Health and the Environment

Volume 6 Number 5, Winter 2000/2001 eurohealth

The challenges of enlargement for public health

Improving the quality of healthcare

The developing role of nursing

The Commission’s Health Strategy: view from the Committee of the Regions eurohealth Public health policy in the EU is being shaped by several political and structural forces. At the political level, the increased emphasis on public health issues that has taken place LSE Health, London School of Economics p in recent years is highlighting the centrality of health issues and Political Science, Houghton Street, across the public policy spectrum. Quite apart from the overt London WC2A 2AE, United Kingdom requirement for public health to be recognised in policy Tel: +44 (0)20 7955 6840 design across directorates, the intrinsic presence of public Fax: +44 (0)20 7955 6803 health issues in various areas of policy requires in itself that Web Site: www.lse.ac.uk\Depts\lse–health there is a health focus in setting the policy agenda. This is perhaps nowhere more true than in environment policy where EDITORIAL r EDITOR: issues such as pollution are in essence public health issues. Mike Sedgley: +44 (0)20 7955 6194 Environment Commissioner Margot Wallström here sets out email: [email protected] the importance of health concerns in environmental policy SENIOR EDITORIAL ADVISER: making and describes the initiatives and polices being pursued Paul Belcher: +44 (0)20 7955 6377 email: [email protected] e in order to address the serious environmental health concerns EDITORIAL TEAM: that face the European Union as a modern industrial society. Johan Calltorp Erwin Jackson of Greenpeace discusses climate change and its Julian Le Grand potential impact on human disease and agriculture. The emer- Walter Holland gence or return of infectious diseases through changing cli- Martin McKee matic conditions is a real issue for public health planners and SUBSCRIPTIONS managers. Mark McCarthy concludes this section with a look f at central and east European countries a decade after the end Claire Bird: +44 (0)20 7955 6840 email: [email protected] of the Soviet era, which left massive environmental problems in a context of economic disruption and institutional break- Published by LSE Health and the European down. Health Policy Research Network (EHPRN) with the financial support of LSE Health and a The approaching enlargement to the east is itself another Merck and Co Inc. political question facing all of Europe’s policy makers. Martin eurohealth is a quarterly publication that McKee and Laura MacLehose discuss the implications for provides a forum for policy-makers and communicable diseases and the ability of Community initia- experts to express their views on health policy issues and so contribute to a construc- tives to deal with an increasingly important policy area in the tive debate on public health policy in Europe. face of an ever broadening single European market. Following c his Health and Enlargement Report to the European The views expressed in eurohealth are those of the authors alone and not necessarily those Parliament, John Bowis MEP discusses the severe problems of LSE Health and EHPRN. facing central and east European countries and the difficulties incurred by the continued delay in their full membership. ADVISORY BOARD Magdalene Rosenmöller notes that while a great deal of Dr Anders Anell; Professor David Banta; Mr Nick Boyd; Dr Reinhard Busse; e progress has been made in preparing for enlargement, there is Professor Correia de Campos; Mr Graham a lot more that both the Commission and the candidate coun- Chambers; Professor Marie Christine Closon; tries need to do. Professor Mia Defever; Dr Giovanni Fattore; Dr Josep Figueras; Dr Livio Garattini; Dr Unto The organisation and structure of healthcare delivery are also Häkkinen; Professor Chris Ham; Professor David Hunter; Professor Claude Jasmin; changing rapidly and are other sources of pressure on policy Professor Egon Jonsson; Dr Jim Kahan; makers, managers and healthcare practitioners. Two important Dr Meri Koivusalo; Professor Felix Lobo; Professor Guillem Lopez-Casasnovas; areas are examined here. Thanks are due to Professor David Mr Martin Lund; Dr Bernard Merkel; Dr Elias Banta for his editing of a series of articles on quality in health- Mossialos; Dr Stipe Oreskovic; Dr Alexander care. This section looks at quality management and the poten- Preker; Dr Tessa Richards; Professor Richard Saltman; Mr Gisbert Selke; Professor Igor tial for improvement in the quality of healthcare across Sheiman; Professor JJ Sixma; Professor Aris Europe. Three articles consider the changing, and expanding, Sissouras; Dr Hans Stein; Dr Miriam Wiley role of the nursing profession within European healthcare systems. © LSE Health 2001. No part of this publication may be copied, reproduced, stored in a retrieval Finally, we begin with a contribution from Roger Kaliff system or transmitted in any form without prior permission from LSE Health. detailing the report of the Committee of the Regions on the Commission’s new health strategy. This will be an ongoing subject of debate in future issues as the effectiveness of the Design and Production: Westminster European, email: [email protected] strategy becomes clear and its various aspects are implement- Reprographics: FMT Colour Limited ed, including the precise shape of the new Health Forum. Printing: Seven Corners Press Ltd

Mike Sedgley ISSN 1356-1030 Editor Contents Winter 2000/2001 Volume 6 Number 5

European Union CONTRIBUTORS TO THIS ISSUE

DAVID BANTA is Senior Scientist at the 1 The European Commission’s proposed health strategy Netherlands Organisation for Applied A regional perspective Scientific Research (TNO) and the Swedish Council for Technology Assessment in Roger Kaliff Health Care (SBU).

ALES BOUREK is a senior staff member at the Division of Health Informatics, Medical Enlargement and public health Faculty, Masaryk University, Brno, Czech Republic. 4 The health challenges of enlargement JOHN BOWIS MEP is UK Conservative Party John Bowis MEP Spokesman on Environment, Health and Consumer Protection at the European 6 Enlarging the European Union: Parliament and a former UK Health Implications for communicable disease control? Minister. Martin McKee and Laura MacLehose AINNA FAWCETT-HENESY is Regional Adviser for Nursing and Midwifery at the 9 Health and enlargement – Half way there WHO Regional Office for Europe, Magdalene Rosenmöller Copenhagen.

PIPPA GOUGH is Director of Policy at the Royal College of Nursing, London.

LASZLO GULACSI is Head of the Unit for Health and the environment Technology Assessment in Health Care, Centre of Public Affairs Studies, Budapest 12 Health and the environmental imperative University of Economics. Margot Wallström ERWIN JACKSON is Climate Change Campaigner at Greenpeace International, 14 The impacts of climate change on European London. population health Erwin Jackson ROGER KALIFF is Vice-president of the European Union Committee of the Regions.

16 Local environment and health practice in central ISUF KALO is Regional Adviser on Quality and eastern Europe of Health Systems at the World Health Mark McCarthy Organisation Regional Office for Europe, Copenhagen.

MARIANNE LIDBRINK is an Adviser to the The developing role of Swedish Association of Health Professionals. Quality in healthcare nursing in healthcare LAURA MACLEHOSE is Research Fellow at 18 Quality of healthcare in Europe: delilvery the European Observatory on Health Care Systems, London School of Hygiene and An introduction Tropical Medicine. David Banta 29 Nursing in the WHO European Region in the 21st MARK MCCARTHY is Professor of Public 20 Development of quality of health Century Health in the Department of Epidemiology systems in Europe Ainna Fawcett-Henesy and Public Health, University College London. Isuf Kalo 32 Nursing and its developing MARTIN MCKEE is Professor of European 23 HTA in Denmark: The role: A British case study Public Health at the London School of connection between health Pippa Gough Hygiene and Tropical Medicine. technology assessment and RAFAL NIZANKOWSKY is Director of the continuous quality development 34 The role of the Community National Centre for Quality Assessment in Steen Henrik Sandø Chief Nurse in the Swedish Health Care, Cracow, Poland. municipalities MAGDALENE ROSENMÖLLER is Professor at 25 From unconscious incompetence Marianne Lidbrink IESE Business School, Barcelona, an expert towards conscious competence: on health and enlargement and a health Quality improvement in economist at the World Bank, Latin healthcare in the CEECs American and Caribbean Region, in Washington. Laszlo Gulacsi, Rafal 37 European Union news Nizankowsky and Ales Bourek STEEN HENRIK SANDØ is a physician with by the European Network of responsibility for clinical databases on qual- 27 The need for cost effective quality ity at the National Board of Health, Health Promotion Agencies Copenhagen. improvement interventions and the Health Development David Banta and Laszlo Gulacsi Agency, England MARGOT WALLSTRÖM is European Commissioner for Environment. EUROPEAN UNION TheEuropeanCommission’s proposedhealthstrategy Aregionalperspective

The mandate of the European Union is such that decisions Is average life expectancy so important? An made, or not made, have an impact on public health. It is increase in the average life span is not only a question of a few extra years at the end of therefore vital that the EU acts with the best interests of our lives, it also has to do with more children surviving infectious diseases and fewer public health in mind when making decisions in a wide middle aged men dying from cardiovascular diseases. The trend means not only that range of areas, for example agricultural policy, priorities in we are living longer, but also that we feel better. Nor have the opportunities for a the social field or the utilisation of research funds. longer and better life been entirely exhaust- ed. They are, however, largely dependent There are major variations in health status on the policies that can be pursued both among the citizens of the Union, and this jointly for, and individually in, the coun- will become even clearer as enlargement tries of the EU. progresses. This means that there will be major opportunities to significantly The importance of various areas of improve health in many countries and policy to public health among large groups of the population, but The Commission has proposed, in accor- this will not happen automatically. dance with the Amsterdam Treaty, that public health aspects should be taken into The report of the Committee of the account in connection with all of the EU’s Regions on the Commission’s proposed proposals and measures. The Committee of health strategy for the EU concludes that the Regions has welcomed this, as the EU the focus of the EU’s new health strategy is the joint body that has the competence must be on achieving improvements in and possibility to influence many of the Roger Kaliff health for all, with the overriding goal factors that are of decisive importance to being to reduce inequalities in health. The health. The EU must now begin to define report is based on broad consultation the impacts that its policies have on the between the regions of Europe. health of the people of Europe and formu- Good health is an issue of the highest pri- late an effective policy that steers the ority for the citizens of Europe and an area Community’s actions in various areas in which they have high expectations, and towards better public health. this will of course continue to be so. If The Committee of the Regions believes young people are asked what they believe that the Commission should begin by to be the most important thing in life, then analysing public health aspects in areas health usually comes at the top of the list. where supranational decisions are made, i.e. agricultural policy, the introduction of the How is health created? common currency and enlargement of the Generally speaking, we can say that our “A change in the EU’s Community eastwards. health has improved enormously within the agricultural policy Union. In only a century, average life Agriculture and agricultural subsidies are expectancy has increased from just over 50 the largest area of work of the EU. A closer could lead to an to almost 80 years in many Member States. examination of the EU’s agricultural policy important improve- In other words, we can count on living reveals that the EU subsidises the cultiva- almost half a lifetime longer than our fore- tion of tobacco to the tune of 1 billion ment in health and bears of a few generations ago. This trend euros per year. This should be seen in light has nothing to do with genetic changes. of the fact that smoking causes over lend credibility to its The reasons for this unparalleled change 500,000 deaths in the EU each year, almost are to be found in background factors such half of which occur within the age range 35 health policy.” as economic development and social policy. to 69. A change in the EU’s agricultural

1 eurohealth Vol 6 No 5 Winter 2000/2001 EUROPEAN UNION

policy could lead to an important improve- Average life expectancy for a newborn boy within the EU and applicant ment in health and lend credibility to its countries, 1999 (WHO 2000) health policy. Years Inequalities in health 90 Creating the preconditions for good health 85 for all of the people of Europe must 80 become a matter of priority for the 75 Community in the future. 70 65 There are major variations in health today, 60 with a higher level of disease and mortality 55 among less privileged groups and in less 50 prosperous areas. However, this is a prob- 45 lem that also presents the Community with 40 a great opportunity to improve the lives of UK Italy Malta Spain many of its citizens. Some examples: the Latvia Turkey Ireland France Austria Poland Cyprus Greece Finland Estonia Belgium Sweden Bulgaria Portugal Slovakia Slovenia Romania Denmark Lithuania average life span for women is five years Germany Netherlands longer in France than in Ireland, while the Luxembourg average life span of men is five years longer Czech Republic in Sweden than in Portugal. Infant mortality is much higher in Greece than in Finland. Average life expectancy for a newborn girl within the EU and applicant countries, 1999 (WHO 2000) The enlargement of the Union involves even greater challenges. The state of health Years in many of the applicant countries is much 90 poorer than in the present Member States 85 (see Tables). 80 The Committee of the Regions feels, there- 75 fore, that the Commission should focus on 70 these inequalities in health and draw up an 65 overall target for the health strategy. This 60 could, for example, state that: ‘The overall 55 target should be to reduce health risks and 50 differences in health throughout the EU. 45 The health status of different countries and 40 UK different population groups should, in the Italy Malta Spain Latvia Turkey Ireland Austria France Poland Cyprus Finland Greece Estonia Belgium Sweden Bulgaria Portugal

long term, approach the level of the best in Slovakia Slovenia Romania Denmark Lithuania Germany

the Union’. The applicant countries should, Netherlands Luxembourg

of course, also be seen as part of the EU in Czech Republic this context. There is no reason not to regard them as ‘target groups’ for measures Infant mortality in the EU and applicant countries, 1998 (WHO 1999) or programmes, although obviously in the form of offers or invitations until they Deaths per 1 000 live births become members. 40 The Treaty and the competence of the EU must of course be taken into account when 30 following up this target and translating it into concrete measures. In the case of concrete measures aimed at achieving the 20 target, the Committee of the Regions points out that the EU should assess what 10 impacts the implementation of decisions taken on various issues will have for different groups of the population. Another 0

example is that special attention should be UK Malta Latvia Turkey Italy(1) Ireland Austria Greece Finland paid to particular groups when the Public Estonia Bulgaria Portugal Slovakia Spain(2) Slovenia Romania Lithuania Denmark Germany Poland(2) France(3) Belgium(1) Health Programme is implemented. Sweden(2) Netherlands Smoking, for example, is especially preva- Luxembourg (1) = 1995; (2) = 1996; (3) = 1997; (4) = 1999 lent in the lower socioeconomic groups and Czech Republic(4) the measures taken should be based on the needs of these groups. EU countries Applicant countries

eurohealth Vol 6 No 5 Winter 2000/2001 2 EUROPEAN UNION

The Public Health Programme feels that a European study, ‘Investing in The Commission’s proposed Public Health Health’, should be drawn up. This would Programme is, like the rest of the health be similar to the report from the World strategy, very ambitious. The Commission Bank. The aim would be to analyse the eco- proposes that a comprehensive information nomic costs of ill health and the value of “There is a risk that the system should be developed and aimed at investments in health. Similar discussions the policy makers, health professionals and have been held previously, but now that health strategy will go the general public. This is a proposal that is the proposal on a new health strategy has well in line with the rapid development of been presented, this would seem to be the up in smoke!” information technology and the opportuni- right time to produce such a report. ties it offers. The Committee fully supports the proposal Surveying and following health trends in that the EU should ‘respond rapidly to the different countries may provide great threats to health’. This must be seen as a added value for public health policy within very important part of the Commission’s the Community, and consequently for the work that may play a major role in the health of the people of Europe. Such com- future. parisons will make it possible to detect ‘Addressing health determinants’ is another health risks that may otherwise be difficult area of work taken up in the proposed to identify. They can also help to tighten Public Health Programme. The Committee up health policy. of the Regions believes that this area must It can be tempting to give priority to mea- be given higher priority. In the present sures in the field of health and medical care proposal, only six million of the 287 mil- when discussing public health. The word- lion euros for the six years of the pro- ing of the proposed strategy indicates the gramme are devoted to health risks relating desire to forge such a link in some cases. to tobacco. This should be seen in the light However, the Committee of the Regions of the fact that the EU is currently spend- opposes any move to extend the compe- ing a thousand times more on the subsidis- tence of the Union to cover healthcare. The ation of tobacco cultivation than on efforts factors that are of primary importance in to counteract the health risks stemming improving the level of health within the from tobacco — there is a risk that the Union lie outside the field of healthcare. health strategy will go up in smoke! Comparing waiting times and queues for operations and treatment and so on may be The role of the regions of interest to the public and is important The Committee of the Regions, naturally when setting priorities or designing health- enough, highlights the importance of the care services. It is unlikely, however, to regions in the field of public health. The have any great impact on public health and fact is that the regions or their equivalent can therefore be performed by those who are responsible for public health and have direct responsibility for healthcare healthcare in many of the Member States, systems. There is also a risk that the EU, by particularly in northern Europe. In many making such comparisons and by providing of these countries, such as those in advice on clinical guidelines, quality and so Scandinavia, the regions have no legal influ- on, will slip into a role in which it controls ence within the EU. The regions must and governs healthcare policy. Such powers therefore be guaranteed the right to exert would clash with the principle of subsidiar- influence over the public health policy of ity as a governing principle for the division the Community in a special statute. of competence within the EU. Healthcare “The Commission and the planning, operation and financing Ethical discussion An ethical discussion on the fundamental should begin by of healthcare systems must remain areas within the competence of each Member values that should apply in the field of analysing public health State. health is required. We are currently wit- nessing a lot of new initiatives in the health The Committee of the Regions proposes, field, many of which are based on ‘the four aspects in areas where on the other hand, that continuous reports freedoms’. The healthcare systems of the on expected health trends should be supranational decisions Member States have been built up over submitted in order to meet new threats to many years and are based on the cultural public health at an early stage. Forecasts, are made.” traditions and ethical principles of the indi- scenarios and so on can help to ensure that vidual countries. Safeguarding these ethical new health threats within the Community principles, as well as cultural diversity, may are dealt with quickly. generate great added value for the In addition, the Committee of the Regions Community in the future.

3 eurohealth Vol 6 No 5 Winter 2000/2001 ENLARGEMENT AND PUBLIC HEALTH Thehealthchallengesofenlargement

“I look to the Commission to initiate more collaborative action with the World Health Organisation”

There is a large majority in the Member States, must be firmly told to put European Parliament and also in away their rule book and get out their the Council and Commission who guide book. want the process of enlargement Our neighbours to the east have seen and to succeed. We must, therefore, felt the seismic changes of the end of com- make it clear both to the applicant munism. When Pandora opened her box all countries and to ourselves that the the ills of mankind were released and some- process of enlargement should not simply be an obstacle course or a times that is how it must have felt as set of exam questions.. It is a opened borders meant a two-way traffic of process whereby we work togeth- bad habits. Bad habits move fast. Good er to enable all of our European practice moves more slowly. And many of family of nations to join us in a these bad habits were linked to health: John Bowis MEP way that makes them and us feel comfort- infectious diseases – some drug resistant able with the Union. and some we thought we had seen the last of; drug abuse and the horrors of AIDS and We must remember, however, just where syphilis; and the negative impact of tobacco we have all been in the past sixty years. and alcohol. First our European family was separated by war and then by peace and by the new But that, of course, happened before, not alliances after the war. The West took the after, enlargement. You cannot erect some capitalist road and the East took the road new curtain – a cordon sanitaire to protect of socialism. That latter road led away from west from east and east from west. freedom, although some of the Eastern Enlargement of the EU or no, it is in our countries had barely experienced freedom mutual and collective interest that such under their ancien regimes. It led to many problems are dealt with. It is my belief that cases of repression. Yet it also provided a enlargement can help that process. degree of stability. Then the iron curtain In my Health & Enlargement Report, now was ripped aside. Freedom dawned, but at a adopted by the Parliament, I summarised price. How often people in some former the position as being that : Soviet republics have said to me, “We like the freedom but we wish we still had the – Virtually all Applicant Countries have economic certainties of the communist economic difficulties, with less money years”. Others have relished the indepen- available for public spending. dence from the old Soviet dominance of – Virtually all have lowered the priority Comecon and the Warsaw Pact and have of health in their spending plans, so moved steadily to a free market system, health has a smaller portion of a smaller despite the odd political, economic or cake. social bump on the way. What is certain is that, give or take Belarus and – Some aspects of health provision were Turkmenistan, virtually all our Eastern good and remain so, such as the number of doctors – even if too many of “Bad habits move fast. family is on the move in a political and economic sense and it is our duty and our wish them are in hospitals and too few in the Good practice moves to help that process. community. – Some aspects were good and have dete- There is, of course, an acquis and there are more slowly.” genuine concerns – some serious – which riorated, such as the vaccination cover- we must tackle and surmount. But those age of children. who say, “Clear the hurdles or don’t come – Some aspects were bad and are now in”, knowing very well that some of the improving, such as the abuse of acquis hurdles are still not met by current psychiatry.

eurohealth Vol 6 No 5 Winter 2000/2001 4 ENLARGEMENT AND PUBLIC HEALTH

– Some aspects hardly existed and are Treaty of Amsterdam. now rapidly growing, such as treating Since the 1950s, we have had standards of sexually transmitted diseases. Health & Safety at Work laid down in the – Some aspects were poor and are getting Treaties of Rome and Paris. Then steadily worse, such as addiction. over the years Europe added competencies – For most the challenge is to reform and standards from Public Health to infrastructures, management and Health Promotion; with rules from tobacco resource systems; to improve health to blood safety; rights from mobility for education and promotion; to protect doctors, patients, services and capital to individual rights; to keep their profes- human rights; and laws such as those on sionals; and to afford drugs and health mental health. Pharmaceutical companies technology. are regulated and medicines for people and animals licensed. Then we have a range of Affording adequate healthcare is a chal- activities in research, dissemination of good lenge for all of us. People are living longer, practice, education and training, and we are with a disproportionate amount of health building a compendium of Directives and and social care resources inevitably going Regulations on matters wholly germane to to older people. Medical science moves on health, such as emissions, pollution, at an exciting but expensive pace, with new radioactive and other dangerous sub- queues forming for new drugs and treat- stances, waste disposal, water and air and ments and public demand for access to soil quality, food safety and novel foods, what is available. If you then consider that, product liability; and a charter of funda- while current EU Member States spend a mental rights of some sort is on the way. weighted average of 8.75 per cent of GDP on health, with Germany at 10.5 per cent, It is a long list, but one that is often more mainland applicant countries spend an honoured in the breach than in observance by Member States. There is a message there for EU governments on compliance and for the Commission on enforcement. More “Not only are infectious and notifiable diseases on the importantly there is a message that we need to use all the channels available to support increase and, but life expectancy has suffered.” progress within Accession Countries. That is why my Report stresses the need to encourage the PHARE Programme to do more in the health field. It is why we average of 5.8 per cent, with the lowest at should bring the countries into partnership 3.8 per cent and only Slovenia some way with us now in the Health Action, research out in front at 9.4 per cent. These are per- and monitoring programmes and organisa- centages of very low GDPs and the size of tions of the Union. I also look to the the problem in cash terms is extremely European Investment Bank to play the big- stark. The awesome comparison in US dol- ger health role I know it is willing to play lars is $1771 per EU citizen and only $357 and I look to the Commission to initiate per applicant citizen. more collaborative action with the World Health Organisation. It is then no wonder that not only are infectious and notifiable diseases on the At the same time we need to look at other increase and that protection campaigns issues than are directly and immediately the such as vaccination and education have domain of the European Institutions. I been cut back, but that life expectancy has think, for example, of the problems or suffered. EU life expectancy is 74.5 for men potential problems of medicines provided and 81.2 for women. Applicant equivalents at discounted prices to Eastern and Central are 67.4 and 75.8. And disability rates too Europe but which, after accession, might show a 20 per cent difference in the years be sold back into the Western countries, at lived with a disability. If we bear in mind a healthy price, but one which could distort shorter life spans, that means disability not both markets. only lasts longer, it starts earlier. We have time to tackle the acquis problems So what does Europe expect from its appli- before accession, but not too much. Then cant friends. In simple health acquis terms we can tick the Health box on the applica- the answer is not a great deal, but that is to tion form and get on with the much more miss the wider health-related acquis and to important and longer term task of working miss the developing acquis that has come together to meet the health and care chal- from recent EU Treaties and notably the lenges of this twenty first century.

5 eurohealth Vol 6 No 5 Winter 2000/2001 ENLARGEMENT AND PUBLIC HEALTH EnlargingtheEuropeanUnion: Implicationsforcommunicablediseasecontrol?

For as long as international trade has existed there has been a tension between the free movement of goods and people and the control of epidemic disease. The planned enlargement of the European Union by 12 countries and 105 million1 people brings this issue to the forefront once again.

In March 1998, accession negotiations were international boundaries. The development formally opened with six countries: the of the European Union has contributed Cyprus, Czech Republic, Estonia, considerably to this increased mobility by Hungary, Poland, and Slovenia. The removing obstacles such as tariffs and, at process was widened in February 2000 to least within the Schengen countries, fron- Martin McKee include six additional candidates: Bulgaria, tier checks. Latvia, Lithuania, Malta, Romania and the Slovak Republic. Turkey is also a candidate The public health response country for accession to the EU although In contrast to this openness, the public not yet in accession negotiations. health response has largely remained con- The first formal agreement recognising the strained within national boundaries. problems created by trade and travel for Surveillance and control systems within the communicable diseases was the adoption of EU continue to be the responsibility of the International Health Regulations by the Member States, with the international 22nd World Health Assembly in 1969. By dimension based primarily on the 1969 the 1960s and 1970s, many were optimistic International Health Regulations. It is, that the burden of disease and premature however, rapidly becoming apparent that death due to infectious diseases would soon the growth in international travel and trade be relegated to history. Fired by the suc- has stretched these systems to the limit, as cesses of anti-microbial drugs and immuni- highly publicised food safety and other Laura MacLehose sation programmes, an American Surgeon crises have highlighted the challenges to General declared that infectious diseases national surveillance systems arising from had been conquered.2 These hopes were an increasing global environment. From the soon dashed. Antibiotic resistance, the European Union perspective, these chal- re-emergence of old threats, such as tuber- lenges emerge in three situations: culosis, and the appearance of new ones – outbreaks detected in one country such as HIV and legionnaires disease, which may affect people in other coun- shattered the complacency. tries; In the past three decades these threats have – outbreaks that can only be detected by returned with a vengeance. One reason is pooling national surveillance data; the vast increase in the scale and pace with which people and goods are moving across – outbreaks arising outside the EU that pose a potential public health threat to the EU.

NOTE: The European Union has responded to This paper draws on a report on the management of outbreaks of these challenges, within the framework of communicable disease affecting more than one EU Member State, undertaken what is permitted by the Treaties. In recog- by the authors and others on behalf of the European Commission (Brand H, nition of the health implications of Camaroni I, Gill N, Fulop N, MacLehose L, McKee M, Reintjes R, increased trade, the European Union’s Schaefer O, Weinberg J. An evaluation of the arrangements for managing an competence in public health has steadily epidemiological emergency involving more than one EU Member State. expanded. While some mention of health Bielefeld: L_GD, 2000) as well as on work being undertaken as part of a study was present in the early treaties, going back of the implications of accession for health and healthcare, by the European as far as European Coal and Steel Observatory on Health Care Systems. Community (ECSC) Treaty of 1951, its

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should be adopted or whether the response RECENT EU SUPPORTED INITIATIVES IN COMMUNICABLE DISEASE should be based on a supranational centre. SURVEILLANCE AND CONTROL In 1998, agreement was reached on a net- 1. Training work approach, which was formalised in ¥ European Programme for Intervention Epidemiology Training (EPIET) Decision 2119/98/EC on setting up a network for the epidemiological surveillance and control of communicable diseases in 2. Surveillance and Related Research the EU.4 The new 2001 to 2006 European ¥ European Working Group on Legionella Infection (EWGLI) Commission proposal for adopting a ¥ European Network on Salmonella and VTEC Infections (Enter-Net) programme of community action in the ¥ European Influenza Surveillance Scheme (EISS) field of public health reinforces these ¥ European Monitoring Group on Meningococci (EMGM) concepts. One of its three objectives is to ¥ EuroTB enhance the capability of the EU to ¥ European Anti-microbial Resistance Surveillance System (EARSS) respond rapidly to threats to health by ¥ EuroHIV strengthening surveillance, early warning ¥ RAPEX (Rapid Alert Information Exchange System incorporating Rapid Alert and rapid reaction systems.5 Food Safety System RASFF) ¥ European Network for Diagnostics of Imported Viral Diseases (ENIVD) These provisions form part of the accumu- lated body of existing EU law, the Acquis Communautaire, that each candidate coun- 3. Information try must incorporate in its entirety into ¥ Eurosurveillance Weekly & Monthly national legislation as a condition for acces- ¥ Health Surveillance System for Communicable Diseases (HSSCD) Information IDA (Interchange of Data between Administrations) sion. Currently, the Acquis is estimated to run to 80,000 pages of documentation and ¥ Inventory of resources for communicable diseases in Europe is continually expanding.6 ¥ Inventory of resources for communicable diseases related to travel and tourism ¥ Inventory on arrangements dealing with zoonoses Networks and initiatives ¥ EUVAX scientific and technical evaluation of vaccination programmes in the The various decisions on communicable EU disease have their concrete manifestations ¥ Development of Minimal Data Set (standardisation of data across the EU) in a number of disease specific networks ¥ An evaluation of the arrangements for managing an epidemiological emer- linking national surveillance centres across gency involving more than one EU Member State (1999-2000) the EU, as well as the beginnings of an early warning system. In addition, two surveillance journals, Eurosurveillance weekly first substantive appearance was in the and monthly, have been established. An Single European Act of 1987, which EU wide training scheme on intervention enabled the development of the Europe epidemiology, EPIET, is also in place. The Against Cancer and Europe Against AIDS box shows some of the initiatives currently programmes. However it was only in 1992, in place or planned. in Article 129 of the Maastricht Treaty, that a competence in the field of communicable Two advisory groups help guide such disease, which could be considered to be activities: the Charter Group (heads of one of the ‘main health scourges’ facing the national communicable disease surveillance population of Europe was introduced. This institutions) and the Network Committee was reinforced in the Amsterdam Treat of (two representatives from each EU 1997, which came into force in 1999, which Member State). An example of a network is emphasised that ‘a high level of health pro- EWGLI, the European Working Group on tection shall be ensured in the definition Legionella Infection. In this network, and implementation of all Community Member States exchange data on cases of policies and activities’. travel-associated legionaires disease. As the disease may only appear 10 to 14 days after The provisions of the Treaties have enabled “Participation in exposure, by which time holiday makers the development of a range of policies on from a contaminated hotel may have European Union communicable disease prevention and returned to their homes all over Europe, an control. The 1996 Decision on AIDS pre- international surveillance system is essen- surveillance and vention,3 for example, has extended the tial if clusters associated with a particular scope for coordinated European action. prevention activities resort are to be identified. ‘Enternet’ is There has been a general agreement among another EU network, in this case focusing Member States that closer coordination is should not necessarily on human salmonella infection and other necessary but the form that it should take gastrointestinal diseases. have to wait for formal has provoked considerable debate. In particular, there have been conflicting The system of networks has facilitated the accession.” views on whether a ‘network’ approach use of common case definitions and stan-

7 eurohealth Vol 6 No 5 Winter 2000/2001 ENLARGEMENT AND PUBLIC HEALTH

dardised laboratory practices for many Figure TUBERCULOSIS INCIDENCE, ALL FORMS, IN THE EU AND common diseases. It has been shown, for SELECTED ACCESSION COUNTRIES example, that EWGLI has detected many more outbreaks than was previously the Rate per 100,000 population case.7

100 Health challenges The health challenges facing the candidate 80 countries vary considerably, with some, such as the Czech Republic and Poland, 60 showing rapid gains in life expectancy while in others, such as Romania and 40 Bulgaria, it is stagnating and, for some 20 groups, continuing to deteriorate. Malta and Cyprus are, of course, exceptions, as 0 they do not display the high levels of adult 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 mortality seen throughout central and eastern Europe. In general, however, levels of Romania Estonia EU average communicable disease are higher than in existing Member States while investment, Lithuania Bulgaria both physical and human, in the capacity to Source: WHO Health for All database detect, investigate and manage them may be more limited. Earlier gains in communicable disease control, particularly with tuber- is a need to identify mechanisms to enable culosis and syphilis, have been lost in some representatives of candidate countries to of countries. Rates of tuberculosis are sig- participate more widely in the existing nificantly higher than in the European European Union schemes as soon as possi- Union, rising to over six and seven times ble. This would bring advantages to both the European Union average in Lithuania candidate countries and the current EU and Romania in 1998 (see Figure).8 Member States.

Participation REFERENCES Against this background, preparation for participation in the EU surveillance initia- 1. European Union Enlargement: A historic tives will be extremely important. Some opportunity. European Commission 2000. candidate countries already participate 2. Fidler D. International Law on Infectious informally in the Enternet network and the Diseases. Oxford: Clarendon Press, 1999; EWGLI network has also expanded p.45. beyond the borders of the EU. There are, 3. Decision 647/96/EC adopting a pro- however, a number of challenges to be gramme of Community action on the pre- “Surveillance and addressed. One is in the training in modern vention of AIDS and certain other commu- epidemiological methods, which has been nicable diseases. European Parliament and control systems within given lower emphasis in some countries Council 1996. because of the dominant role of microbiol- the EU continue to be ogists in the response to communicable dis- 4. Decision No 2119/98/EC of the European Parliament and Council of 24 September eases. Microbiology laboratories will also the responsibility of 1998 setting up a network for the epidemio- need to be upgraded in some areas and in logical surveillance and control of communi- some cases, the use of common case defini- Member States.” cable diseases in the Community. European tions and laboratory procedures may need Parliament and Council 1996. to be introduced. The speed with which disease can now spread means that there is 5. Proposal for a Decision of the European also a need for enhanced communication Parliament and of the Council adopting a systems, taking advantages of the growing programme of Community action in the role of the internet. field of public health (2001–2006). 2000/0119 (COD). Participation in European Union surveil- 6. Wider Still and Why. The Economist lance and prevention activities should not 23 October 1999. necessarily have to wait for formal accession. The scale of the challenge is such that, 7. Legionnaires’ Disease in Europe. WER if it is left until accession negotiations are 1999;74:273–80 completed, it will be many more years 8. World Health Organisation. Health For before common systems are in place. There All database. June 2000.

eurohealth Vol 6 No 5 Winter 2000/2001 8 ENLARGEMENT AND PUBLIC HEALTH Healthandenlargement Halfwaythere

Nearly two years have passed since the Staff Working Paper on Health and Enlargement was published. The Commission has gone some way towards addressing the issues identified in this paper, but approaching the EU average. Infant mor- there is a need for greater effort and closer collaboration between tality has improved, too, except in Romania, where a worryingly high rate the different health and enlargement related Commission services. persists. In most countries healthcare is still very clinically orientated, while primary care and public health concepts are elabo- The health reforms in the candidate coun- rated, but not really implemented. tries were undertaken in the very adverse Expectations in relation to healthcare are context of the wider political and economic rising, especially with increasing access to transition.1 Despite considerable progress, the Internet. At the same time the popula- the feeling is that health sector reforms tion remains poorly informed about the have gone only ‘half way’. Western coun- reforms, as public communication is weak. tries have all realised that reform is a never ending story, and should be considered Healthcare reforms have been supported more as a continuous improvement effort. by technical assistance from various In the candidate countries, unfortunately, sources, such as the Phare programme, the effort seems to have come to a halt. especially Phare Consensus. Twinning pro- Reforms are stagnating and policies are not grammes between candidate countries and being implemented as planned. In many Member States promote the transposition Magdalene cases the system seems to be a ‘patchwork’ and implementation of the acquis commu- and remains ill defined. New and old insti- nautaire, i.e. occupational health and safety Rosenmöller tutions have competing responsibilities, and phyto-sanitary control. Phare supports procedures are unclear and regulations are the participation in Community public lacking. health programmes and the fifth framework programme. Substantial bilateral The legacy of the communist system has support has been, and still is, provided by been slow to disappear. The vertical, Member States and others. A recently hierarchical and party-influenced command signed Memorandum of Understanding structure prevented people from develop- serves as a foundation for co-financing of ing their capabilities; many still have programmes between the Commission and difficulties with decision analysis and risk the International Financing Institutions. taking. Political instability and the slow The cooperation with WHO-Europe recovery of economic growth have further activities – the HIT series,2 liaison officers, hampered reform efforts, while the early and specific programmes – is likely to be decentralisation has complicated national enhanced on the basis of the recent decision making. The challenges of imple- exchange of letters between the menting the reform have been underesti- Commission and WHO-Geneva. “New and old mated, with politically sensitive issues such as excess capacity in human resources and Progress towards accession institutions have hospital beds often not being tackled. The Most candidate countries now meet the infrastructure is old and poorly maintained so-called Copenhagen criteria, as stated in competing as resources are lacking and managerial the Agenda 2000: stable institutions guar- capacity has not been sufficiently devel- responsibilities, anteeing democracy, respect for human oped at the different levels. Healthcare pro- rights, a functioning market economy and fessionals have poor working conditions, procedures are unclear the capacity to absorb the acquis commu- are badly paid and unmotivated; often they nautaire. The regular reports on progress feel they are expected to make up for the and regulations are towards accession review progress in the inefficiencies of the system. lacking.” different areas of the acquis communau- Health status indicators are starting to taire, the most recent one dating from recover from the downturn of the early November 2000.3 The legal transposition is nineties, and life expectancy is now underway, but most countries lack proper

9 eurohealth Vol 6 No 5 Winter 2000/2001 ENLARGEMENT AND PUBLIC HEALTH implementation and enforcement struc- gramme and the European Health Forum. tures. This is also true for health related Although the reports concentrate mainly areas such as health and safety at work, on the acquis as such – and there are not phyto-sanitary health and consumer many ‘hard’ acquis related to health – they protection. stress that most countries are lagging Progress on the Tobacco directive has been behind in healthcare reform, especially mixed, with the Czech Republic, Estonia, with regard to economic sustainability. In Lithuania, Romania, Cyprus and Malta still Hungary, for example, “the weak financial lagging behind. In most countries the structures (in the healthcare system) conditions for the mutual recognition of continue to place a heavy burden on public healthcare qualifications, allowing the free finances”. Unfortunately, there is some movement of professionals, have not yet inconsistency in the reports, which makes been created. This is mainly due to the comparison difficult. The reporting of overlapping responsibilities of different health related issues in the different coun- professional organisations. Similarly, the tries could be improved through closer network for epidemiological surveillance cooperation between DG Enlargement and and control of communicable diseases has DG Sanco. not yet been set up in most countries. Drug use is generally on the rise and even though The Staff Working Paper candidate countries are increasingly collab- In June 1999, the European Commission orating with the European Centre for Drug published the Staff Working Paper (SEC) Monitoring in Lisbon, nationally the fight on health and enlargement.5 The against drugs is hindered by the lack of November 1999 Health Council under the internal and interministerial coordination. Finnish Presidency reacted very positively to the SEC asking the Commission to Corruption is still a significant problem. It follow up on the different options put for- is particularly prevalent in healthcare, and ward.6 The European Parliament Bowis the Czech Republic, Romania and Slovakia report from last summer again stressed the receive special mention. Although not all importance of health and enlargement.7 “A country approach, the countries are mentioned by name, it is to be suspected that the problem is wide- The Commission has started to tackle some developing specific spread, as reported in a study on Bulgaria of the issues identified in these reports, and Hungary.4 The deficient health situa- especially by fostering the participation of health and the candidate countries in the different tion in prisons in some countries is pointed enlargement strategies out, notably in Slovenia, Latvia and public health programmes. But several of Lithuania. In Romania there is an overall the issues have not been fully addressed, in collaboration with “degradation of social, education and such as the idea of developing a specific healthcare infrastructure”. action plan for each candidate country, the candidate countries, including health status reports and infor- Participation in Community programmes mation exchange on resource allocation and would be beneficial.” has increased. Interest is strongest in the health system issues. A country approach, AIDS, Cancer, Drugs and Health developing specific health and enlargement Promotion programme. The Czech strategies in collaboration with the candi- Republic, Hungary, Romania and Slovenia date countries, would be beneficial. are the most active participants. Even though there is still some hesitation on the Another option envisaged in the working part of the candidate countries, mainly for paper was to promote research into health budgetary reasons, they are becoming more and enlargement related issues. So far no familiar with the bureaucratic hurdles, as a related project line has been opened under series of expert meetings were organised in the fifth framework programme. A great the different programmes for this purpose. deal of effort has been put into raising gen- And yet, no country is formally taking part eral awareness of the European research programme in the candidate countries. All in the recently created health monitoring the same, better coordination between DG programme, which is quite relevant to Sanco and DG Research would be a good accession. There is some doubt whether it thing. is reasonable to begin the lengthy administrative procedure for the four more recent A start has been made to allow candidate programmes as the new European public countries to participate in health activities health programme is due to start soon. at EU level. Officials from the candidate However, it is foreseen to involve the can- countries’ health ministries now regularly didate countries very actively in the prepa- take part in the meetings of the High Level ration and implementation of the new pro- Committee on Health. Candidate countries

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“All Commission now participate as observers in public task would be: to act as an information health programme committees, and have a point for all health and enlargement related services related to say on programmes that directly concern questions that officials in the candidate them. Yet there are no experts from candi- countries might have; to liaise with DG health and enlarge- date countries in the all important scientific Enlargement on priority fixing for twin- ment should increase committees, which are generally open to ning, Phare and Taiex activities; to support non-EU scientists. A targeted search for Member States in preparing for twinning or collaboration” suitable scientists would elicit candidatures bilateral support; and to enhance guidance and help strengthen the countries’ scientific to the candidate countries in their partici- capacity in health and consumer protection. pation in public health programmes, especially in view of the implementation of The Commission has organised various the new public health strategy. The once expert rounds on different health related proposed EC health and enlargement inter- topics specially aimed at the candidate net portal – to be created as part of the countries. The Commission’s Public proposed ‘virtual health forum’ – could Health Policy Unit and Taiex (Technical foster information exchange, offering links Assistance Information Exchange Office), to health related activities at Community together with the Spanish and Catalan level and to the national health pages of Health Ministries, organised a workshop candidate countries. It could also provide REFERENCES on health and enlargement at IESE answers to frequently asked questions and Business School in Barcelona in July 1999. 1. Rosenmöller M. a discussion forum for exchanging experi- This workshop offered officials from can- Enlargement of the European ences. Health should be given higher didate countries a comprehensive overview Union: Challenges for Health priority under the Phare programme, for of health related areas at European level. and Health Care. Eurohealth example by using twinning for public 1998;4(4):18–21. Enlargement has been on the programme health and health systems issues. A well of the yearly European Health Forum, defined general and country strategy would 2. World Health Organisation. Gastein and there is an increasing number help to seriously address the problems HIT Health Care in of informal exchanges at all levels. But Transition Profiles. 1998 identified in the EC document. more guidance or support from the Copenhagen: WHO Regional Commission would be helpful. Office Europe, 1998. Conclusions There is still a lot to be done in health and 3. European Commission. Although Commissioner Byrne, at the EP enlargement. To make activities consistent Regular Report from the Public Hearing on health and enlargement with the issues identified in the Staff Commission on Progress in July 2000, again described the Staff Working Paper and others that have towards Accession by each of Working Paper as an important initiative, appeared since, all Commission services the Candidate Countries. he did not give details about how the Brussels: European ‘options’ it put forward have actually been related to health and enlargement should Commission. 2000. followed up. The reorganisation of the increase collaboration and efforts. Commission in 1999 strengthened the role 4. Delcheva E, Balabanova D, On the other side, candidate countries, too, McKee M. Under the Counter of health at EU level, but the inevitable need to step up their efforts. They need to Payments for Health Care: delay in the Commission’s activity and the pay more attention to their health systems Evidence from Bulgaria. departure of the Director of the Public in their preparation for accession. Talented Health Policy 1997;42:89–100. Health Directorate in summer 2000 go people in the public administration are some way to explaining why health and 5. European Commission. trying to work miracles against heavy odds. enlargement did not get attention as Commission Staff Working Accession is very demanding, and people in promptly as it deserved. It is to be hoped Paper on Health and the candidate countries have ever higher that with the arrival of Fernand Sauer as Enlargement. Brussels: EC, expectations. These countries need to cre- 1999. the new Director in December 2000 and ate the conditions in which their public the timely launch of the New European administrators can work effectively 7. Bowis J, Oomen-Ruijten R. Public Health Strategy, work on health and towards accession, giving them the Draft Report on Public Health enlargement issues will be intensified. In resources in time and money to carry out and Consumer Protection. the meantime Commissioner Byrne has health and enlargement related activities Aspects of Enlargement. started a series of visits to the candidate effectively. Brussels 1999: European countries. Poland was first, in October, fol- Parliament. Provisional The Swedish presidency has put enlarge- lowed by Hungary and the Czech Republic 2000/2081 (INI). ment very high on its agenda. A special in November and December 2000, to be conference on ‘EU Enlargement, Research 6. Council of the European continued this year. Public health is on the and Public Health: Health as a Lever for Union. Health Council agenda, but evidently the acquis takes Economic Growth’ is planned for June Conclusions. Annex. Health in precedence over health system issues. the Applicant Countries and 2001. The Baltic countries, in particular, are Increased Cooperation in the The creation of a ‘coordination centre’ for hoping for a drive on health and enlarge- Sphere of Public Health. enlargement issues within the Public ment issues, and we can only join them in Brussels, 1999. Health directorate would be helpful. Its this hope.

11 eurohealth Vol 6 No 5 Winter 2000/2001 HEALTH AND THE ENVIRONMENT Healthandthe environmentalimperative

The link between environment and health is easy to recognise. In Europe alone, several thousand people die from air pollution each year. More children are suffering from asthma, many of our rivers and lakes are still not safe to swim in, and there is evidence that particulate matters such as dust and ground-level ozone affect the health of people and provoke premature deaths. We also face emerging issues such as endocrine disrupters, which may have serious impacts on people’s health. MargotWallström

A study conducted in Austria, France and sents four key areas of action: Switzerland concludes that air pollution – Fighting climate change. caused six per cent of total mortality, or more than 40,000 attributable cases per – Nature and biodiversity – protecting a year in these countries. About half of all unique resource. mortality caused by air pollution was – Health and environment. attributed to motorised traffic, accounting – Ensuring the sustainable management of also for: more than 25,000 new cases of natural resources and wastes. chronic bronchitis (adults); more than 290,000 episodes of bronchitis (children); The overall environment-health objective is more than 0.5 million asthma attacks; and to achieve a quality of the environment more than 16 million persondays of where the levels of man-made contami- restricted activities! nants do not give rise to significant impacts on, or risks to, human health. Special atten- Environment, along with health, is among tion is paid to the handling of chemicals, the top concerns of the citizens of the pesticides, water, air pollution and noise. European Union. They expect action from the European Institutions regarding the The causes of environment-health prob- environmental causes of health problems. lems are numerous and include transport, Environment and health are policy areas agricultural activities, industrial processes that have special status at the European and domestic waste. Environmental policy level. The Amsterdam Treaty requires that alone will not solve all problems – action “We must take both environmental and health concerns be and initiatives must be taken on many different fronts. One of the key objectives precautionary action taken into account when decisions are made in other policy areas. Much progress has for the new environmental action where there are serious been made regarding single pollutants in air programme is consequently that environ- and water, but many problems clearly still mental concerns must be better integrated concerns but not yet a remain, e.g. regarding chemicals and noise. into all other policy areas. It is important to improve the understand- clear picture.” New initiative ing of how different pollutants are spread I declared health one of my priority areas and how we can tackle their aggravated when I took office as Environment combined effects. In the programme, the Commissioner in 1999. This is reflected in Commission suggests that particular atten- the new environmental action programme tion is paid to how we can improve our Environment 2010: Our future, our choice.1 research efforts and that early warning sys- The programme, which outlines environ- tems are established. The programme also mental policy for the next ten years, pre- suggests a review of the approach in which

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“One of the key some existing standards have been estab- associated with the use of many of these lished with the ‘average’ adult in mind substances were not always evident when objectives for the new without taking into account the need to they were first brought into use and it is protect particularly vulnerable groups in important that our regulatory system is environmental action society such as children and elderly people. capable of assessing and managing these programme is that risks. The current system has proved to be Children – the ‘living’ indicators of incapable of dealing with the vast number environmental our environmental state of chemicals that need to be reviewed and As the first victims of any environmental we will give priority to overhauling our concerns must be better disturbance, children are the first to show chemicals legislation in order to implement signs that something is seriously wrong a system which can give the citizen the integrated into all with the environment. Even the foetus is protection he/she deserves. other policy areas.” threatened. Through the placenta the foetus takes in environmental toxins which enter Cooperation with the WHO its body and cardiovascular system in It stands clear that health is the most pow- concentrated form. Toxins that pass erful argument in environmental policy- through the placenta include lead, mercury, making. The European Commission and DDT and dioxins. Environmental toxins WHO have together started to identify can cause miscarriages or impair foetal strategic areas for further cooperation in growth in different ways. In the worst case the field of environment and health. the child will sustain serious injury for life. Discussions cover issues such as air and After birth, children are also more vulnera- water quality, transport, noise, chemical ble and sensitive. Many of the body’s main safety, radiation protection (both ionising organs, such as the kidneys, the liver and and non-ionising radiation, including the brain, undergo significant development electro-magnetic fields), climate change, during the first few years of life. In addi- environment and health indicators, as well tion, children do not have the knowledge as international issues, in particular the or know-how to avoid environmental risks. preparation of the Rio+10 Conference due On the contrary: abandoned industrial sites to take place in 2002. and refuse dumps can be exciting play- Joint research efforts will be strengthened grounds! Children are in several ways more in order to enhance the application of exposed to environmental pollution than scientific knowledge in standard setting by adults – they are crawling on the ground or both WHO and the EU. As I have on the floor, and they are – due to their size mentioned, I think it is necessary to use the – subject to a more direct inhalation of vulnerability of children as a starting point fumes from cars. Furthermore, children eat when setting standards of protection. proportionately more food, drink more Indicators and health impact assessments fluids and breath more air per pound of will be examined in relation to complex, body weight than adults. cross-sector issues such as transport and Newly born children are extremely vulner- children’s environment and health. able since their immune system is not fully developed and they are completely at the Need to be proactive mercy of those around them. Nature has Health remains a key area for the future. solved this problem by allowing the We need to find out more about how vari- mother’s protective antibodies to be passed ous environment pollutants are influencing to the infant in the mother’s milk. It is also our health in order to shape policies so as part of our natural instincts to protect and to avoid further health problems. Therefore look after small children. However, we must continue to invest resources in because of our influence on the environ- research and development. It is crucial to ment and environmental impacts on us and provide consumers – and parents of course our health, breast milk has often been – with basic information to allow them to found to contain chemicals which are also make informed choices and to take individ- passed on to the child. I have been told that ual responsibility for protecting themselves as adults we have 300 to 500 ‘unnatural’ and their children from environmental chemicals in our bodies! health threats. In short, we need to be more REFERENCE proactive rather than reacting with hind- 1. The full text of the new pro- Chemicals – we use them daily sight to serious problems. We must take gramme will be available on Our society uses many thousands of chem- precautionary action where there are seri- the DG Environment web site: icals in the manufacture of the wide variety ous concerns but not yet a clear picture. http://europa.eu.int/comm/en of products that we have come to rely on. This proactive approach is fundamental for vironment/newprg/index.htm. The environmental risks potentially my role as Environment Commissioner.

13 eurohealth Vol 6 No 5 Winter 2000/2001 HEALTH AND THE ENVIRONMENT Theimpactsofclimatechangeon Europeanpopulationhealth

Climate change threatens human health on projected increased frequency, severity and a global scale. The current scale of human geographical extent of extreme climate activity and the consequent impacts on the events. Indirect effects include changes in Earth’s life support systems – stable food supply owing to the disruption of climate, high levels of biological diversity, agriculture and fisheries, the spread of adequate food and protection from UV infectious diseases, and the climate- radiation – are unprecedented in human enforced mass migration of populations. history. Various international, regional and These impacts will interact with each other. national assessments of the consequences For example, the direct loss of life from for human population health have conclud- flooding is often followed by the spread of ed that the impact of these global changes infectious disease as social dislocation and will be largely negative.1 favourable environments for disease carri- ers are created. Erwin Jackson Assessing the impacts of climate change on the health of human populations is a The populations most vulnerable to climate difficult task. While environmental factors change will be those on the ‘edge’ – the “The most severe such as temperature and rainfall affect poor, the poverty stricken, homeless, the human health in many ways, socioeconom- aged, the chronically ill and drug depen- effects of climate ic factors also play a significant role. For dent. These populations are more vulnera- example, the climatic conditions suitable ble to climate change because they lack the change on human for malaria transmission currently exist in capacity and resources to respond effective- health are expected to parts of Europe. However, public health ly to the short and long term changes in measures have all but eliminated the dis- weather and climate. As a result, the most occur in developing ease. In addition, many uncertainties exist severe effects of climate change on human in the projection of future climate change health are expected to occur in developing countries.” and many of the influences of climate and countries. For example, the effects of its interaction with other factors are poorly climate change on cereal production have understood. Despite this ambiguity, a been estimated to place an additional consensus has emerged of the types of 40–300 million people at risk of hunger in health impacts that climate change will the developing world by 2060. cause. Direct effects of climate change on In general terms, the impacts of climate change can be broken into two groups – health in Europe direct and indirect. Direct impacts involve Extreme weather events can have signifi- the loss of life and sickness from the cant health and economic consequences (see Table l.) and climate scientists project significant changes in weather extremes Table 1 Examples of the extreme weather event impacts in Europe 2,3 across Europe over this century.2 For example, a heat wave that would be expect- Extreme event Health impact Economic ed to occur once every 310 years under the impact (US$) Heat waves current climate in the UK is expected to UK (London) 1995 137 excess deaths (compared occur once every five to six years by 2050. with the seasonal average) Under one scenario for Spain, the current Greece (Athens) 1997 2000 deaths one ‘hot’ summer in ten becomes four to Floods five times more frequent by 2050. At the Central Europe (Germany, Over 100 deaths, ~$5 billion opposite end of the temperature extreme, Poland, Czech Republic, Slovakia, 200,000 homeless ‘cold’ winters are projected to have almost Austria, Hungary, Romania and entirely disappeared across large parts of the Ukraine) 1997 Europe by 2080. Windstorms An increase in heat waves will cause January — February 1990 159 deaths $8.6 billion increases in the number of deaths due to Mud slides hot weather. Hot weather can also increase Italy (Naples region) 1998 150 deaths the health impact of certain air pollutants (for example, ground level ozone).

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“Climate change It is also expected that the number of temperature affects the reproduction and deaths related to cold weather will maturation rate of the disease. would be expected to decrease. For example, one study of the A number of European vector-borne dis- UK suggests a decrease in annual deaths eases are likely to be affected by climate exacerbate problems from cold by around 20,000 by 2050. change including Lyme disease and tick- However, as social and behavioural borne encephalitis (TBE).3,4 Lyme disease with malaria in eastern changes play a major role in cold related is the most common vector borne disease in deaths in countries with high rates of European countries.” Europe and there is concern about its winter mortality, improvements in socio- increased incidence, as well as that of TBE, economic conditions – e.g. reduced fuel in the northern part of the continent. poverty in the UK – will probably play a bigger role in reducing cold related deaths Climate directly and indirectly affects the than will climate change.3 disease carrying ticks, their environment and host animals (e.g. mice, deer and birds), In addition to the direct loss of life and the time between blood meals, and disease injury associated with extreme events, transmission. If host animals are available, floods, storms and heat waves have other climate change is expected to enable short term and long term health conse- tick-borne diseases to expand into higher quences. Floods for example, may increase latitudes and altitudes. Milder winters the risk of communicable diseases such as could reduce host mortality and extend the leptospirosis, overload water purification time that the ticks are active. Swedish and sewage systems, and cause the dis- researchers conclude that the recent north- charge of toxic chemicals as waste sites and ern shift of one tick species is related to the industrial centres overflow. Mental health decrease in winter days below –12ºC.5 problems have also been associated with In extreme weather. For example, in Poland 50 southern Sweden, milder spring and suicides were attributed to floods in 1997. autumn months also appear to have increased tick activity. Indirect effects of climate change on In addition to tick-borne diseases, climate health in Europe change would be expected to exacerbate Climate change is expected to affect the problems with malaria in eastern European distribution and occurrence of a number of countries where the public health infra- infectious diseases. The World Health structure has broken down and poverty has Organisation has identified diseases carried increased. Changes in average climate or by intermediate (‘vector’) organisms such extremes could also facilitate the introduc- as insects as being particularly vulnerable tion of previously unidentified diseases into to climate change. Climatic factors such as populations (such as hantavirus pulmonary temperature, humidity and rainfall have a syndrome in the USA). strong influence on both the disease and the host organism. In the case of malaria, Conclusions for example, rainfall affects the availability Climate change is likely to affect the health of breeding sites for mosquito vectors, and of European populations in a multitude of ways. While significant uncertainties exist, it is the judgement of health experts that REFERENCES these impacts will be largely negative. Some impacts will be obvious and direct (mortal- 1. McMichael AJ, Haines A, Slooff R et al (eds). Climate Change and Human ity from flood and heat waves) while others Health – An Assessment Prepared by a Task Group on Behalf of the WHO, will be indirect and harder to identify (the WMO and UNEP. WHO/EHG/96.7. Geneva: World Health Organisation, spread of infectious disease). It is also clear 1996. that populations in poorer eastern 2. Parry ML (ed). Assessment of Potential Effects and Adaptations for Climate European countries will suffer more than Change in Europe: Summary and Conclusions. Norwich, UK: Jackson richer northern and western European Environment Institute, University of East Anglia, 2000. populations. Outside Europe significant 3. Kovats S, Haines A, Stanwell-Smith R et al. Climate Change and Human impacts are expected across developing Health in Europe. British Medical Journal 1999;318:1682–85. country populations. 4. Githeko AK, Lindsay, SW, Confalonieri UE et al. Climate change and vec- While policy measures are required to tor-borne diseases: a regional analysis. Bulletin of the World Health adapt to the climate change that is already Organization 2000;78:1136–47. occurring, unless the primary causes of cli- 5. Lindgren E, Tälleklint L, Polfeldt T. Impact of Climatic Change on the mate change are addressed – the burning of Northern Latitude Limit and Population Density of the Disease-Transmitting fossil fuels – the rate and magnitude of European Tick Ixodes ricinus. Environmental Health Perspectives impact will grow along with the accelera- 2000;108:119–23. tion of changes in the climate.

15 eurohealth Vol 6 No 5 Winter 2000/2001 HEALTH AND THE ENVIRONMENT Localenvironmentandhealthpractice incentralandeasternEurope

A striking revelation to people in western European countries following the ‘velvet revolutions’ in countries of central and WHO Europe eastern Europe in 1989/90 was the state of the environment. The World Health Organisation European Region has taken a steady and progressive Dramatically evident in the Ukraine in the aftermath of the approach, working from principles of Chernobyl nuclear power station explosion, many other coun- scientific evidence towards action programmes. WHO has organised three inter- tries also revealed pollution from heavy industry at levels only national meetings for ministers of environ- seen in western Europe many years ago. ment and ministers of health of its member states. (The WHO European region Rapid changes in economic conditions in includes states of the former Soviet Union, the 1990s have led to many of the industrial and thus ranges from countries with a long sites closing, and investment in cleaner environmental tradition, such as Norway technologies has also reduced pollution. to the new central Asian republics with But there remains strong public and politi- pressing environmental problems, such as cal concern for the environment, and its the Aral Sea region in Uzbekistan.) consequences for health. The European Union’s ‘acquis Communautaire’ (criteria Much of the science linking environment for accession) includes exacting standards with health was set out in an authoritative in environmental Directives. National report, Concern for Europe’s Tomorrow, legislation is needed, but local management prepared for the second WHO Ministerial and control will be crucial for effective Conference held in Helsinki. The report implementation. considers traditional environmental concerns, such as drinking water purity, waste The systems of the former governments disposal and air quality. But the debate on Mark McCarthy did, in fact, often include decentralised environment has broadened for two environmental services with epidemiologi- reasons. The ‘determinants’ of pollution are cal expertise. But these services had little seen to include more complex human sys- encouragement to investigate state- tems such as transport and habitation; and managed industries, and could be sidelined environmental concerns for sustainable into monitoring rather than intervening. development have shown the need to work Much local action at present is led by new across sectors as well as within them. non-governmental organisations (NGOs), often supported by western aid agencies as Issues alternatives to the public structures and The third Ministerial Conference held in sympathetic to western commercial invest- London in June 1999 discussed two big ment. issues – water quality, and transport, environment and health – as well as nine Developments other themes including research, children The environment has received less attention and local implementation. from the health sector in recent years than economic and organisational reform of Water is of greatest concern in the east of health services for two reasons. Environ- the region, especially the Newly Independ- mental action is usually outside the control ent States (NIS). More than 100 million (especially economic) of the health sector; people are without an adequate supply, in addition, epidemiological evidence link- either an absolute lack or using water that “National legislation ing diseases with environmental exposure is polluted. Water borne infectious diseases has been less strong than conventional ‘risk such as hepatitis A and parasitic infections is needed, but local factor’ approaches. Especially when large are common, even in major cities, and spo- management and populations are exposed at very low levels, radic outbreaks of cholera have occurred. the causal links are often open to debate. The solutions are partly technical, includ- control will be crucial Considering how the tobacco industry has ing better equipment and alternative meth- sought to deflect the compelling evidence ods of water capture and supply. They are for effective of the effects of cigarettes, it is not surpris- also economic, for example in reducing ing that the effects of other low level envi- industrial pollution. And they are social, implementation.” ronmental exposures remain controversial. including improving hygiene in rural areas.

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“While industry has Transport, environment and health was the taged groups (such as maternal and child second main theme of the conference. This health) than with a population perspective. been the major is the first time that WHO has formally recognised the importance of the whole Healthy Planet Forum polluting agency in transport sector to health. Indeed, it is During the London Ministerial the past, traffic is important not only for its environmental Conference, the UN Environment and damage – through air pollution and acci- Development Committee held an open increasingly the major dents – but also through behaviour (walk- meeting for NGOs – the Healthy Planet ing and cycling promote cardiovascular Forum. People attending the Healthy cause of urban air health) and social support functions. Planet Forum tended to know more about the environment than about health. But a Up until now, thinking on transport, pollution.” special effort was made to invite profes- environment and health have often been sionals working in local health and compartmentalised rather than integrated. environment departments in CEECs. Municipal environment departments measure air pollution but not the health conse- A workshop was organised during the quences; epidemiologists measure health Forum for 40 professionals from health and impacts without political action; traffic environment departments in 15 central and engineers build more roads to save lives eastern European countries. It was funded from road accidents without understanding by grants from the European Commission the other health impacts of their work. The and the UK Department for International Ministerial Conference agreed a declaration Development. The chance to exchange on transport, environment and health, a ideas was welcomed because domestic document less binding than a protocol, but problems in the period of political and eco- giving national health ministries support nomic transition were frequently similar. and encouragement to develop policies for The WHO declaration on transport, action and research in transport. environment and health was seen as an important opportunity for collaboration. Transport is of particular relevance to the countries of central and eastern Europe. As a contribution to discussion, a report on Gains in air quality from industrial change environment and health in London brought are being reversed by rising pollution from together quantitative information and motor vehicles. The boom in cars during presented the data in accessible visual form. the 1990s is a result both of pent-up The report showed that 60 per cent of demand, and of active marketing by west- Londoners are concerned with the health ern companies that have invested heavily in effects of poor air and many of the repre- car production for the east. In addition, sentatives from eastern European cities with falling tax revenues, investment in agreed that air quality was an important public transport has been minimal. Central issue for them. While industry was the and Eastern European countries (CEECs) culprit in the past, traffic is increasingly the are rapidly developing private transport major cause of urban air pollution. systems that imitate the western countries, and with their attendant damaging environ- Conclusion mental and health effects. The CEECs had well established sanitary- epidemiological departments that collected Local practice valuable routine data on environment and While international health work is often hygiene. These departments offer an impor- REFERENCES focused on Ministries of Health, ministers tant information base for health needs 1. Concern for Europe’s of health come and go, and the powers of assessment and monitoring. Through their Tomorrow: health and the central ministries vary. Sustained public influence on local political processes, the environment in the WHO health action also requires participation at environment and health departments can European region. Stuttgart: local level, and local authorities are crucial together contribute significantly to local Wiss. Verl.-Ges., 1995. for popular involvement and democratic public health, and thus collectively to the decision making. nation’s health. They can also provide a link 2. Declaration of the Third at local level for improving clinical manage- Ministerial Conference on Some CEECs have long traditions of local ment in the reformed health services. Environment and Health. public health departments. Hungary and www.who.dk/London99/Welc Croatia both have well established services It is important that the contribution of omeE.htm at county level, linked to academic schools local practice is recognised in national 3. McCarthy M, Ferguson J. of public health. Elsewhere, modern public health planning, both in health services Environment and Health in health perspectives are less strong, and reforms and in health strategies. It is also London. London: Kings Fund, municipal health departments are con- important that assistance is given in capaci- 1999. cerned more with clinical care for disadvan- ty building through international exchange.

17 eurohealth Vol 6 No 5 Winter 2000/2001 QUALITY IN HEALTHCARE QualityofhealthcareinEurope: Anintroduction

Concerns about the quality of healthcare are increasingly visible in health policy circles in Europe. While the overall health outcome is considered the predominant factor in defining and measuring qual- benefits of healthcare seem relatively clear, there is ity of care, and the goal of quality assur- considerable evidence that optimal care is not being ance or quality improvement activities is – and should be – primarily the improvement given.This set of articles concerns quality of healthcare in health outcomes. in Europe. They focus on approaches to improving the Evidence of problems in quality of quality of care. care Evidence of unsatisfactory care comes from many sources.3 Ideally, one would wish to No country can claim to have addressed evaluate quality on the basis of health out- quality concerns adequately, although comes and compare doctors, facilities, and some countries are certainly attempting to even countries in order to identify and dis- improve quality with more structured seminate practices shown to be beneficial approaches to the problem, and there is and cost-effective. However, mortality is some evidence of improving quality in not very susceptible to healthcare interven- these countries. tion. Studies of the use of mortality rates in measuring quality in Europe has not pro- Definitions of quality of care duced useful insights on quality. For exam- To discuss quality it is necessary to have a ple, Mackenbach et al found that eleven clear definition. ‘Quality’ implies a degree studies of mortality from ‘amenable causes’ of excellence. However, there is no consen- (causes that could be addressed effectively David Banta sus on the actual definition of quality nor by healthcare) showed relatively little dif- on those aspects of care that should be ference between Western European coun- measured to determine quality. This is dif- tries.4 In fact, death rates from amenable ficult to understand. The goal of the health causes were low and had declined rapidly. system is to help the individual and the The picture was not so positive in Eastern population to become more healthy. For European countries, but the main differ- example, the US Office of Technology ences could be attributed to environmental Assessment in 1988 defined quality as “the and personal behavioural factors, not to degree to which the process of care increas- differences in healthcare. es the probability of outcomes desired by patients and reduces the probability of Therefore, tentative conclusions concern- undesired outcomes, given the state of ing quality of care must come from indirect medical knowledge.”1 This definition is evidence, such as evidence of use of ineffec- consistent with definitions put forward by tive health technology, broadly defined, the World Health Organisation and others, and evidence of lack of use of effective in emphasising health outcomes. However, technology. Twenty years of studies of others consider the focus on health out- variations of use in different regions and comes alone inadequate. For example, countries have shown dramatic differences Wilson and Goldschmidt insist that the that are difficult to explain.3 The problem definition has four elements: of variations in use has led to studies of inappropriate care. Care considered to be 1. technical quality (leading to improved inappropriate, that is, use of technology health outcome) “Health outcome is that has not been found to be beneficial in 2. cost of care the defined circumstances, has been found the predominant 3. patient satisfaction to occur in as many as 30 per cent of cases. factor in defining The rates of medical errors have been 4. value trade-offs among the three examined by the US Institute of Medicine, dimensions.2 and measuring which concluded that a large number of Others emphasise equity, access, or effi- preventable errors in healthcare occur in quality of care.” ciency. For the purposes of this paper, the United States.5

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Approaches to improving quality of will be to try to improve information on care quality and approaches to its improvement, The papers that follow will give some including carrying out and implementing 7 insights into formal programmes for health technology assessments. Eastern improving quality and their cost-effective- Europe is behind Western Europe in such ness. The traditional method is to examine developments, but as the article by Gulacsi structure, process or outcomes of care in et al shows, rapid progress has been seen in relation to accepted norms or standards of some countries. REFERENCES care, although the relation between the Quality improvement and HTA 1. Office of Technology structure and process of care and the out- The main goal of health technology assess- Assessment. The Quality of comes of care is often not clear. Evidence ment (HTA) is to improve health outcomes Medical Care: Information for for the validity of many standards, which Consumers. Washington DC: assume links between structure/process of by assessing technology and implementing US Government Printing care and health outcomes, is generally lack- its results into policy and practice. Virtually Office, 1988. ing, and hampers the evaluation of such every Member State of the European quality activities as medical audits and hos- Union now has a formal agency or pro- 2. Wilson L, Goldschmidt P. pital accreditation. Gulacsi and Banta gramme in HTA, and Eastern European Quality Management in examine this problem further in the last countries are rapidly following suit. One of Health Care. New York: paper in the section. the main activities of HTA is to examine McGraw-Hill Book Company, the efficacy (health benefits) from new and 1995. A more recent development has followed existing technology, broadly defined. 3. Banta HD, Luce B. Health from the introduction of ideas concerning Care Technology and its quality from outside the health field. These ‘Health technology’ includes the drugs, Assessment: An International approaches emphasise the providers’ moti- devices, and medical and surgical proce- Perspective. Oxford: Oxford vations to provide good care and seek to dures of healthcare and the supportive and University Press, 1993. help them meet their goals in this area. organisational systems in which care is pro- Thus, such terms as ‘continuous quality vided. Thus, a drug or machine is a tech- 4. Mackenbach M, Bouvier- management’ and ‘quality improvement’ nology, but so is a system of care. For that Colle M, Jougla E. ‘Avoidable’ seem to be supplanting the earlier terms matter, quality improvement activities can mortality and health services: a be considered a health technology and also review of aggregate data stud- such as quality assessment and quality need assessment. Another aspect of HTA is ies. Journal of Epidemiology assurance. This is well-illustrated by Isuf examining the effectiveness of care. While Studies 1990;44:106–11. Kalo’s paper, describing the approach of the World Health Organisation. efficacy refers to care in ideal or optimal 5. Spath P (ed). Error conditions, effectiveness refers to the out- Reduction in Health Care: A The evidence of widespread use of ineffec- comes under ordinary conditions of health- Systems Approach to tive technology or overuse of beneficial care practice. Efficacy is essentially always Improving Patient Safety. San technology has led to the establishment of greater than effectiveness. One could say Francisco: Jossey-Bass agencies and programmes to assess health that one of the main tasks of quality Publishers, 2000. technology, broadly defined, in terms of improvement is to narrow the gap between 6. Anderson C, Cassidy B, health outcomes and costs. This subject is efficacy and effectiveness. Riverburgh P. Implementing covered in more detail below. HTA agencies generally have limited means continuous quality improve- to implement their findings. They must ment (CQI) in hospitals: Institutionalisation of quality of care make alliances with other programmes that lessons learned from the Europe shows a mix of voluntary internal International Quality Study. and external mechanisms for improving can use their results. While links between Quality Assurance in Health quality of care. It has been stated that the quality improvement and HTA are not Care 1991;3:141–46. definition of quality in Europe has often great today, they are growing, and such a been physician-orientated, whereas the trend will no doubt continue. This is an 7. Commission of the United States and Canada have followed a area examined by Steen Henrik Sandø in his European Communities. more patient-orientated definition empha- article on continuous quality development. Communication from the 6 Commission to the Council, sising health outcomes. Conclusions the European Parliament, the As shown in the papers that follow, Europe Quality of care in Europe can and should Economic and Social has made progress in implementing quality be improved. Quality management and Committee and the Committee improvement programmes during the last improvement can lead to such improve- of the Regions, on the health decade, although it must be said that this ments. However, quality improvement strategy of the European progress is disappointing in relation to the Community. Presented by the encompasses a wide variety of approaches, needs for quality improvement. many of uncertain usefulness. There is a Commission, Brussels, 16 May Developments in quality improvement 2000. (COM(2000) 285 final). pressing need to evaluate such activities and have been given a further impetus by the use the information obtained to improve health policy paper published by the programmes in the future. This will European Commission in 2000. The main CONTACT undoubtedly be a thrust of European approach by the European Commission [email protected] health policy initiatives for years to come.

19 eurohealth Vol 6 No 5 Winter 2000/2001 QUALITY IN HEALTHCARE Developmentofqualityofhealth systemsinEurope

Around the world interest is increasing in improve. Quality can be assessed through the improvement of quality in health sys- collection of data on the basis of interna- tems. This is linked to the changes in the tionally standardised outcome indicators paradigms of health systems from biomed- accepted by providers in the field. By using ical to social accountability: citizens, electronic patient records, information can patients, politicians, health authorities and be transferred to servers or nodes via the professionals, payers, and other national or internet and anonymised for comparison international partners in health are and identification of best practice. demanding the highest possible quality in Dedicated servers within the Regional terms of health improvement, responsive- Office can host such data enabling cross- ness to people’s expectations and cost European comparison, feedback and effectiveness. benchmarking. In the St Vincent Diabetes Programme (Diabcare) and in perinatal care In addition, due to globalisation and the IT (the OBSQID project) it has been shown revolution, countries are looking beyond Isuf Kalo that this concept is feasible and works. their borders in their common quest for policy, tools and methods, and are sharing These projects have been widely dissemi- and learning from each other. nated to the countries for implementation. This approach has shown improvement in The WHO Regional Office for Europe the outcomes of quality at individual or model and experience in quality centre level but has been impossible to development document at national level. It was expected, based on these models, that Regional The Quality Assurance and Health Office member states would design nation- Technology Assessment (HTA) pro- “No comprehensive al policies and programmes for the devel- gramme established in 1980 pursued a opment of quality of care. However, only quality development continuous quality of care development Belgium, Denmark, Sweden, and the approach, focusing on the improvement of United Kingdom have in fact done so, and systems function at the quality of care by developing information these policies have only been partially tools and systems for measuring and com- national level.” implemented to date. paring clinical outcomes. This approach was based on self assessment and self regu- The recent situation of quality of lation of quality by healthcare providers who used comparison with peers, feedback, health systems in Europe and the identification of the best demon- Due to the lack of reliable evidence and strated practice as motivation for bench- adequate information systems to monitor marking and continuous incentives to quality, it is impossible to draw a comprehensive picture of the quality of health systems (QHS) in Europe and beyond. Most THE CONCEPT OF CONTINUOUS QUALITY OF CARE DEVELOPMENT quality health systems operate as a set of distinct, unconnected entities rather than as one coherent system. Although quality ini- User wellbeing tiatives have been launched in several coun- Medical outcome tries, no comprehensive quality develop- Quality indicators Cost effectiveness ment systems function at the national level. Data collection In addition to the Regional Office, the fol- Healthcare Anonymous providers lowing European and international soci- comparison eties and organisations are dealing with Outcome Policy makers quality programmes in Europe: The Benchmarking Payers European Commission Directorate Feedback Users General for Research, Council of Europe, Intervention World Bank, European Forum of Medical Associations (EFMA), European Organ- isation for Quality (EOQ), International PROCESS STAKEHOLDERS Society for Health Technology Assessment

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THE QUALITY INFORMATION SYSTEM Regional/district Country WHO server server server Aggregated data Aggregated data

Scanner

Case- based data Modem

Fax Electronic Patient Record Local District National results results results

(ISTAHC), International Society for The new concept of quality Quality (ISQua), ExPeRT (European development Union project on External Peer Review In line with current reforms within the Techniques), European Forum for Quality Regional Office and the new country strat- Management (EFQM) European Quality egy of ‘Matching services to new needs’, “The main idea of the Awards, and European Clearing House on the former Quality of Care and Health Outcomes. Technologies programme has broadened its quality programme is At the national level, several countries, scope to become the Quality of Health including Belgium, Denmark, Norway, Systems (QHS) programme. The quality to apply evidence based concept is based on a system approach Sweden, and the United Kingdom have ini- which aims to optimise interaction between thinking at the level of tiated national strategies for quality devel- all parts of the health system. The develop- opment. Most of them focus on development of quality is based on management of everyday practice to all ment of quality of care. In other member stability or minimisation of variation (qual- states (Hungary, Poland, Romania and ity assurance) and progressing upwards in a activities of a health Slovenia), national quality and HTA struc- spiral of continuous quality improvement. tures have been set up which are acting as system.” The main idea of the quality programme is National Coordinating Centres for quality to apply evidence based thinking at the development. In the field of accreditation level of everyday practice to all activities of particularly, several programmes are oper- a health system. In this context the QHS ating at national level in Croatia, France, programme will advocate that: Germany, Ireland, Italy, the Netherlands, Slovenia, Spain and the United Kingdom. Quality should be considered in all components of the health system National societies for quality in healthcare It should encompass not just the field of have been established in Austria, Belgium, care provision but all activities pertaining Denmark, Germany, Greece, Hungary, to the promotion, restoration and mainte- Ireland, Italy, the Netherlands, Norway, nance of health. Also, it will focus on a Poland, Spain, Sweden, the United country framework rather than on individ- Kingdom and Yugoslavia. In some coun- uals, clinicians or health centres. tries of central and eastern Europe and newly independent states (Bosnia & Health system quality should be Herzegovina, Estonia, Kazakhstan, approached in its complexity as an interface Kyrgyzstan, Russia and Uzbekistan) World between quality at the ‘macro level’ and Bank and USAID have initiated accredita- ‘quality/best practice level’ tion projects focused mainly on specific This means tackling different dimensions activities or subsystems such as primary and components including: healthcare or hospitals. – service organisations (standards,

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accreditation, documentation) own vision and expectations of quality. – finance (budget reports, payment sys- Other challenges are related to the difficul- tems and control mechanisms) ty in measuring quality, generating valid information, and making policy decisions, – technical performance (external quality given the inadequate, incomplete or assurance systems) ambiguous evidence available. In imple- – clinical practice (internal self assessment, menting quality programmes, an appropri- clinical audit, guidelines, indicators) ate mix of incentives and sanctions, and an – clinical training (curriculum, licensing, acceptable mix of quality components, certification, accreditation) should be requirements for the development of quality in accordance with country – citizen and patient satisfaction (well- specifics. That is to say, quality has a being, rights, empowerment) limited meaning within a given culture, – safety and health protection (legislation, social structure, level of development and inspection, risk management) organisation. – linked quality information systems (indicators, databases, standards, tools, Future strategies evidence) The strategies for development of quality in health systems in Europe should aim at: A broader scope should be applied to quality values – Advocating and supporting the develop- In addition to best outcomes, safety, equi- ment of national strategies, policies and ty, effectiveness, efficiency, appropriate- programmes on quality in the countries ness, access, user choice, acceptability and of Europe. availability are now all being taken into – Creating a framework for quality devel- account. opment policy based on best practice and ‘model cases’ in the countries, and Countries should identify an appropriate enhancing research to ensure evidence mix of values and design quality pro- for quality development. grammes by making choices and trade-offs in accordance with their priorities and cir- – Developing coherence and cooperation cumstances. with other quality initiatives and programmes in the European region, The involvement of all stakeholders particularly with ISTAHC, accredita- In addition to politicians, health adminis- tion agencies and European associations trators and professionals, payers, users, for quality. other interested local and international parties, particularly the EU, World Bank, – Developing quality information tools industry and NGOs should be approached. and systems and promoting incentives to encourage rewards for quality. Links should be established with health technology assessment institutions and programmes REFERENCES Health technology programmes are crucial for helping health systems to select and do 1. Wu A, Staehr Johansen K. Lessons from Europe on quality improvement: the ‘right things’ and the quality develop- Report on the Velen Castle WHO meeting. Journal on Quality Improvement ment programme has to ensure adequate 1999;26(6):316–29. mechanisms to monitor and evaluate con- 2. Fifth Meeting of the St Vincent Declaration Action Programme on Diabetes tinuously to ensure that things are done Care and Research in Europe. Copenhagen: WHO Regional Office for correctly. Joint activities between the Europe, 1999. (document EUR/00/5016723). Regional Office and ISTAHC have been 3. Quality development in perinatal care: the OBSQID Project. Report on the planned for setting up national comprehen- Fifth WHO Workshop. Copenhagen: WHO Regional Office for Europe, sive strategies for health technology assess- 1998. (document EUR 03 02 03(B)). ment and quality development. 4. Kalo I, Juncher OV. A WHO/EURO information tool for quality of care Challenges for development of development in Europe. Sixteenth Annual Meeting of the International Society of Technology Assessment in Health Care: Book of abstracts. The quality in health systems Hague, 2000. The development of quality is difficult and progresses slowly, requiring fundamental 5. Shaw C. External quality mechanisms for health care: summary of the change in the health system. It must bring ExPeRT project on visitatie, accreditation, EFQM and ISO assessment in together, in a common strategy framework, European Union countries. International Journal for Quality in Health Care four main players: healthcare providers, 2000;12(3):169–75. health authorities, consumers and payers, 6. Klein R. Can policy drive quality? Quality in Health Care 1998;7(BMJ taking into account that each group has its Suppl):S51-S53.

eurohealth Vol 6 No 5 Winter 2000/2001 22 QUALITY IN HEALTHCARE HTAinDenmark: Theconnectionbetweenhealthtechnologyassessment andcontinuousqualitydevelopment

The history of health technology assess- Efficiency: the ability to obtain the greatest ment and the history of continuous quality health improvement at the lowest cost. development both go back many centuries, Optimality: the most advantageous balanc- and although they derive from different ing of costs and benefits. origins they have many similarities. Where the health technology assessment could be Acceptability: conformity to patient prefer- defined as “What is the right thing to do?”, ences regarding accessibility, the patient- continuous quality development could be practitioner relation, the amenities, the defined as “Do we do it in the right way?”. effects of care, and the cost of care. The nature of continuous quality development differs from health technology assess- Legitimacy: conformity to social prefer- ment. While health technology assessment ences concerning all of the above. systematically seeks new knowledge in Equity: fairness in the distribution of care Steen Henrik order to evaluate a technology, continuous and its effects on health. quality development systematically reviews 3 Sandø data to ensure optimal use of new validated Quality can be divided into the quality of: knowledge. Both however, require – Structure methodology based on sound scientific – Process principles. – Outcome The purpose of health technology assessment is to inform technology related policy Where structure is concerned with the making in healthcare. Health technology buildings, equipment and the human assessment should be carried out by inter- resources, process is related to the process disciplinary groups. Health technology of care and the outcome is related to the assessment can be described as an evalua- health impact. In the Danish National tion of:1 strategy for Quality Development,4 quality – Technical properties, such as perfor- is described as: mance characteristics, conformity with – a high degree of professional excellence; specifications and standards and reliabil- – efficiency in the use of resources; ity. – minimal risk to the patient; – Safety as a judgement of the risk associated with the use of the technology. – patient satisfaction; – Efficacy and/or effectiveness. Efficacy – the final health impact. refers to the health outcomes provided The process of quality development is by the technology. Effectiveness refers described as: to the benefit of using the technology for a specific problem under routine Goal setting which means defining criteria conditions. and standards for quality – Economic attributes or impacts. Quality assessment meaning defining indicators of quality, and collecting and “The use of meta – Social, legal, and/or political impacts. Health technologies may raise social and analysing data, and giving feedback to care analysis provides us ethical concerns. providers. Data collection and analysis mean both identifying the best results and Corresponding to health technology thus the processes and structures conducive with knowledge that 2 assessment, quality can be defined by to them, and when the quality of care does could not have been Efficacy: the ability of care, at its best, to not meet the criteria or standards set, find- improve health. ing reasons and solutions. obtained in any other Effectiveness: the degree to which attain- Quality improvement meaning developing way.” able health improvements are realised. and taking action.

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Follow up meaning monitoring and evaluat- Figure 1 The description of the process of Health Technology Assessment ing the impact of the action taken, continu- and of Continuous Quality Development ously monitoring and assessing the quality of care, and identifying positive outcomes in order to update the quality criteria and Quality standards. (documentation) Knowledge Primary As described above there is an overlap Review* between health technology assessment (HTA) and continuous quality develop- Secondary ment both in methodology and definitions. Review* Figure 1 shows a model of health technology assessment. A health technology assess- DECISION HTA ment starts with the documentation, con- by Clinician, Management, Policy maker CPG tinues with the primary review of knowl- influenced by social, legal and ethical factors edge acquired by existing data sources such as research, clinical databases and health- * based on clinical databases, statistical databases and research care statistical databases, leading to the proposal of Clinical Practice Guidelines ment that have been used in evaluation of (CPG), and ends with the decisions based technology5,6 It is however known that the on social, legal and ethical factors. collection of data from a daily clinical setting normally will cause problems with the The process of continuous quality develop- validity of the data. Experiences have ment contains the same elements, starting shown that through quality assurance and with the clinical practice guidelines and the external evaluation of the data collection results of the health technology assessment, these problems can be solved. It is certain criteria, standards and indicators are devel- that the use of meta analysis provides us oped. This is followed by documentation in with knowledge that could not have been clinical databases followed by secondary review of the collected knowledge. This obtained in any other way, but the imple- review should be followed by a revision of mentation of clinical documentation sys- the Clinical Practice Guidelines. After this tems and the use of continuous quality the circle is repeated. As a consequence, development might lead us to a more scien- continuous quality development can be tific and solid solution based on practice seen as continuous or repeated health tech- data. nology assessment. Some basic requirements of continuous quality development REFERENCES should be observed: 1. Goodman CS, Ahn R. Methodological – When clinical practice guidelines are approaches of health technology assessment. developed evaluation of the guidelines International Journal of Medical must be included. Information 1999;56:97–105. – For the acceptance of quality develop- 2. Donabedian A. The seven pillars of quali- ment staff participation and commit- ty. Archives of Pathology and Laboratory ment is mandatory. Medicine 1990; 114:1115–18. – Professional acceptance of the developed 3. Donabedian A. The quality of care. How standards and indicators is necessary. can it be assessed? JAMA 1988; 260:1743–48. Even though there are many overlaps 4. Taehr-Johansen K, De Neergaard L, between the theory and the implementation Hermann N, Blomhøj G. Continuous of health technology assessment and con- Quality Development: A Proposed National Strategy. Copenhagen: World Health Org- tinuous quality development, there are anisation Regional Office for Europe, 1993. some basic differences. Health technology assessment has a long tradition for basing 5. Grabau DA, Jensen MB, Blichert TM, et the knowledge acquisition on evidence al. The importance of surgery and accurate based medicine in the form of meta analy- axillary staging for survival in breast cancer sis. There has lately been a discussion about (see comments). European Journal of the problems of selection bias and publica- Surgical Oncology 1998; 24:499–507. tion bias of this type of analysis. 6. Jensen LP, Schroeder TV, Lorentzen JE, Continuous quality development is primar- Madsen PV. Fire ars erfaringer med Karbase. ily collection data through the use of clini- Et redskab til kvalitetsudvikling i karkirurgi. cal databases. Over recent years several (Four years of experiences with Karbase. A studies have reported on databases con- tool for quality development in vascular structed for continuous quality develop- surgery) Ugeskr Laeger 1994;156:7032–35.

eurohealth Vol 6 No 5 Winter 2000/2001 24 QUALITY IN HEALTHCARE Fromunconsciousincompetence towardsconsciouscompetence: QualityimprovementinhealthcareintheCEECs

“There is no evidence that we are better today at applying what we know than we were 30 years ago.”

East-West life expectancy gap: the probably ineffective. Research findings possible role of quality improvement indicate that a great deal of ineffective Life expectancy at birth in EU countries technology is in use, and/or effective tech- for males as well as females is five to ten nologies are frequently over used and/or years longer than in most of the Central under used. and East European Countries (the Medical errors: Laszlo Gulacsi CEECs), and that between 1990 and 1995 As Berwick points out: “Between three and 1 the gap has widened instead diminished. four per cent of hospital patients are As Jozan et al point out, “In the first harmed by the care that is supposed to help decade of the 20th Century, men and them. …We estimate that between 44,000 women in the Netherlands could expect to and 98,000 Americans die in hospitals each live about 10 to 15 years longer than year as a result of errors in their care.”5 2 Hungarian citizens.” Although no information about medical Improving effectiveness of healthcare is errors is available in the CEECs, this argu- among the main goals of quality improvement may be relevant to the CEECs. ment (QI), and might provide a positive contribution to the population’s health Inconspicuous incompetence: the status. Some indirect evidence shows that socialist era the East-West life expectancy gap is, at In the socialist era, the quality of healthcare least, partly due to the lack of effectiveness in the CEECs was declared by the commu- of medical care in the CEECs.3 nist parties and the governments as the best Rafal A number of factors might have direct in the world. Reerink saw the situation implications for health: correctly when he wrote, “Formal quality Nizankowsky assurance programmes were not possible Increasing complexity of medicine: under former socialist governments for This is an issue identified by Brook et al: ideological reasons.”6 Not only was it not “Although the likelihood that a person will allowed to criticise the quality of health- benefit from medical care is better now that care, but it was not possible to analyse and it was a third of a century ago, largely as a investigate it, as data that would have result of investment in basic science and enabled such analyses were partly non- clinical research, there is no evidence that accessible and partly not usable for we are better today at applying what we researchers. know than we were 30 years ago. Indeed, we may be worse because the complexity Quality improvement in the CEECs 4 of medicine has increased so greatly.” 1990–2000 Massive diffusion of healthcare technology In 1993, the representatives of medical has occurred in the CEECs since 1990, and societies in the CEECs agreed upon the the complexity of medicine increased quality improvement targets of the World rapidly within the last two to five years. Ales Bourek Health Organisation and signed the No systematic method to translate scientific ‘Recommendations for National Medical evidence into clinical decision making and Associations Regarding Quality of Care clinical practice: Development’ that were endorsed at The Commonly used interventions in different European Forum of Medical Associations areas are either definitely ineffective or and WHO.7

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Quality improvement in the CEECs was “Quality improvement should be identified as an initiated by the European Concerted Action Programmes on Quality Assurance important tool of health policy and planning.” in Hospitals, COMAC/HSR/QA and BIOMED/PECO, which were part of the Medical and Health Research Coordination Programme of the European Commission. Service under the Ministry of Health in These were multi-centre comparative stud- Lithuania has recently begun to operate. ies on different QI strategies and their effect on improvement of care with respect to: Towards conscious competence (a) preoperative assessment in surgery; Based on the findings of the QI studies in the CEECs the following recommenda- (b) prevention and treatment of bedsores; tions can be made: (c) keeping patients record; REFERENCES (a) Quality improvement should be identi- 1. Klazinga N. A better use of (d) prophylactic antibiotic use in surgery. fied as an important tool of health policy existing resources; managing Altogether, 465 hospitals participated and planning. According to the Hungarian the quality of structure, process between 1992 and 1997 from 14 European experience, some form of QI activity has to and outcome of health care sys- countries, mainly Member States of the be in place in order to allow for a particular tem. International Journal of European Union. Hospitals from CEECs problem, and the extent of the burden it Bioethics 1996;7(2): 90–93. creates needs to be identified. The example were involved: 37 from Hungary, 67 from 2. Jozan P, van der Velden K, of studies on pressure ulcer (PU) showed Poland, 25 from Russia and two hospitals Ginneken J, et al. Ageing mor- that the real problem is considerably worse from the Slovak Republic. tality, morbidity and health than expected. The prevalence of PU is 16 care. In: Beets G, Miltenyi K Professionalisation to 27 times higher than the published rate (eds.) Population ageing in Societies on QI were established in (3.7 to 5.7 per cent, as opposed to 0.18 to Hungary and the Netherlands, Hungary (1992), in Poland (1994), in 0.21 per cent). 2000 (chapter 13). Utrecht: Yugoslavia (1995) and in Lithuania (1999). (b) A national QI policy should be formu- THELA THESIS Population Legislation lated. Long term strategic goals have to be Studies, NIVEL, 2000. As required by the ‘Act 154 of 1997 on clear and known. This policy should clearly 3. Velkova A, Wolleswinkel- Health Care’, QI is increasingly present in separate areas where QI should have an van den Bosch J, Mackenbach the daily work of the Hungarian hospitals. important role from areas within the J. The East-west life expectan- The Lithuanian National Health Concept healthcare system where other types of cy gap: differences in mortality and Health Programme gives priority to activity – such as management or finances – from conditions amenable to healthcare quality and effectiveness. Issues have priority. medical intervention, related to quality and effectiveness is con- International Journal of Epid- (c) A good professional body on QI, sup- emiology 1997;26(1): 75–84. sidered in existing regulations in Poland ported by a strong QI research capability is 4. Brook RH, McGlynn EA, and Russia. In the Czech Republic the necessary to achieving improvement. responsibility of the Medical Chamber is to Shekelle PG. Defining and look after the quality of medical care. (d) More comprehensive data collection is measuring quality of care: a needed as a routine in healthcare settings. perspective from US Institutionalisation In the CEECs, 80 per cent of time and researchers. International Institutionalisation of QI started in Poland resources have been spent on collection of Journal of Quality of Care where the National Centre for Quality basic data of limited utility and quality 2000;12(4):281–95. Assessment in Healthcare (NCQA) was checks on these data. Further QI activities 5. Berwick D. Medical errors: created in 1995. NCQA is developing evi- will be very difficult to implement without improving quality of care and dence based practice guidelines and run- more focussed and structured data of good consumer information. ning a successful accreditation programme. quality. Data collection and processing Statement to the Senate In the Czech Republic, the National Board have often been successful, but interpreta- Committee on Health, for Medical Standards evaluates the current tion and presentation of findings have often Education, Labor and Pensions. state of the medical guidelines and converts been forgotten, contributing to a lack of Montpelier, Vermont 2000. them into standards of effective medical intervention. 6. Reerink E. (ed) Report on care. In Hungary the Ministry of Health quality assurance programmes (e) Steps have to be taken in order to and the National Health Insurance Fund in different countries. Present- achieve the support of the healthcare pro- have departments dedicated to QI. The ed to the Institute of Medicine. fessionals and their professional organisa- Hungarian Healthcare Quality Award was Washington DC, 1992. tions. Quality of care cannot be improved launched recently. In Slovakia, in 1996 the without the active involvement of the pro- 7. Worning AM, Mainz J, Ministry of Health accepted the concept Klazinga NS, et al. Policy on fessionals. for development of a national policy for quality development for the QI, and in 2000, the Centre for Quality (f) All of these strategies point to the need medical profession. Journal of and Accreditation in Healthcare was creat- for more education and training in the field the Danish Medical Association ed. The State Healthcare Accreditation of QI. 1993; 49(154):3523–33.

eurohealth Vol 6 No 5 Winter 2000/2001 26 QUALITY IN HEALTHCARE Theneedforcosteffectivequality improvementinterventions

Need for evaluation of the effective- charge. It requires staff, clinicians’ time, ness, cost and cost effectiveness of facilities, equipment, information and other quality improvement programmes resources. All these resources might be The articles in this section have indicated used in other ways, such as to treat that quality improvement (QI) is a very patients, to undertake clinical research, or to engage in education or professional important tool. However, the same or development. In the long run, the invest- similar goals might be achieved through the ment of healthcare resources in QI activi- implementation of very different QI pro- ties has to be justified by results. grammes. Structure, process and outcome David Banta orientated programmes can be used sepa- rately or in almost infinite combination. Judging quality and cost Numerous process and/or outcome indica- There is no general understanding and agreement on the meaning of quality and tors can be used and various educational, cost. The term ‘quality’ is used in many training, regulatory and control methods different ways. In fact, QI does not often can be implemented. There are many ways focus on health outcomes. Most QI activi- to improve the effectiveness of QI, for ties have dealt with the structure or process example to improve cost effectiveness. of care. Administrative, financing and regulatory tools can be used, licensing, accreditation, There is also a lack of clarity in definitions peer review, audit and guidelines are com- of cost. Is it direct, indirect, average, mar- mon tools. Healthcare settings have to ginal, incremental or opportunity cost? implement effective and cost effective QI Each of these has a very different meaning. programmes to improve their capacity to Is it the cost of poor or good quality? Poor provide cost effective services. quality is expensive and a waste of Laszlo Gulacsi resources while improvements in quality The role of QI can reduce costs and might be considered As already discussed in these papers, the as investment instead of expenses. Pure main aim of QI activities is to improve the data on costs of quality are impossible to actual benefit of a given healthcare service interpret and cost information without where there is the possibility of achieving understanding of quality is meaningless. further benefit. This is a rather narrow, but very practical focus of QI, which is used in Towards cost effective QI this paper. To create cost effective QI interventions, four challenges have to be faced. Good QI is part of medical technology information is needed on: According to the definition of the US – effectiveness (both achieved and achiev- Office of Health Technology Assessment able) of healthcare interventions; (OTA, 1978) the “Medical Technology: – effectiveness (both achieved and achiev- The drugs, devices, and medical and surgi- able) of QI interventions; cal procedures used in medical care, and the organisational and supportive systems – cost; “Quality improvement within which such care is provided.” QI is – cost effectiveness of QI programmes. just one more health technology competing First challenge – effectiveness of healthcare can be seen as a mirror for scarce healthcare resources. It is an confronting healthcare organisational technology, well within a It is clear that information about the effec- standard definition of technology, and it tiveness of present healthcare interventions providers with the should be subject to rigorous assessment, in is often lacking. The actual performance of the manner now properly being demanded the care processes can only be described in results of their work.” for all health technologies. QI is not free of qualitative terms and virtually no quantita-

27 eurohealth Vol 6 No 5 Winter 2000/2001 QUALITY IN HEALTHCARE tive data on actual effectiveness can be instance, evidence is available to show that “Very little is known found. practice guideline setting and implementation is a good tool in changing physicians’ about the cost Given limited resources and the difficulties behaviour and probably to improve health in changing professional behaviour, QI outcomes.2 effectiveness of QI activities should be focused on those areas of clinical practice where good evidence Third challenge – economic costs programmes.” exists and change would be worthwhile. Studies conducted in industry show that Measuring the size of the gap between effi- the cost of quality is estimated to equal 20 cacy and effectiveness is crucial. Efficacy per cent to 40 per cent of the total organisa- shows the maximum benefit achievable by tional costs.3 These costs are due to the a given intervention under idealised condi- waste incurred through poor quality and tions; effectiveness show the actual benefit unnecessary work, rework waste and achieved under actual conditions. Due to redesign waste. In healthcare, the cost of the different conditions, especially the providing quality care, including the price patient sample (co-morbidity, severity of of conformance and the price of non- illness) and settings of care, efficacy as conformance, was estimated by Berwick et defined by randomised clinical trials can al. to consume up to 50 per cent of all rarely be achieved. There are differences in healthcare costs.4 the actual effectiveness due to the limited availability of resources (financial Unfortunately, very few studies on the cost resources, knowledge, staff); differences in of quality are available and most of them the health or sickness of patients, and dif- are incomplete and suffer from various ferences in the appropriateness and effec- methodological weaknesses.5 Development tiveness of the quality assurance tools. The of guidelines and other QI tools has largely achievable benefit of every given situation ignored the issue of costs.6 has to be defined carefully, by benchmark- Fourth challenge – cost effectiveness of QI ing in any given QI programme. programmes Policy makers and administrative and According to the literature very little is clinical decision makers at all levels need known about the cost effectiveness of QI this information. The marginal utility of programmes, due to the lack of data on additional spending may be quite low. REFERENCES quality of care and its outcome and the cost Large differences between efficacy and implications of different alternatives. 1. Donabedian A. effectiveness can point the way to signifi- However, this probably means a lack of International Society for cant cost effective interventions to improve evidence rather than a lack of cost effective- Quality of Health Care. 13th quality within a relatively short time frame. ness of all QI interventions. International ISQua Conference, Jerusalem 1996. Second challenge – effectiveness of QI interventions Accountability of QI 2. Grimshaw JM, Freemantle Further development of QI requires infor- N, Wallace S. Developing and Another challenge is to find information on mation about its results, costs (cost per unit implementing clinical practice the effectiveness of investment in QI strate- of additional benefit has to be calculated – guidelines. Quality in Health gies. As it was pointed out by Donabe- incremental cost) and cost effectiveness. Care 1995;4:55–64. dian,1 there is very little information avail- New evidence needs to focus on the cost 3. Crosby PB. Quality without able on the effectiveness of QI. Developing effectiveness of improvements in the ‘real tears. New York: McGraw- information indicates that a great deal of world’ (how should it be done?). Hill, 1984. ineffective and/or non cost effective quality Increasingly, studies on the effectiveness of assurance activity is in use in healthcare. 4. Berwick DM, Blanton A, QI programmes have to include considera- Roessner J. Curing Health The level of achievable benefit has to be tion of cost effectiveness. Care. San Francisco: Jossey- defined, predicted and explicitly stated Quality improvement can be seen as a mir- Bass, 1990. within all QI programmes. Achievable ben- ror confronting healthcare providers with 5. Jarlier A, Charvet-Protat S. efit, as a crucial cornerstone of every QI the results of their work. The time has Can improving quality activity, has to be tailor made. Different come to hold up the same mirror to QI decrease hospital costs? aspects have to be taken into consideration, programmes, evaluating their effectiveness International Journal for for example, the size, location and teaching and probably most important, demonstrat- Quality in Health Care 2000; status of the hospitals or other healthcare ing their cost effectiveness. On the one 12(2):125–31. settings. hand, this is required by ‘clients’ of quality 6. Shaneyfelt TM, Mayo-Smith Although there is some evidence of the effi- endeavours: providers, purchasers and MF, Rothwang J. Are guide- cacy of various QI tools (for example, patients; on the other hand, this has lines following guidelines? medical audit, peer review, accreditation become an increasingly important factor Journal of the American status) there is little evidence of their effec- for quality professionals trying to promote Medical Association 1999;281 tiveness. According to the literature, for their work. (20):1900–05.

eurohealth Vol 6 No 5 Winter 2000/2001 28 THE DEVELOPING ROLE OF NURSING NursingintheWHOEuropean Regioninthe21stCentury

“Nurses and midwives are voting with their feet and leaving the professions in droves.”

In January 2001 the WHO Executive and debate the concerns and aspirations of Board,1 which comprises representatives of the professions. Ministers, or their repre- 32 of the 191 member states, had a lengthy sentatives, attended from 48 European discussion on nursing and midwifery glob- member states. Each delegation endorsed Ainna Fawcett- ally. It was acknowledged that nursing and the Declaration3 which emanated from the midwifery are in crisis worldwide and that event and which summed up what needs to Henesy there is an urgent need to tackle the root happen if nursing and midwifery are, first- cause of the problem. Minister after ly, to continue to be professions to which Minster spoke passionately about the people are attracted and wish to remain importance of the profession in helping associated with; and secondly, if the profes- Governments to tackle the health and sion is to continue to add value to the sickness needs of the population of the health of the population of each country. It respective countries. The unique role of the was a successful event as demonstrated by professions in addressing the issue of acces- the standing ovation when the then sibility to the healthcare system, for the Minister of Health for Germany symboli- more vulnerable, was strongly emphasised cally signed the Declaration on behalf of all by many. It was however acknowledged Governments and the Regional Director of that words of encouragement, important the WHO Regional Office for Europe thought they are, are no longer enough in signed it on behalf of WHO. themselves. One of the member states called for an action plan that addresses the In many ways the debate at the Executive problems within the professions not least Board echoed that of the Munich the issue of recruitment and retention. This Conference. Nurses and midwives are in turn means tackling the issue of better voting with their feet and leaving the pro- pay and working conditions, greater fessions in droves, in particular in Western acknowledgement of the autonomous role Europe. Almost every country in Western of the professions, capacity building and a Europe has a nursing and midwifery recognised role in research as well as influ- shortage. ence at the policy making level. Worse still those who may previously have The Regional Directors from the WHO chosen nursing and midwifery as their regional offices added their support to the preferred career option are looking else- debate in very positive terms. Consensus where. The outcome is huge staff shortages, was reached that Nursing and Midwifery inadequate cover for clinical areas which in should be on the agenda at the World turn means those who remain are having to Health Assembly, the Ministerial meeting work twice as hard and provide far lower of the 191 countries in membership with standards of care than they would wish. WHO in May this year. A Resolution and This results in an unfulfilled and disillu- an Action Plan is proposed for the meeting. sioned workforce, as many of the surveys point out. This situation has also resulted European Ministerial Conference on in industrial disputes in many European Nursing and Midwifery countries the latest of which has been in In June 2000 the WHO European Regional Poland where during the Christmas period, Office for Europe demonstrated its own disillusioned nurses occupied government commitment to the professions by organis- buildings and brought traffic to a standstill ing a Ministerial Conference2 to discuss in the capital, Warsaw.

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The picture at face value looks gloomy. Yet many countries have amended their legisla- despite all the negatives, the vast majority tion, which has in turn allowed nurses and of nurses and midwives seem to be pushing midwives to practice in more autonomous back the frontiers and doing their utmost roles. Such new legislation and regulation, to manage the crisis and develop their roles in some instances, requires nurses to base in a changing healthcare world in the their practice on research evidence as in European region. The lead up to the WHO Austria as well as apply health promoting Ministerial Conference on Nursing and principles and practice in their work with Midwifery in Munich in June 2000 provid- patients and clients. ed a useful opportunity to do a stocktake In line with increased decentralisation, on where nursing and midwifery is posi- nurses and midwives are now being tioned at the beginning of the 21st century. employed in several countries as indepen- Numerous conferences and summits over dent contractors, in particular in primary the previous decade, advocated a range of care. This arrangement may be on an indi- developments in education, practice, man- vidual basis or through agencies established agement and research. But perhaps the by groups of nurses. Such independent overriding recommendation at all these past contractual agreements are either with events was that nurses and midwives health insurance funds or with regional should be acknowledged as autonomous health authorities and some are even with and distinct but complimentary to other family physician practices. This is not only healthcare practitioners. happening in the western part of the region “Nurses are beginning Indeed the first ever WHO European con- but also in countries of central and eastern 6 to assume roles ference on Nursing and Midwifery held in Europe, such as in Poland and Croatia. Vienna in 19884included a Declaration with previously perceived as a long list of issues that needed to be New Roles for Nurses and Midwives addressed both within and outside the pro- Primary healthcare is the preferred the prerogative of the fessions if nurses and midwives are to con- approach7 for most countries as they re- tribute in an effective way to meeting the organise their health systems. Hospitals physician.” health and related needs of the populations across the region continue to be ratio- of the European region. Key was that nurs- nalised in size and numbers. In-patient 7 es and midwives should be a resource to stays are becoming shorter and shorter the public and that their practice should be with often only the very sick being admit- based on the principles of primary health- ted to hospital and as a consequence neces- care as espoused at the Alma Ata sitating very good follow up home care ser- Conference in 1978.5 Owing to their inti- vices. The role of the Family Physician is mate knowledge of the needs and wants of becoming much more commonplace across patients and their families as well as the the region with him/her acting as gatekeep- very personal nature of their work 24 hour er to the hospital services. Substitution is a day and in every setting, it was believed also becoming the norm and many of the that nurses and midwives should play a key activities that were previously carried out role at all health policy making levels. in hospital are being carried out in the community. Nurses are beginning to The analysis6 or ‘stocktake’ undertaken in assume roles previously perceived as the the 51 member states of the WHO prerogative of the physician. In the same European region was illuminating. Some way nurses are transferring some of their countries had really demonstrated that they responsibilities to other professionals and had listened to the various debates on nurs- to healthcare assistants. Vast areas of care ing and midwifery and had taken appropri- are also taking place in patients’ own ate action. For example in the Scandinavian homes, clinics and on the premises of the countries, the Netherlands, and the United family physician. There is also a gradual Kingdom nurses and midwives are in move to promote self-care and give more receipt of a much more rounded education responsibility to families and carers. and on a continuing basis too. Many coun- Nurses are increasingly moving from the tries are now educating nurses on 3–4 year hospital to the community and health pro- programmes, beyond 12 years secondary motion and illness prevention are becoming education, at university level in line with an integral part of their role. There is some WHO policy. Nurses and midwives are good evidence of nurses and midwives also availing themselves of advanced educa- developing partnerships with the commu- tion at Masters degree level. More nurses nity, working alongside them, helping them than ever before are studying for PhDs. to solve their own problems. Working with As part of the healthcare reform movement the voluntary sector is also on the increase,

eurohealth Vol 6 No 5 Winter 2000/2001 30 THE DEVELOPING ROLE OF NURSING

“Many countries are an important new development as this outreach services for the elderly. Nurses in sector increases its role in service provision. Belgium have for example developed new now educating nurses Nurses are also beginning to work more services for the elderly mentally frail so effectively in integrated teams of physicians that they can stay in their own homes for as beyond secondary and others. long as possible, yet not be a burden to the family. education, at university In some countries nurses are taking a more crucial role in primary care, acting as front Nurses in Ireland have worked with the level. … More nurses line workers and only referring to the fami- travelling community, a section of the ly physician when the needs of patients and population with the worst health problems, than ever before are families can be met more adequately by to agree together what are the their needs studying for PhDs.” his/her expertise. and helped develop the most appropriate In the United Kingdom, nurses, through services to meet them. the advent of the Primary Care Trusts, are Nurses and midwives in Finland have managing the whole primary care service helped women and their families to access a and are employing doctors, social workers whole wealth of information through the and others to provide comprehensive care internet to make the experience of child- to individuals and families. Nurses in birth and afterwards an informed and a Iceland8 are undertaking the direct access happy experience. Nurse Practitioner role and nurses in Sweden are assuming innovative leadership Conclusion roles with the elderly population at region- Nurses and midwives are making concerted al level. Nurses are also establishing open efforts to develop their roles in line with access clinics for the more vulnerable, those the needs of the respective populations of with mental health problems, those who their countries. They are also in many misuse drugs and those who are for what- instances showing demonstrable improve- ever reason without a home. Nurses and ments in the health gain agenda. Yet often midwives are also providing sensitive ser- such achievements are ignored and rarely is vices for refugees, newly arrived immigrant money forthcoming to ensure sustainabili- groups such as for the Ethiopian community. Is it any wonder therefore that the pro- ty in Israel and for those who are reluctant fession feels disillusioned and undervalued? or feel unable to use the regular health As was evident during the lead up to the services on offer. Midwives in Austria have Munich Conference and during the meet- created unique personal midwifery services ing itself, there is no lack of goodwill from for the family preparing for the birth of a the professions. What has been truly lack- baby With an increasing elderly population ing is political will. Despite the warning nurses are re-engineering old services as signs over many years of an imminent crisis well as designing new services including in nursing and midwifery recruitment and retention, little notice was taken. These problems will not go away overnight unless REFERENCES their root cause is tackled. 1. Meeting of the WHO Executive Board Geneva, May 2001. At the Munich Conference in June last 2. WHO Ministerial Conference on Nursing, Munich, June 2000. year, the enthusiasm and commitment of 3. WHO Regional Office for Europe. Munch Declaration: Nurses and those present to ensure that nurses and Midwives – A force for health. Copenhagen: WHO Regional Office for midwives maximised their efforts in the Europe June 2000. interests of meeting the health and related 4. Fawcett-Henesy A. Nursing in Context. Background paper prepared for needs of the people of Europe, were electri- the Ministerial Conference on Nursing and Midwifery, June 2000. fying. A whole set of achievable recommendations was set out in the Munich 5. Primary Health Care. Report of the International Conference on Primary Health Care, Alma Ata USSR 6–12th September 1978. Jointly sponsored by Declaration. These included tackling the the World health Organisation and the United Nations Children’s Fund, obstacles to progress for example medical Geneva. Alma Ata: World Health Organisation Health for All series No 1. dominance, education, legislation, regula- 1978. tion, developing a research and evidence base for the profession and most impor- 6. Analysis of Nursing in the 51 member states (internal document of the tantly nurses and midwives having a place WHO Nursing Programme Regional office for Europe). of influence at all policy making levels. 7. Saltman RB and Figueras J (eds). European Health Reform, Analysis of Without doubt if each member state took Current Strategies. WHO Regional Publications, European Series No each of these recommendations seriously 72.Copenhagen: WHO Regional Office for Europe, 1997. the current crisis could be averted and a 8. Warrier S. Portfolio of Innovative Practice in Primary Health Care Nursing profession fit for it purpose could lead us and Midwifery. Copenhagen: WHO Regional Office for Europe 2000. safely through 21st Century

31 eurohealth Vol 6 No 5 Winter 2000/2001 THE DEVELOPING ROLE OF NURSING Nursinganditsdevelopingrole: ABritishcasestudy

The UK Government published its National Health Service (NHS) 1 Plan for England at the end of July 2000. This plan is the blueprint organise and develop the environment of for how the Government wants the NHS and social services to care. meet health and social care needs for the next ten years. The main – A focus on patient centred measures of quality. theme underpinning the plan is that of ‘modernisation’ – requiring All of these things recognise the enormous fundamental changes in attitude and culture. potential of nurses and nursing to develop modern patient centred care and patient It is a rare moment when there is a coming centred services. And yet there are some together of ideas and beliefs, as has hap- enormous challenges that must be pened with nursing and Government poli- addressed, for instance: cy over recent years. Nursing’s credo is – The nursing shortages. Despite a founded upon being patient centred and Government promise in the NHS Plan upon social justice. Essential to these ideas of 20,000 more nurses by 2004, there are are equality of access, compassion and currently 21,000 nursing vacancies in humanism, and the promotion of patient England alone.2 We cannot under autonomy. Putting the person back into estimate the scale of recruitment and patient care has been at the heart of nursing retention that lies ahead. innovation over the last 20 years. And now – The development of 5,000 new interme- so much of nursing’s agenda – of what we diate care beds. The predominant thera- think is important in the way care is deliv- py in intermediate care is nursing. How Pippa Gough ered – suddenly resonates with the present do we create quickly the nursing work- Government’s modernisation programme. force to design, manage and lead this vital component of care? Opportunities for nurses The opportunities opening up for nursing – The perennial issue of pay and reward. and nurses are huge. The power base with- If you want nurses and nursing to in the heath service is beginning to shift. change and modernise our health “The power base This is especially apparent with innovations services then pay is a crucial factor. such as the nurse-led telephone triage ser- Many senior nurses are leaving the NHS within the heath vice in England known as NHS Direct. citing low pay as a significant factor. service is beginning This is nursing at its creative best with nurses being free right from the start to Changes in culture and attitude to shift.” develop a brand new service, unrestricted The Government has identified changes in by the structures and structures of the past. culture and attitude within the health The service not only enables nurses to service as the key factor for successful become the new gatekeepers of the NHS. It modernisation. Investment in nurses and is also pioneering a model of healthcare nursing and achieving this change are two that is driven by what people want and sides of the same coin. The Government’s how people live their lives today. concerns are that the NHS has been too professionally dominated for too long. This Further opportunities include: inhibits more patient centred care where – Nurses taking up posts in the planning the patient has a major say in decisions and commissioning of healthcare. about the care he or she receives. – The introduction of consultant nurses. Moreover, there exists a pressing political – Investment in nursing leadership. imperative to stop the recent scandals and horror around professional neglect, incom- – The development of new and compre- petence and misconduct. There is now a hensive intermediate care services. growing loss of trust and confidence by the – The creation of the ‘modern matron’ public in the health professions to provide where senior clinical nurses are given safe and effective care. This isn’t confined more responsibility and authority to just to doctors – nurses too are tainted. The

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“We cannot under Government has to be seen to improve whole different set of values. Best nursing standards of patient care generally and to practice is characterised not by paternalism estimate the scale of overcome unacceptable variations in but by partnership; not by authoritarianism efficiency, access and outcomes of care but by collegiality and collaboration; not recruitment and from place to place. There is a determina- by a mastery of knowledge but by shared retention that lies tion both in the Government and among and borrowed knowledge and by reflective the public to see the professions brought to practice and lifelong learning; not by aloof- ahead.” heel. There are moves in the NHS Plan to ness and detachment but by engagement; develop competence assessment linked to not by control but by empowerment – of systems of clinical governance and to intro- self and others. Celia suggests this is the duce revalidation for doctors and the basis of a ‘new professional’ model; a new review of re-registration for nurses. The professional identity. Many of these attrib- changes to our systems of statutory regula- utes of the ‘new professions’ are at the tion are all part of this. heart of the Government’s modernisation agenda – issues of partnership, lifelong Linked to all these issues is an urgent need learning, flexibility, and collegiality. to address shortfalls in the workforce. We are all being urged to break down profes- The professions as we know them are a sional boundaries, to work more flexibly, social construct that emerged from 18th to be less tribal and to develop new roles. and 19th century society. That society has The emphasis here is on how the patient now moved on. We are in a new era charac- can be served best through new ways of terised by consumerism, citizenship and working – not on shoring up old profes- new democracies. We are now seeing new sional demarcations and engaging in professions emerge. People will always endless turf wars. need nursing and nursing care. Our biggest challenge in modernising is to ensure that The future of the professions they receive this in the most compassion- Implicit within modernising is the notion ate, humane, well informed and competent of change. ‘Traditional’ practices – ways of way. Our professional identity should be being, thinking and doing – must be re- founded on this. examined. But there is a paradox here. For despite nursing and nurses finding them- Leadership selves very much in sync with Government The NHS Plan places significant emphasis policy, and seeing nursing come of age in on leadership as a major vehicle for change political minds, we are also being asked to and developing new roles. The approach discard much of what we have subscribed that is being espoused is of transformation- to in terms of professional identity. That is al leadership – where leaders work to not to say that empowering patients and enable others to change and cope with making them centre stage was not overdue change. It is only through this type of lead- but it is to recognise that part of this ership that the desired culture and attitudes approach is to unpick the professions and will become reality. The position of the the old style model of professionalism. So professions is, arguably, increasingly whilst celebrating the role that nurses and unsustainable. Our old professional frame- nursing have to play we must also look works are no longer a suitable vehicle to deep into our hearts to ask whether we are deliver the type of care that is expected and ready to deconstruct some of the beliefs, needed. But our first step is to transform ourselves. the mores, the attributes that are at the very core of the professional model to which There are therefore some tough questions nurses have for so long aspired. to be addressed. If enabling people around REFERENCES us to cope with change is dependent upon Professor Celia Davies has argued that 1. Department of Health. The transforming ourselves first, how far along nurses in search of professional status have NHS Plan. A Plan for the road of this personal journey are we? Investment. A Plan for looked to the ‘old professions’ such as How far are any of us along the path of Reform. London: TSO, July medicine and law for a lead and have ended that emotional and intellectual change; of 2000. up subscribing to a model of ‘old profes- stepping out of old professional ways of sionalism’.3 She argues that the this model 2. Royal College of Nursing. being, thinking and doing; of changing our is characterised by elitism, paternalism, Making up the Difference. beliefs and ideas about who we are and authoritarianism, highly exclusive knowl- London: RCN, Dec 2000. how we do what we have always done; of edge, control and detachment. 3. Davies C. Gender and the letting go of old certainties and being Professional Predicament for She goes on to argue that aspiring to this courageous enough both professionally and Nursing. Milton Keynes: OU professional paradigm creates real tensions personally to view the world through a dif- Press, 1995. for nursing. Progressive nursing espouses a ferent lens?

33 eurohealth Vol 6 No 5 Winter 2000/2001 THE DEVELOPING ROLE OF NURSING TheroleoftheCommunityChiefNurse intheSwedishmunicipalities

The function of the Community Chief Hence, the municipalities were given med- Nurse (CCN) was established in Sweden ical responsibility, including the services of with the implementation of the so called registered nurses, enrolled nurses as well as Care of the Elderly Reform in January the services of physical therapists and occu- 1992. The aim of the reform was to give the pational therapists. municipalities more comprehensive respon- The municipalities deliver care in so called sibility for long term care, nursing, and ser- assisted living environments, which include vices for the elderly and disabled. Through facilities such as nursing homes, group the reform, the municipalities have become homes for patients with dementia and for financially liable for patients, who, when retarded people, group homes for the long Marianne found to have completed their medical term mentally ill, and day activities. treatment, could not be discharged to their Lidbrink Furthermore, more than half of the munici- own homes owing to inadequate assistance palities in Sweden have also taken over the or unsuitable housing. Hence, the munici- responsibility for home nursing, following palities became financially liable to pay for agreements or contracts with their county each day the patient remains in the hospital. councils. In 1995, the responsibility was broadened Accordingly, the municipalities have, to apply to the mentally retarded and the through the reforms, taken over a large part long term mentally ill. of the county council’s responsibility for The aim of the Care of the Elderly Reform healthcare. The extent of the responsibility is to coordinate – into a common working can, among other things, be illustrated with organisation with a uniform direction – the the aid of particulars concerning access to social and medical expertise required to ful- numbers of beds etc (see box). fil the responsibility of the municipalities as The Community Chief Nurse has played stipulated by the Social Services Act and and plays a key role in the implementation the Health Services Act. of the changes.

The Function of the Community Chief In 1991 there were approximately 93,000 beds available under county council management, or 10.8 beds per 1,000 inhabitants.* Slightly more than 30,000 beds Nurse were transferred to the municipalities in connection with the change in 1992. According to the Health Services Act, §24, During following years, the number of county council beds was reduced by a fur- the municipalities, to meet their medical ther 33,000 by 1998, corresponding to 3.8 beds per 1,000 inhabitants.** The fig- responsibilities, shall have a Community ures should be seen in light of there being approximately 135,000 persons in so Chief Nurse who is responsible for the called assisted living environments in 1997 — a collective name for nursing homes, service flats (also known as sheltered accommodation) or group dwellings in the following: municipalities. In the same year, just over 145,000 persons with physical disabili- 1. that routines are in place to assure that a ties received some form of home-help service or care in their own homes.*** physician or other medical staff member is This development has been made possible not only because the municipalities have taken over a large share of the county councils healthcare responsibility but contacted when a patient’s condition so also, among other things, technological development has facilitated shorter requires, healthcare times. Day surgery and home care have, for example, become more common through refined operation and anaesthesia methods. New IT has Follow-up: improved communication between different healthcare units, also as far as health- The physicians’ work in primary health care in the home is concerned. care is financed through taxes levied by the * Statistics — Health and Medical Care, Yearbook of Health and Medical Care county councils. Elderly people, like 1998. The National Board of Health and Welfare, Stockholm 1998. anyone else in Sweden, have the right ** County Council Statistics Yearbook 2000. Federation of County Councils, according to law , to have access to a gener- Stockholm, 2000. al practitioner (GP). When the need arises *** Statistics — Social Welfare, Service and Care to Elderly and Disabled persons for nursing in assisted living environments, 1997. The National Board of Health and Welfare, Stockholm, 1998. experience shows that patients tend to lose contact with their GP. Special local agree-

eurohealth Vol 6 No 5 Winter 2000/2001 34 THE DEVELOPING ROLE OF NURSING

“Community Chief ments between the municipalities and pharmaceutical incidents. This reduction county councils are therefore needed to has progressed over several years and Nurses are unique to ensure that the elderly in these settings cannot be regarded as random, but almost receive proper medical care. A survey has certainly corresponds to the introduction Swedish healthcare.” shown that collaboration works best where of safer procedures in dealing with pharma- there are written agreements regarding the ceuticals in assisted living environments.3 contributions from the physicians. In the Other explanations may also be found, for same survey, directed towards the example that, at the outset, the Community Community Chief Nurses, 70 per cent of Chief Nurses reported incidents unneces- them replied that such agreements exist but sarily. Awareness of what is and what is that there is still room for improvement.1 not to be reported to the National Board of Health and Welfare** has improved. 2. that decisions to delegate responsibility for care activities are compatible with Another statute requires the Community patient safety. Chief Nurse to be responsible for the following: Follow-up: A survey directed at the country’s approxi- 1. that patients receive safe and appropriate mately 384 Community Chief Nurses (86 care and treatment of good quality within per cent response) showed that 72 per cent the field of responsibility of the municipality. consider that the delegation of nursing Follow-up: assignments functioned well or very well, In the 1999 survey, 37 per cent of the while 22 per cent consider that it functions Community Chief Nurses replied that it is less well or badly. When this is the case, possible always to guarantee safe and this depends primarily on the fact that the appropriate care and treatment. Fifty-two assignments are delegated to too many per cent state that they can only sometimes individuals or that there are too few nurses do this and only two percent consider that in the enterprise.2 they can seldom do this. If there is a prob- 3. that a report is made to the board in lem with guaranteeing safety, this is charge of medical services if a patient, in primarily due to inadequate resources and 2 conjunction with care and treatment, is collaboration with other levels of care. affected by, or exposed to the risk of being 2. that patient records are kept in accor- affected by serious injury or disease - Lex dance with the Patient Records Act. Maria.* Follow-up: Follow-up: The patients in the municipalities are In the years following implementation of frequently in need of both health and social the Care of the Elderly Reform, municipal care. In Sweden this means that different healthcare noted a considerable increase in occupational groups work according to the number of Lex Maria complaints. The different statutes implying that differing complaints primarily concerned mistakes preconditions apply for the care. This also or faults related to pharmaceutical treat- applies to the documentation. As far as the ment, surgical or pharmaceutical measures, patient is concerned it is of little interest and nursing issues. The greatest number of that this is the case. Regardless of the rules, complaints was noted in 1994 – after this one has the right to receive safe and appro- the numbers have diminished in the priate care and treatment. A large part of municipalities. The reduction here consists the work of Community Chief Nurses has mainly of a reduction in the number of been to provide the requisite safe documentation. A survey from 1997 shows that 84 per cent of the Community Chief Nurses questioned work with quality * Lex Maria – the regulations are to be found in the Health and Medical related to documentation.4 Services Act (Professional Activity) (1998:531) on occupational activities in the field of healthcare, and in directions and general recommendations in this The same statute also states that patients field issued by The National Board of Health and Welfare (SoSFS 1996:23). A shall receive the care and treatment pre- report is to be filed if a patient undergoing healthcare suffers or encounters the scribed by a physician and that there shall risk of suffering serious injury or illness. A great number of complaints be appropriate, properly functioning proce- regarding a certain activity need not indicate that the activity is extremely bad, dures for handling pharmaceuticals. but rather that the care provider has a properly functioning quality system Follow-up: capable of tracking and noting faults and deviations. As seen earlier, various surveys indicate ** The National Board of Health and Welfare is the governmental authority that there are shortcomings with regard to responsible for health and medical care issues, and serves as the expert body physician participation and pharmaceutical on these issues for the Swedish Government handling in the municipalities, but that the

35 eurohealth Vol 6 No 5 Winter 2000/2001 THE DEVELOPING ROLE OF NURSING

Community Chief Nurses are working to common that the municipalities employed “The status in the bridge this with the aid of agreements and the Community Chief Nurses on a part guidelines, etc.1,2,3 time basis, with employment, for example, organisation of the as a nurse at a nursing home at the same Discussion time. The 1999 survey fortunately shows Community Chief It can be established that the municipalities, that the municipalities make better use of during the 1990s, have been given several the potential provided by the Community Nurses varies new roles and a particular responsibility in Chief Nurses’ function. The Community the issue of healthcare and nursing. considerably, which Chief Nurses are in general responsible for Community Chief Nurses have had the presentation of reports to local political considerable importance for the safe and means that they still committees regarding healthcare issues.2 successful implementation of the changes. play many different However, there remains potential to render However, with the detailed regulation of healthcare more effective. A recently the function that only exists in municipal roles.” completed report, initiated by the Ministry healthcare, Community Chief Nurses are of Health and Social Affairs, therefore unique to Swedish healthcare. They have a proposes that municipalities and county comprehensive responsibility while at the councils shall have the right to form joint same time it is not a question of an committees to solve their common assign- executive function in its traditional ments in the field of healthcare. One may meaning. A primary responsibility for the assume that a solution that attempts to individual patient is not included in the originate from the needs of the patient can function. On the other hand, they are liable greatly contribute to facilitate the tasks of to intervene in individual cases if this is Community Chief Nurses to ensure safe needed to provide safe and appropriate quality in healthcare. care. The responsibility may be designated as supervisory and when carrying out the The operations in the municipalities are statutory assignments, the Community exposed to constant development, as are Chief Nurses are neither subordinated to the role and function of the Community the head of the enterprise, nor any other in Chief Nurses. The municipalities’ health- the municipality. care and nursing responsibilities and the importance of this sector as a labour The status in the organisation of the market for the occupational groups organ- Community Chief Nurses varies consider- ised by the Swedish Association of Health ably, which means that they still play many Professionals, will play an increasingly different roles. Twelve per cent of important part in the near future. The Community Chief Nurses are also heads of Swedish Association of Health enterprises2 with budget responsibility, Professionals therefore follows and partici- which means that in this case the pates continuously in the discussions and Community Chief Nurses supervise their development of municipal healthcare. As own functions. There is presently an inten- part of this, the Association has developed sive discussion underway concerning the a standard: ProCare – proper care of elder- expediency of such an organisation. ly patients, consisting of a number of quali- Ever since the introduction of the ty criteria that together express what the Community Chief Nurse function, the Swedish Association of Health Swedish Association of Health Professionals believes is the minimum Professionals*** has maintained that the quality acceptable for healthcare of the function is so comprehensive, that the elderly. potential to perform supervision is weak- ened if the function is splintered into a number of different roles. Initially it was

REFERENCES 1. Physician Participation in Municipal Healthcare. Stockholm: The Swedish *** Swedish Association of Health Association of Local Authorities, 1998. In Swedish only. Professionals organises 93 per cent of all reg- 2. Safe and Appropriate Healthcare of Good Quality in the Municipalities – istered nurses, registered nurse midwives, The Role and Function of the Community Chief Nurse. Stockholm: Swedish biomedical scientists and radiographers in Association of Health Professionals, 1999. In Swedish only. Sweden. The purpose of the Association is to represent its 110,000 members in profes- 3. Risk Rounds Special – Information Concerning Risks in Healthcare no. 1, sional and labour issues. Welcome to our Örebro: The National Board of Health and Welfare, 1998. In Swedish only. web site! 4. The Function and Development of the Community Chief Nurse. The www.vardforbundet.se/english/english.htm. National Board of Health and Welfare, Stockholm, 1996. In Swedish only.

eurohealth Vol 6 No 5 Winter 2000/2001 36 News from the European Union compiled by Ingrid Stegeman at ENHPA and HDA

NICE SUMMIT French Presidency Health Conference The European Council convened an Intergovernmental Conference (IGC), held in The French Presidency and the Nice 7-11 December, to address issues left open in the Treaty of Amsterdam that European Public Health need to be settled before the enlargement of the EU. Association (EUPHA) organised a Five main themes were on the agen- to fight social exclusion and to mod- Conference in Paris on 14–16 da; the size and composition of the ernise social protection systems. December 2000 on Access to Health EU, the weighting of votes in the This does not, however, entail the Care for the most Underprivileged Council, the possible extension of harmonisation of laws and regula- and on Nutrition and Health in qualified majority voting in the tions between Member States, as the Europe. Amongst the aims of the Council and other amendments EC must respect Member States’ Meeting were to collate Europe regarding the European institutions rights to define the fundamental wide experience on access to and pending enlargement. Some principles of their systems. The healthcare for the most disadvan- issues remain unsettled, including Social Policy Agenda (which was taged sections of society and to ini- for example the size of the accepted during the Social Affairs tiate a European network on access Commission following enlargement. Council on 28 November 2000) was for all. During the Meeting, also formally adopted during the EUPHA put forward proposals to The Nice Council led to some posi- summit. develop a European policy to tive developments in the area of reduce inequalities in morbidity social affairs. Article 137 of the The Nice Treaty and the Presidential and mortality rates. Treaty drawn up at Nice, for exam- Conclusions of the Summit are avail- ple, gives the EC greater competence able on the Council website: A detailed account of the meeting, to complement and support actions http://ue.eu.int/en/summ/htm speeches given and the topics covered is available on website: www.sfsp-publichealth.org/page- European Commission and World Health Organisation to intensify congres.htm their cooperation World AIDS day: Commission On 14 December 2000 Dr. Gro tives.” The WHO and the EU have pledges action Harlem Brundtland, Director- been working together since 1982, While attending World Aids Day on General of the World Health which has produced positive results 1 December 2000, European Organisation (WHO) and Health in areas such as health research, Commissioners Poul Nielson , and Consumer Protection development and humanitarian aid, Pascal Lamy, Philippe Busquin and Commissioner David Byrne signed environment, chemical products and David Byrne confirmed their com- an agreement to strengthen and food safety, surveillance of commu- mitment to combat the disease by all intensify cooperation in the field of nicable diseases and health monitor- means at their disposal. Trade health between their two institu- ing. The Agreement reflects a major Commissioner Lamy pledged that tions. According to Dr. Brundtland, political commitment to intensify the Commission would pursue its “Whist the nature, means and proce- this cooperation. campaign to make safe, affordable dures (of the two institutions) are The letters exchanged between the medication available. Research different … Member States of the WHO and the Commission concern- Commissioner Busquin stated that European Communities and those of ing the consolidation and intensifica- the European Science community the WHO have repeatedly stressed tion of cooperation can be viewed on and vaccine industry are working the need for cooperation that will website: http://europa.eu.int/comm/ together to develop vaccines. help reduce unnecessary duplication health/ph/key_doc/who_letters_de. in the effort to reach common objec- Information: html DG Development’s policy on Health, AIDS and Population programme at Swedish Council Presidency http://europa.eu.int/ comm/development/sector/social/health_en.htm On 1 January 2001 Sweden for the will aim to ensure that the new public DG Trade Action for Access to first time assumed the Presidency of health framework programme is Medicines at http://europa.eu.int/ the EU Council of Ministers, a posi- adopted and that efforts to ensure a comm/trade/ csc/med.htm tion it will hold until 30 June 2001. high standard of health protection are DG Research’s vaccine and drug The Swedish Government’s initiatives intensified. The Government’s public research, contact Stephane Hogan will focus on three principal areas – health initiatives will focus on alco- (+32 2 299 1860) or Michel Claessens the ‘three Es’ of Enlargement, holism, drug abuse amongst young (+32 2 295 8220) Employment and Environment. The people, tobacco and blood safety. Swedish Presidency also intends to DG Health and Consumer strengthen the Union’s profile in pub- Sweden’s programme is available on Protection “Europe against Aids” lic health issues. A document outlin- the Swedish Presidency website: programme at www.europa.eu.int/ ing the programme states that Sweden www.eu2001.se comm/health/index_en.htm

37 eurohealth Vol 6 No 5 Winter 2000/2001 News from the European Union

HEALTH COUNCIL

The Health Council met on 14 December 2000.

The Council approved the extension of the six existing Community action programmes in the field of public health until 31 December 2002 as the new programme (2001–2006) due to replace them will not be adopted in time. The Health Council also held a policy debate on the new programme. The European Parliament has not yet adopted its opinion regarding the programme and key questions such as the budget, the idea of setting up a Community structure for health monitoring and the scope of the programme (notably concerning work on health systems) remain unresolved.

A draft Council Resolution on Health The Commission informed the Member States. Following the discus- and Nutrition was put forward for Health Council on progress made on sion the Council concluded that while adoption. The Resolution invites the the health aspects of the e-Europe respecting Member States’ powers, Commission to investigate ways to 2002 Action Plan approved by the efforts regarding research, monitor- promote better nutrition in the EU Feira European Council. The Action ing, assessment and eradication of and present appropriate proposals. Plan includes a health online section, BSE and the provision of medical care which provides for measures aimed at and social support to patients and The Commission informed the collecting and circulating examples of families should be concentrated at the Council on three different matters good health practice online, establish- Community level. Commissioner regarding tobacco. It reported on its ing the quality criteria applicable to Byrne also insisted that although intention to submit, during the first websites and linking up existing data Member States have chosen to con- half of 2001, a new proposal for a networks. The Health Council fine discussions regarding BSE largely Directive on tobacco advertising to emphasised the importance of coop- to the Agricultural Council, Health replace Directive 98/43/EC, which eration among Member States in Ministers must also have a leading was annulled by the European Court implementing this Plan. A document role in decisions on BSE. of Justice last October. The containing a preliminary list of indi- Commission also informed the The Commission also presented two cators for monitoring the e-Europe Council of the outcome of the new texts to the Health Council. The Action Plan was adopted by the European Parliament’s vote at a sec- first was a Proposal for a Council Internal Market Council on 30 ond reading on 13 December con- Recommendation on alcohol and November 2000 and formally noted cerning the draft Directive on the young people, which was adopted by by the Nice European Council. More Manufacture, Presentation and Sale of the Commission on 27 November information regarding this initiative Tobacco Products. Finally, the 2000. This a first step towards com- can be found on website: http:// Commission submitted a report on bating the problems associated with europa.eu.int.comm/information_soci the outcome of the first meeting of alcohol consumption by children and ety/eeurope/actionplan/index_en.htm the WHO Framework Convention adolescents, which is a growing phe- on Tobacco Control that is under The Health Council approved by a nomenon in some Member States. negotiation in Geneva. This qualified majority all of the amend- Under the Recommendation, Convention will require ratification ments that the European Parliament Member States will have to imple- by Member States and the adopted at its second reading con- ment measures on health promotion, Community to enter into force. cerning the draft Directive on Clinical education and information, and mea- Minutes of this meeting are available Trials on Medicinal Products for sures relating to codes of conduct on website: http://europa.eu.int/ Human Use. There is currently a lack aimed, inter alia, at the producers and comm/health/ph/programmes/tobac- of binding legislation on the conduct retailers of alcoholic beverages. The co/who_en.htm of clinical trials in the EU. The pro- proposal will be put for adoption on posed Directive therefore sets techni- the agenda of the Health Council The Council also discussed a propos- cal standards and harmonises admin- under the Swedish Presidency. This al by the Swedish Presidency for a istrative procedures used in the con- proposal is available on website: Council Resolution on Paediatric duct of trials. It covers regulations http://europa.eu.int/comm/health/ph/ Medicines. The draft resolution out- concerning the informed consent of key_doc/ke04_en.pdf ) lines that there is currently a lack of participating patients, authorisations suitably adapted medicines available The second text presented was a by the competent authorities, safety for children and that a European Proposal for a Council and European standards (monitoring, inspections approach to resolving this issue is Parliament Directive on the safety etc.) and also codifies a number of required. It invites the Commission and quality of blood and blood com- terms in order to facilitate the dissem- to make proposals in the form of ponents. This Proposal aims to ensure ination of results of clinical trials. incentives, regulatory measures or that EU citizens can rely on safe med- other supporting measures to ensure The Council held a detailed discus- ical treatments wherever they go. The that medicinal products for children sion on the report presented by Proposal was adopted by the already on the market as well as new Health and Consumer Protection Commission on 13 December 2000 ones are fully adapted to the specific Commissioner, David Byrne, on the and will be examined in detail under needs of children. epidemiological situation of BSE in the Swedish Council Presidency.

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RESEARCH

Europe funds a scientific world first: breakthrough in Commissioner Busquin reinforces sequencing the plant genome genomics research The first full sequencing of a plant completely sequenced so far. This Research Commissioner Philippe Busquin genome has been completed with represents a major breakthrough has launched an initiative to reinforce the help of a EUR 26m European in the scientific understanding of European activities in genome research relat- research grant. This scientific plants, including how they cope ed to human health. On 8 November 2000 breakthrough is the longest and with pests and diseases and how the European Commission and Member most complete sequencing of a they interact with their environ- States’ experts agreed to create a Forum of genome yet achieved. Fifteen lab- ment. The sequence was made Genome Research Managers to develop syn- oratories from the European available to the international sci- ergies between European level and Member Union, the United States and entific community through publi- States’ activities and to help network nation- Japan sequenced 115 ‘base pairs’, cation in the Scientific Journal al programmes. Over EUR 100m is expected encoding nearly 26,000 genes – Nature on 14 December 2000. to be available for this initiative in 2001. more than any other genome to be Full details are available on the Quality of Life website: www.cordis.lu/life Conference on genetics and the future of Europe As part of the Commission’s ini- High Level Group that was The European Group on Ethics tiative to stimulate scientists to assigned by European Research communicate with society (politi- Commissioner Philippe Busquin opinion on ‘therapeutic cloning’ cians, industry and social leaders), to advise him on any likely devel- The European Group on Ethics in Science a Conference on Genetics and the opments of life sciences and tech- and New Technologies, a Committee man- Future of Europe was held on 6–7 nologies. dated by the EU to give opinions on ethical November 2000. The aim of the More information about the aspects of scientific developments, issued an Conference was to generate Conference and its outcomes is opinion on human stem cell research on 24 debate on the responsible use and available on website: November 2000. The group considers thera- exploitation of genome informa- http://europa.eu.int/ peutic cloning to be premature. tion in health, food, environment comm/research/quality-of- and society. It was the first event The opinion can be viewed on website: life/genetics.html arranged by the Life Sciences http://europa.eu.int/comm/secretariat_ general/sgc/ethics/en/opinion_15.pdf

Commission stimulates ‘science-society’ debate Commissioner Busquin has introduced a discussion paper entitled Parliament proposes a Science, Society and the Citizen in Europe to European Research committee on genetics Ministers that proposes initiating a wide ranging debate on the role and The Parliament has proposed the establish- place of science in society. The paper raises questions about the relation- ment of a temporary enquiry committee on ship between the public and science, society’s expectations of research human genetics and other new technologies and the responsible use of technological progress. The debate is part of in modern medicine that will examine new the initiative to establish a European Research Area. and potential developments and uses of Further information on the European Research Area is available on web- genetics and examine their ethical, legal and site: http://europa.eu.int/comm/ research/area.html socioeconomic implications.

EUROPEAN ECONOMIC AND SOCIAL COMMITTEE (ESC) OPINIONS

On 29 November the ESC adopted an European Health Forum, the ESC sug- • the role of the EU in promoting a opinion on the new programme of gested that official bodies responsible pharmaceutical policy reflecting Community action in the field of pub- for health services, together with citizens’ needs; regional and local authorities and social lic health proposed by the • the new Social Policy Agenda; Commission. The ESC was concerned stakeholders, be given an adequate say • the programme of Community about the absence in the action pro- and the chance to help frame relevant action to encourage cooperation gramme of formal proposals and schemes. Other recent ESC opinions between Member States to combat resources dealing with Community have been issued on the following: social exclusion. analysis of health issues and their rele- • the proposal to extend certain pro- vance to other policy areas. Rather grammes of Community action in the The full texts of the ESC’s opinions are than the Commission’s proposal of a field of public health; available on website: www.esc.eu.int

39 eurohealth Vol 6 No 5 Winter 2000/2001 News from the European Union

NEWSINBRIEF

Report of the EU-US Commission proposes registry to gramme of Community action on Biotechnology Consultative run ‘.eu’ domain health promotion, information, edu- Forum Available The European Commission has cation and training is available on: The EU-US Biotechnology adopted a proposal to create a reg- http://europa.eu.int/comm/health/ph Consultative Forum presented its istry to run the Internet top level /programmes/health/docs/work2001 report at the EU-US summit of 18 domain ‘.eu’. Enterprise and _en.pdf Information Society Commissioner December 2000. The purpose of the The annual 2001 work programme Erkki Liikanen has stated that whilst Forum was to examine a broad range of Community action on the preven- national extension codes will contin- of issues of concern to the European tion of drug dependence is available ue to exist, the ‘.eu’ top level domain Union and the United States regard- on: will provide European companies ing biotechnology. It has produced a http://europa.eu.int/comm/health/ph with the additional possibility of consensus report on the complex /programmes/drugs/work01_en.pdf and critical issues related to the use identifying themselves as European of biotechnology in food and agri- or pan European companies on the The annual 2001 work programme culture. Internet. of Community action on the preven- The report is available on website: tion of AIDS and certain other com- http://europa.eu.int/comm/dgs/exter Commission adopts exceptional municable diseases is available on: nal_relations/index_en.htm measures to address BSE http://europa.eu.int/comm/health/ph The Commission formally adopted a /programmes/call/aids/work2001_en Commission adopts new range of radical measures in .pdf December to halt the spread of mad Community guidelines on state The annual 2001 work programme cow disease across the EU, such as a aid for environmental protection to combat cancer within the frame- temporary ban on feeding protein The Commission has adopted new work for action in the field of public based meal to all farm animals. guidelines that establish the condi- health is available on: A document on main EU legislation tions under which Member States http://europa.eu.int/comm/health/ph on BSE is available on website: may grant firms aid to promote /programmes/cancer/wrkprog2001_e http://europa.eu.int/comm/food environmental protection. The n.pdf guidelines prevent States from pro- /fs/bse/bse19_en.html viding firms with assistance that For information regarding how to interferes with competition or Commission White paper on participate in the EU's public health undermines the ‘polluter pays’ prin- chemical testing programmes consult: ciple. According to experts, there are http://www.europa.eu.int/comm/hea between 30,000 and 70,000 chemicals lth/ph/programmes/call/how.htm Commission adopts proposal for in use across the EU that have not establishment of a European been subjected to Union level safety NOTICES checks. These are products that have Food Authority been in use since before the Treaty The Collaborative Centre for On 8 November the European of Rome was signed in 1957. The Economics of Infectious Disease Commission adopted a Regulation Environment Commissioner Margot invites you to an International that establishes the fundamental Wallström and Enterprise Conference on the Economics of principles and requirements of food Infectious Disease to be held at the Commissioner Erkki Liikanen are law and sets up a European Food London School of Hygiene & currently drawing up proposals to Authority (EFA). The proposed Tropical Medicine 29 & 30 March update existing rules on the use of Regulation defines the general objec- 2001. For further details please con- chemical products and to overhaul tive of food law as the protection of tact: [email protected] the EU’s chemical policy. human and animal health and the Tel: +44 (0)20 7927 2222 environment and the supply of cor- EU Health programmes: annual * * * rect information to consumers. The work plans If you wish to publish a short Regulation also sets up the EFA. The Commission published the notice of between 20 and 60 words More information regarding food annual draft work plans of a number in the next issue of eurohealth safety can be found at website: of EU health programmes: please contact the editor: http://europa.eu.int/comm/food/fs/i [email protected] ntro/index_en.html The annual 2001 draft work pro-

The ENHPA and HDA can be contacted at the following addresses: European Network of Health Promotion Agencies, 6 Philippe Le Bon, Brussels Tel: 00.322.235.0320 Fax: 00.322.235.0339 Email: [email protected] Health Development Agency for England, Trevelyan House, 30 Great Peter Street, London SW1P 2HW Email: [email protected]

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