full continuity or a return to that led to the purchaser/provider split in the past; and in that sense they do represent the first place. a Third Way. It is too early to say whether the new way will actually work better than New organisational costs either of the old ways; but so far, with one Then there are the PCGs. These are much or two exceptions (such as the large size of bigger than most fundholders; and again some PCGs), the signs are quite encourag- this has positive and negative aspects. Each ing. purchaser now has quite a large risk pool, REFERENCES and given that, unlike most fundholders, they are purchasing the full range of sec- Department of Health. The New NHS – Modern, Dependable. CM 3807, London: ondary care services, this is probably sensi- HMSO, 1997. ble. On the other hand, the larger they are the more difficult they are to organise. Hausman D, Le Grand J. Incentives and 'Free-riding' may become more of a prob- health policy: primary and secondary care in lem, and there may be other incentive the British National Health Service Social issues that need resolving (see Hausman Science and Medicine 1999;14:1299–301. and Le Grand, 1999, for a more detailed Le Grand J, Mays N, Mulligan J, (eds). discussion of this question). The experience Learning from the NHS Internal Market. of fundholding suggests that the smaller London: Kings Fund, 1988.

33 eurohealth Vol 5 No 3 Autumn 1999 HEALTH POLICY AND REFORM IN THE UK The new Health Development Agency for England workforce to deliver national strategies, and on their education and training needs What will it do? Although many of these aims are new, the HDA will not be an entirely new organisation since it will take over the staff and much of the budget of the existing Health The British Government’s recently published public Education Authority (HEA). The HEA has long been respected nationally and 1 health strategy (White Paper) for England, has internationally for its extensive knowledge proposed the creation of a new base on health promotion, but its main function has been to carry out Government organisation, called the Health funded programmes on lifestyle issues (e.g. Development Agency (HDA), HIV/Aids, smoking, coronary heart disease, etc). Some of these will continue to be to promote public health in carried out by the HDA, which will be launched in January 2000 with a likely England. Will the annual budget around £30 million and people of England be any between 150 and 200 staff, mainly based in London. healthier as a result? Brave new idea or quick fix We know what it won’t be doing – sending gimmick? a free tooth brush to every child in the Most UK commentators have welcomed Donald Reid land, inscribed “best wishes from the the HDA, as part of the government’s Minister for Health” – as happened once in strategy to improve health overall, and to narrow the gap between the health of rich another EU country just before a general and poor in particular. Although the HEA election. Its stated role, according to the is respected for its existing research base, in White Paper, is: the past it has lacked the necessary authori- “to ensure that organisations and individual ty to be truly influential, and has been gen- practitioners base their work on the highest erally known as the lead agent for the standards (in order to) raise the quality of implementation of Government lifestyle the public health function”. programmes rather than as a national centre for research and evaluation. Its functions will include: – Maintaining an up-to-date evidence base The creation of an organisation which will focus on developing a research base and for public health standards for the implementation of – Commissioning research and evaluation national programmes, will therefore be to strengthen the evidence base very welcome. It will undoubtedly con- – Advising the Government on the setting tribute significantly to improvements in the of standards for public health and health standard of the public health function in promotion practice, and on their imple- the National Health Service (NHS) in the mentation by national and local organi- long run, as the Government intends. sations However, there remains concern over a – Providing advice on targeting health number of unresolved issues. For example, promotion most effectively on the worst the requirement for the new Agency to off, and narrowing the gap in standards conduct health promotion programmes of health between rich and poor does not fit well with its primary function – to compile and disseminate research find- – Disseminating effectiveness and good ings and advise on standards – since it is practice to those working in this field difficult to see how a monitoring organisa- – Advising the Government on the capaci- tion can objectively assess the value of its ty and capability of the public health own programmes. It seems inevitable that

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“Success in reducing health inequalities will obviously being given to the need to reduce England’s unenviable record of health inequality – depend on the Government’s willingness to create a more where men aged 25 to 39 in the most deprived social class are five times more equal society – which requires increased benefits for the likely to die each year than men in the poor, healthier housing, reduced unemployment and better wealthiest class. Success in reducing health inequalities will health services in deprived areas” obviously depend on the Government’s willingness to create a more equal society – which requires increased benefits for the the programme delivery function will even- poor, healthier housing, reduced unem- tually be transferred elsewhere - perhaps to ployment and better health services in the Government Department of Health, as deprived areas, etc. Some would argue that in Wales, Canada and Australia. “to redistribute health, you must first redistribute wealth” – which implies the Other possible controversies concern the need for higher taxes on the better off. It is scope of its functions in relation to public difficult to believe that the Government health. Public Health Departments within will allow the HDA to commission the National Health Service (NHS) have a research into areas as sensitive as the link wide range of functions, which include between income inequality and health. advising on the most cost effective arrangements for clinical services, preventing com- And even if politically unpalatable findings municable disease, promoting lifestyle pro- do emerge from its research, it is unlikely grammes locally, and working with munic- that the HDA will be allowed to speak ipal Councils and others to improve health freely about their implications. There is no in the locality (e.g. by providing healthier sign that it will become an independent housing). Currently, all NHS public health force, making public pronouncements on departments are led by medically qualified the effectiveness of broad Government Directors of Public Health (DPHs). It policies on health inequalities. seems unlikely that the HDA will be asked to pronounce on the more clinical aspects Conclusion of the work of DPHs, nor on the preven- The British Government’s initiative in set- tion of communicable disease - but this ting up a central agency to provide a coor- clearly needs to be clarified. dinated, evidence-led base for public health in England is greatly to be welcomed. It is The issue of standards may also lead to dis- likely to result in more cost effective pro- sent, especially as the HDA could be per- grammes in the future, which will con- ceived as some kind of national regulatory tribute to significant long term advances in agency for public health. Health promotion the public’s health. However, it is doubtful officers within NHS public health depart- whether the new organisation should also ments, who are chiefly responsible for local be responsible for the delivery of the very implementation of national lifestyle pro- programmes that it has been set up to eval- grammes, have traditionally looked to the uate – the two functions are basically HEA for resources and advice on effective incompatible. methods. However, they do not expect the HEA to play a significant role in drawing And it will be essential to clarify the limits up quality standards, and may therefore to its remit as soon as possible – the present not take kindly to the new Agency’s vagueness of definition can only lead to involvement. DPHs may be even more confusion. Finally, welcome though the “even if politically resistant to attempts to set standards across HDA is in its present form, it would be all of the broad functions of public health even more valuable if it became an indepen- unpalatable findings do departments – especially if the HDA’s first dent watchdog for public health – able to Chief Executive is not a former DPH. speak directly to the public provided it emerge from its could produce sound evidence for its But by far the most testing question con- judgements. This, unfortunately, is most research, it is unlikely cerns the limits to the HDA’s remit in the unlikely to happen. field of “broader public health”. The new that the HDA will be Labour Government is rightly focusing on REFERENCES allowed to speak freely the root causes of ill health - such as pover- 1. Dept of Health for England: Saving Lives: ty, unemployment etc, rather than the Our Healthier Nation. London, Dept of about their lifestyle focused campaigns of its predeces- Health, 1999 Available on the internet at sor (though these will continue to a http://www.official-documents.co.uk/docu- implications” reduced extent). Particular emphasis is ment/cm43/4386.htm

35 eurohealth Vol 5 No 3 Autumn 1999 News from the European Union

PRODI’S COMMISSION

Mr.RomanoProdi,thefutureEuropeanCommissionPresident,announcedthenamesandportfoliosofthe19proposedCommissioners on 9July1999(seeBox1).TheEuropeanParliamenthasnowalsoapprovedMr.Prodi’snominations.

During a speech to the European the Public Health Directorate (for- the prospective Commissioners’ Parliament on 21 July 1999, Prodi merly DG V/F) has been removed thinking regarding their future areas promised a “revolution in the way the from the Social Affairs DG and fused of responsibility, and their personal Commission works”. Prodi stated, with Consumer Protection to form a views on key priorities and policies. “The organisational structure of the new DG called Health and Consumer Profiles of all the prospective Commission has not been substan- Policy. In a speech to the European Commissioners can be found at tially altered in 40 years”, reflecting Council on the 3rd of June, Prodi Internet address: http://europa.eu. that “the world has moved on and the stated that the objective of such int/comm/newcomm/index_en.htm Commission has not kept pace.” To mergers is to remove overlaps and resolve the collective loss of confi- duplications and, so far as is possible, The European Parliament’s question- dence amongst European citizens, to group together one or two DG naires and the answers from each Prodi claimed that he will make the policy areas that fall under the prospective Commissioner can be European Union more relevant for responsibility of a single Commis- found at: http://europa.eu.int/comm/ the European public, by addressing sioner. newcomm/hearings/index_en.htm issues such as jobs, growth and the The 19 prospective Commissioners Mr David Byrne has been appointed challenge of sustainable development, appeared before the European Commissioner of the Directorate on which balances wealth creation, social Parliament in special hearings during justice and the quality of life. Prodi Health and Consumer Policy. Mrs. the week of 30 August–7 September, stated that transparency, accountabil- Anna Diamantopoulou, the new after having provided written answers ity and efficiency will be the watch- Commissioner for Employment and to questionnaires that they received words at every stage of this process. Social Affairs will have health inter- from the European Parliament. The ests in her portfolio, which includes In line with this, important changes answers to written and oral responses social exclusion and poverty, and have occurred within public health, as present a comprehensive overview of occupational health and safety. The following provides brief overviews of the new Commissioners’ curriculum BOX 1 vitaes, as well as some of the com- THE PRODI COMMISSION ments that they made during the par- The new organisation of the European Commission liamentary inquiries. President Romano Prodi (Italy) Mr David Byrne (Ireland) Vice President for Administrative Reform Neil Kinnock (UK) Since 1970 Mr Byrne has served as a Vice-President for relations with the European Loyola de Palacio (Spain) Barrister in Ireland, where his prac- Parliament, and for Transportation and Energy tice was exclusively in civil law, with Commissioner for Competition Mario Monti (Italy) a significant emphasis on commercial law. This involved a requirement to Commissioner for Agriculture and Fisheries Franz Fischler (Austria) be familiar with community law. He Commissioner for Enterprise and Information Society Erkki Liikanen (Finland) served as the Irish member to the Commissioner for Internal Market Frits Bolkenstein (Netherlands) International Court of Arbitration in Commissioner for Research Philippe Busquin (Belgium) Paris between 1990–1997. Since his student days Mr. Byrne has been very Commissioner for Economic and Monetary Affairs Pedro Solbes Mira (Spain) active in issues relating to access to Commissioner for Development and Humanitarian Aid Paul Nielson (Denmark) justice and he has also been involved Commissioner for Enlargement Gnter Verheugen (Germany) in legal education. From June 1997 until his resignation in July 1999 he Commissioner for External Relations Chris Patten (UK) served as Attorney General in Commissioner for Trade Pascal Lamy (France) Ireland. Commissioner for Health and Consumer Protection David Byrne (Ireland) Mr. Byrne supports the merging of Commissioner for Regional Policy Michel Barnier (France) the public health and consumer Commissioner for Education and Culture Viviane Reding (Luxembourg) responsibilities within a single directorate general, as it will bring greater Commissioner for Budget Michaele Schreyer (Germany) coherence to these two policy areas. Commissioner for Environment Margot Wallstrom (Sweden) On food safety he has said that food Commissioner for Justice and Home Affairs Antonio Vitorino (Portugal) legislation must be simplified and Commissioner for Employment and Social Affairs Anna Diamantopoulou (Greece) shortcomings remedied; specific rules must be tightened up, and controls

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toughened. While stressing the the Hellenic Organisation of Small New European Parliament importance of food safety and health, and Medium-Sized Enterprises and Mr. Byrne stated during his Handicrafts (EOMMEX), member of Parliamentary hearing that he was the Central Committee of PASOK, Followingtheentryintoforceofthe uneasy that the debate on Secretary General for Youth, AmsterdamTreatyon1May,the Community health was being overly Secretary General for Adult EuropeanParliamentwillhaveconsid - dominated by the food crisis. He has Education, and Prefect of Kastoria. erablymorepowerstoshapelegisla - stressed that he will focus on ensur- Mrs. Diamantopoulou has stressed tion. ing transparency, and on working the importance of social policy as a together with Parliament in order to key factor in improving productivity About 80% of all Community restore public confidence, which has and economic performance, and that legislation must now pass through been shaken by the recent food crisis. it should not therefore be regarded as Parliament before it becomes law. On public health Mr. Byrne has stat- burdensome. She has said that some Nevertheless, under half the elec- ed that it is important to be proac- of the major elements of the torate voted during the elections tive, and that a fundamental review of European social model, such as pen- that were held on June 10-13 Community public health policy is sions and work-related social protec- 1999. In the Netherlands only one underway with the aim of presenting tion, are in urgent need of reform, if third of the electorate voted, a comprehensive framework in this they are to remain financially sustain- while in the UK less than a quar- area for the future. He intends to able. Member States must cooperate ter cast a ballot. at the European level to make sure present ideas on how best to exploit The election results herald signifi- that the European social model the new Treaty opportunities provid- cant changes for the Parliament, remains central to the European way ed for by Article 152 in the Treaty of with more than half of the mem- of life, and a key factor in ensuring an Amsterdam in the field of public bers being new to it, as well as effective integration of applicant health. He also stressed that there is a being younger and including sig- countries into the Union. need for much better information on nificantly more women. In addi- how public health systems work, in In the area of health and safety at tion, for the first time since direct order to generate knowledge and to work, she will be guided by the four elections were held 20 years ago, make comparisons as to best prac- priorities that were laid out in the the Socialists have lost control of tices. mid-term report on the “Community the chamber to the centre-right Some of the areas that he intends to Programme Concerning Safety, European People’s Party. Socialist focus on in the future are: the Hygiene and Health at Work bloc losses came in particular increase of environment-related dis- (1996–2000).” These are, a stronger from Germany and the UK. emphasis upon proper implementa- eases such as allergies and asthma The elections saw defeat for Clive tion and practical application of legis- affecting children and young people; Needle MEP (UK), who was the lation; preparing for enlargement, the decline in rates of vaccination Labour spokesman for health in and ensuring that applicant countries amongst children; and the adverse the European Parliament. Ken comply with the social policy aspects effects of genetic modification. He Collin MEP (UK), the rapporteur of the acquis communitaire; to also intends to focus on health prob- on the Public Health framework strengthen understanding of the link lems of the elderly and disabled peo- communication, and Christian between improving the working ple, and he will investigate ways of Cabrol MEP (UK), two staunch environment and employability; and responding preventively to mental health supporters, did not stand to focus on the potential risks gener- health problems. for re-election. ated by new technologies, new mate- Mrs. Diamantopoulou (Greece) rials and new forms of organisation However, the new chairperson of Mrs. Diamantopoulou trained as a in the world of work. the Committee on Environment, Public Health and Consumer Civil Engineer and did her Other Commissioner designates Protection, Caroline Jackson Postgraduate studies in Regional whose portfolios also include a wide MEP (UK) has committed herself Development. She has worked as a range of issues that relate to public to raising the profile of public Civil Engineer, as a Lecturer at the health are: health. New members of this Institutes of Higher Technological Committee include former UK Education, and as Managing Director Franz Fischler (Austria), junior health Minister John Bowis of a regional development company. Commissioner for Agriculture and MEP (UK), and Torben Lund Mrs. Diamantopoulou also has exten- Fisheries MEP (Denmark), former Danish sive experience in politics. Most Erkki Liikanen (Finland), Health Minister. recently, (1996 –1999) she served as Commissioner for Enterprise and an elected politician in the European Information Society A full list of the MEPs on the Council of Ministers, where she was Environment, Health and Margot Wallstrom (Sweden), a Deputy Minister for Development. Consumer Protection Committee Commissioner for Environment She has also been a Member of can be found on Internet address: Parliament for Kozani, Secretary Pascal Lamy (France), Commissioner http://www.europarl.eu.int General for Industry, President of for Trade

37 eurohealth Vol 5 No 3 Autumn 1999 News from the European Union

HEALTH COUNCIL MEETING Commission sets out TheHealthCouncilmetonthe8thofJune1999. Millennium Round Priorities

TheCommissionpublisheda Future Community Action in the Field of Public Health Communicationon8thJulythatsetout The dioxin food scandal in Belgium Finally, they agreed on the need to itsproposalsfortheagendaofthe and health and humanitarian aid prevent diseases both through broad MillenniumRoundofglobaltradetalks aspects of recent events in Kosovo health promotion activities and spe- tobelaunchedthisNovemberin left little time for an in depth discus- cific actions targeting specific areas. Seattle. sion of the future framework for Ministers also indicated a need for a public health policy. Nevertheless better structuring of the health pro- The Commission proposes a strat- the Council did exchange views on grammes by integrating all pro- egy that includes ensuring that the future Community action in the grammes under a single umbrella WTO continues to address issues field of Public Health. Ministers programme. of concern to the public at large, agreed to focus on three important such as environment, health and It was also considered necessary that areas. social concerns. Other aspects of the future health programme would the strategy address more specific First, they suggested developing a adopt a more horizontal approach trade issues. comprehensive system for collect- covering health aspects in other ing, analysing and distributing infor- fields of Community policies, such The Communication also stresses mation on public health. as internal market, environment and the importance of working with Second, they stressed the impor- social affairs. Ministers invited the civil society, and of explaining to tance of reacting quickly to health European Commission to draw up a the public the benefits of the mul- threats by means of a Community new legislative proposal promoting tilateral trading system. surveillance system, including early public health “as a matter of Furthermore, it suggests further warnings and rapid reactions. urgency”. steps that could be taken to improve WTO transparency. On the issue of consumer health, Resolution on Antibiotic Resistance the Report states that members may resort to restrictive measures Ministers adopted a Resolution that lance and control of communicable in order to ensure the level of pro- underlined their commitment to diseases resulting from antibiotic tection that they have established. devising an overall strategy to guard resistance. Nevertheless, it emphasises that against the development of resis- The Scientific Steering Committee’s these measures should be taken on tance to antibiotics. The Resolution the basis of the ‘precautionary was a response to an Opinion hand- “Opinion on Anti-microbial principle’, rather than on the ‘zero ed down by the Scientific Steering Resistance” is available at the fol- risk approach’. This means that Committee on 28 May. lowing Internet address: http://europa.eu.int/comm/dg24/hea products that have been identified The Resolution calls on member lth/sc/ssc/outcome_en.html as posing a potential threat to peo- states to cooperate to monitor the ple, animals or plants should be supply and use of antibiotics, boost For information on an international assessed on a case by case basis, research and promote health-orien- scientific conference on anti-micro- and according to the scientific evi- tated animal production systems to bial resistance that was organised by dence available. The definition of reduce the need for antibiotics in the Commission on 20 July please the precautionary principle is not, feed. It also calls for more surveil- see: http://europa.eu.int/comm/dg24 however, entirely clear, and arriv- ing at a common interpretation of the principle may prove to be a Informal meeting with the Health Ministers of CEECs and Cyprus sensitive issue during the Round. As part of a pre-accession strategy, with applicant countries their pre- During his hearing at the agreed to at the Luxembourg sent health laws and practices; and European Parliament, Pascal Summit on 12–13 December 1997, to identify potential areas of cooper- Lamy, the new Commissioner of the Health Council met Health ation. The Council adopted a Trade, stated that in the US autho- Ministers from the CEECs (Central Resolution to review present work- risation to the trade of a product is granted as long as that product has and Easter European Countries) and ing methods with the applicant not been proven to pose a risk. Cyprus for the second time in an countries and called on the informal meeting. Europeans, on the other hand, Commission to draft a proposal that believe that a product should be The Council’s objectives were three- could be integrated into the future banned if it is thought to pose a fold: to exchange views; to discuss Health Framework Programme. risk.

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COMMISSION ADOPTS A COMMUNICATION ON MODERNISING SOCIAL PROTECTION TheEuropeanCommissionadoptedaCommunicationinJuneonaEuropeanUnion-widestrategyformodernisingsocialprotection,in theface ofcommonchallengessuchasthechangingworldofwork,newfamilystructuresandthedemographicchangesoftheforthcomingdecades.

They must do so while balancing the Communication states that it is now health care, to treat illness, and to pro- clearly expressed wishes of citizens time to deepen the existing coopera- vide care and rehabilitation for those for continued high levels of protection on the European level in order to who need it. While the health of the tion against the requirement that assist Member States in formulating a Community population is better than public services should be economical common political vision of Social ever before, demand on the health and efficient. The Communication is Protection in the European Union, systems is increasing and will contin- a contribution on the part of the including the objective of high quali- ue to do so with an ageing population. Commission to an ongoing process, ty and sustainable health protection. Constant innovation in medical tech- which has been underway since the nology can bring great benefits but beginning of the 1990s, to establish The Communication asserts that also increased costs. The Commission social protection as an integral part of everyone should be in a position to thus invites the Council to endorse the European Social Model. The benefit from systems to promote formally the following objectives as the basis of future deliberations: • contribute to improve the efficien- Dioxin Scandal cy and effectiveness of health sys- OnthesecondofJuneEUveterinaryofficialsorderedtheBelgianauthoritiestodestroy tems so that they achieve their allchicken,eggsandderivedproductscomingfromfarmsthatusedfeedthatcouldhave objectives within available beencontaminatedwiththecarcinogendioxin. resources. To this end, ensure that medical knowledge and technolo- The restrictions were later extended over tranquillisers in Belgian pork gy is used in the most effective to cover products from pork and and hormones in beef, and it has way possible and strengthen co- bovine farms that may also have used shaken consumer confidence even operation between Member States contaminated feed. Animal fat, which further. Former Consumer Affairs on evaluation of policies and tech- is likely to have been tainted with Commissioner Emma Bonino stated niques motor oil, was supplied to animal that doses of dioxin that were found • ensure access for all to high quality food companies in late January and in Belgian chicken “gave rise to con- health services and reduce health fed to birds on a quarter of Belgium’s cern”, although acute near-term inequalities 1,500 poultry units. Suspect poultry effects were unlikely. There is, how- was also traced and destroyed in the ever, a chance of long-term effects, • strengthen support for long-term Netherlands, Germany, France and since dioxin is a category one car- care of frail elderly people by, Portugal. The ban applies to all prod- cinogen. inter alia, providing appropriate ucts coming from potentially infected care facilities and reviewing social In attempts to restore consumer con- farms, which were produced between protection cover of care and carers. fidence, Farm ministers agreed to 15th January and the first of June draft a new directive to amend the • focus on illness prevention and 1999. The EU stopped short of existing one to provide a method to health protection as the best way imposing a total sales ban after the prohibit the use of certain raw mate- to tackle health problems, reduce authorities insisted that they could rials in animal feed that have harmful costs and promote healthier trace the contaminated feed back to health or environmental effects and lifestyles. specific farms. Farm Minister Karel require labelling for animal waste. Pinxten and Health Minister Marcel The strategy that the Communication The new directive would also include Colla resigned over the scandal on outlines aims at deepening the co- proposals to facilitate the traceability the first of June. The Commission operation through exchange of expe- of raw materials. Community legisla- has launched legal proceedings rience, policy discussion and moni- tion on the harmonisation and co- against the Belgian government over toring, in order to identify best prac- ordination of inspections will also be its handling of the dioxin crisis. tice and to give the process a higher revised. Agricultural ministers are Although farmers first noticed health public and political profile. To this setting up a scientific committee to problems with poultry in January, it end, Member States will be invited to look at how the risk of animal feed was not until 26th April that the designate senior officials to act as contaminated with dioxin can be authorities had proof of high dioxin focal points for exchange and infor- reduced. The World health levels, and notified other member mation gathering activities. The Organisation and the Food and states. The Commission was not told Commission will regularly organise Agricultural Organisation are in the until 27th May. Belgium also failed to meetings of these officials to analyse process of reviewing guidelines for comply fully with an order to and evaluate the progress made. dioxin exposure in foods, which remove and destroy foodstuffs. should in turn provide the EU with The new communication is available Europe’s latest food crisis follows the tools to implement stricter monitor- on Internet at the following address: scare over BSE and the controversy ing of such contaminants. http://europa.eu.int/comm/dg05/soc- prot/social/index_en.htm

39 eurohealth Vol 5 No 3 Autumn 1999 News from the European Union

NEWS IN BRIEF

IT WILL soon be possible to detect sult with an ethics committee. prevent severe vitamin A deficiencies more quickly and with greater preci- Ministers also agreed on basing any in countries that rely on rice as a sta- sion animals suffering from BSE. new decision on the precautionary ple food. So far, researchers have not Three rapid post-mortem BSE tests, principle, and on ensuring the trace- applied for a permit to release the which were developed by different ability and labelling of GMOs or rice outside of controlled test sites. groups of independent scientists in products containing them. The max- Passing all European safety regula- Ireland, Switzerland and France as imum period for authorisations to tions may take at least five years; part of a comparative Community place a product on the market before this time, the rice cannot be evaluation programme, have shown should not exceed ten years. The planted in developing countries. remarkable effectiveness in distin- Environment Minister also agreed to guishing animals clinically affected a three-year moratorium on approv- with BSE from healthy animals. ing new biotechnology varieties. The THE EUROPEAN Commission Since the tests were obtained from common position will go for a sec- intervened against a quota arrange- animals showing clinical signs of ond reading to the newly elected ment to control expenditure on BSE, however, it remains to be seen European Parliament. pharmaceuticals in Denmark. This if these tests are equally effective in agreement, which was concluded the case of animals that, although between the Danish Ministry for affected with BSE, show no clinical DAVID BOWE, the Parliament’s Health and the Danish Association signs of it. This new development former rapporteur on proposals to of Pharmaceutical Producers (Lif), has not led to any changes to current revise the EU’s procedure for aimed to control public expenditure Community BSE legislation. The approving GMOs, has expressed his on price subsidies for pharmaceuti- Scientific Steering Committee will support for the adoption of the case cals by freezing prices for prescrip- publish the results of its evaluations by case precautionary principle. This tion drugs and placing a cap on total of the tests as rapidly as possible. follows recent evidence that the US public expenditure on price subsidies. Furthermore, if Lif-members The statement of the Scientific government and the US Food and exceeded the quota that they were Steering Committee on the tests will Drug Administration (FDA), which allocated on a monthly basis, they be available under the following is responsible for food safety, had to eliminate their surplus by Internet address: http://europa. ignored its own scientists’ advice on means of price reductions during the eu.int/comm/dg24/health/afh/index the potential risks of GMOs. following three months’ period. In _en.html Documents obtained by the Iowa- based lobby group Alliance for Bio- the Commission’s view the quota Integrity reveal that a senior advisor arrangement violates Article 81 of the EC Treaty because it has anti- THE GERMAN Presidency put on plant toxins warned that “geneti- competitive effects and because less forward the idea of setting up an cally modified plants could contain restrictive means to reduce public agency within the Commission to unexpectedly high concentrations of expenditure are available. Following handle all future approvals for genet- plant toxins”. the Commission’s intervention the ically modified organisms (GMOs). parties agreed on a quota scheme Peter Jorgensen, former spokesman that does not force Lif-members to for the former Environment IN RESPONSE to growing public reduce prices below a calculated Commissioner Ritt Bjerregaard, concern about production processes European average price for each called this plan to update the 1990 and their risks to the environment individual product. directive (90/220) on GMOs unac- and human health, Romano Prodi ceptable, and accused the German has raised the possibility of estab- Presidency of deliberately stalling lishing an independent European A NEW study, commissioned by efforts to revise legislation on food-safety agency along lines of the Eurostat, has established a set of approval procedures for all new American Food and Drug non-monetary indicators on social crops and seeds containing GMOs. Administration (FDA). More infor- exclusion and poverty. While non- EU Environment Ministers agreed mation on this will be given when it monetary indicators should not be on a common position on the becomes available. regarded as an alternative to mone- revamped Directive on releasing tary indicators, the identification and GMOs into the environment. The analysis of these indicators may Ministers agreed that GMOs must MEANWHILE, despite the negative enhance understanding of this com- pass a risk assessment before they attention being received by the GM plex phenomenon. are first marketed, and they insisted industry, European researchers have on regular, written procedures successfully managed to incorporate The study is available under Internet involving consultations with scien- the production of beta-carotene into address: http://en/comm/eurostat/ tific committees in all circumstances rice. This achievement represents a research/supcom.95/result/result02.p as well as on the obligation to con- major breakthrough in the quest to df

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