The Future for Health everyone has a role to play 001_224 ING Final_LM.indd 1 15/01/15 09:18 Editor PublishEd by Lord Nigel Crisp Calouste Gulbenkian Foundation Av. de Berna 45 A Editing Coordinator 1067-001 Lisbon Cristina Monteiro Portugal Tel. (+351 21 782 3000) Design TVM Designers Email: [email protected] http://www.gulbenkian.pt Printing Gráfica Maiadouro, S.A. ©Calouste Gulbenkian Foundation 2014 For further information on the Print run Future for Health Gulbenkian Platform, 300 copies or to download the original report, please visit: www.gulbenkian.pt Or contact: ISBN 978-989-8380-17-3 Gulbenkian Programme for Innovation in Health LegaL DepoSIt 379 935/14 [email protected] 001_224 ING Final_LM.indd 2 15/01/15 09:18 The Future for Health everyone has a role to play Lord Nigel Crisp (Chair) Donald Berwick Ilona Kickbusch Wouter Bos João Lobo Antunes Pedro Pita Barros Jorge Soares COLLABORATION: 001_224 ING Final_LM.indd 3 15/01/15 09:18 Foreword from the President of the Calouste Gulbenkian Foundation the heaLth of the portugueSe popuLatIoN has made a remarkable progress in the last few decades, a fact that was recognized internationally and is the most positive achievement of our forty-year democratic regime. However we cannot ignore the limitations of our resources and how it affects our options. We are well aware of the need to prioritize our problems and the allocation of our resources. We must decide wisely, with boldness and courage. The progress achieved in the health system is due to enlightened policies but also to scientific advances and technological innovation. However the progress in terms of life expectancy must be supported by discerning judgment, to ensure a fair and lasting commitment. Right from the beginning, the Calouste Gulbenkian Foundation has sought to be part of this evolution, trying to grasp the different signs and adapting its intervention strategy in the Health area to what it believed, and still believes, better embodies a contribution to the quality, accessibility, and equity providing for health care. Thus, what began as a residual and complementary action to public service – mainly supporting the outfitting and technological modernization of health units – has shifted since the late 90s to a more pro-active attitude, looking for answers to new problems and contributing to the identification and dissemination of best practices. The Foundation has also sought to keep up with the significant shift of the intervention paradigm in the Health sector. This requires an approach beyond national boundaries, demanding the intervention of a wide range of actors and partnerships, multidisciplinary analysis and a close partnership between scientific research and clinical practice. We have therefore tried to be a catalyst of wills and synergies, national as well as international, so as to pave the way for changes and for adapting to new realities. 001_224 ING Final_LM.indd 4 15/01/15 09:18 The Project “Health in Portugal: a Challenge for the Future” mobilized an exceptional number of leading national and international personalities to prepare a report on the structure of the health care system. The results, reported in this volume, are the Foundation’s contribution to this challenge. The Board of the Calouste Gulbenkian Foundation welcomes therefore the contribution of all members of the different teams who worked on this report: the Commission, the Advisory Board, the various working groups, the group of young professionals, the support team, and also all the institutions, bodies and leading personalities involved, as well as the suggestions that have reached us in various ways. I want specially to acknowledge the work of Professors João Lobo Antunes, Pedro Pita Barros and last but not least Jorge Soares, director of the Gulbenkian Program Inovar em Saúde. Their absolute dedication and outstanding competence were of great benefit to the work done. A special word of recognition is due to Lord Nigel Crisp, Chairman of the Commission, who generously applied his qualified experience, talent and enthusiasm in the leadership of this project. Finally, the Foundation has made a commitment to start working on the three “Gulbenkian Challenges”, presented by the Project’s Commission. The purpose of this decision is not to engage in a short-term discussion, but rather to build a wide global commitment: the vision for the future of a strengthened and sustainable Health System for the new generations, in which we all have a role to play. Artur Santos Silva 001_224 ING Final_LM.indd 5 15/01/15 09:18 Foreword from the Commission 001_224 ING Final_LM.indd 6 15/01/15 09:18 Dear President and Trustees It has been a privilege and a pleasure to undertake this review on your behalf. We have received a warm welcome and generous help from everyone we have met during this process. This is undoubtedly due to the reputation and standing of the Calouste Gulbenkian Foundation, but it is also because so many people in Portugal are committed to the enduring vision of a high quality health system accessible by everyone in the country. We have set out a simple vision about empowered citizens, an active society and a continual quest for quality and called for a new Compact for Health. This is supported by a new approach to implementation that literally has a role for eve- ryone to play in improving health and well-being and in creating and sustaining the health system into the future. Achieving this will require farsighted and bold leadership which is able to set out the direction of travel, build public and politi- cal support and create a major programme of change. We believe that there is an excellent basis to build on in Portugal and that the country can position itself very well to take advantage of the developments in science and technology that we can all anticipate in the next 25 years. We are delighted that the Foundation will support the three Gulbenkian Challenges we have proposed. Many of our other recommendations can start to be implemented in 2015 and begin to have an impact in 2016. We very much look forward to hearing about progress. We wish to thank the many people who have assisted us and in particular the members of the 4 Working Groups which were so ably chaired by Maria do Céu Machado, José Pereira Miguel, José Carlos Lopes Martins, and Peter Villax. We are especially indebted to the project leader Sérgio Gulbenkian and his team of Lucy Irvine, Francisco Cluny, Francisco Wemans and Inês Mascarenhas; and to the lead Trustees, Isabel Mota and Diogo Lucena. We are also very grateful to Health Cluster Portugal for their support and for technical support from KPMG. Yours sincerely Lord Nigel Crisp (Chair) João Lobo Antunes Pedro Pita Barros Donald Berwick Wouter Bos Ilona Kickbusch Jorge Soares 001_224 ING Final_LM.indd 7 15/01/15 09:18 Contents 001_224 ING Final_LM.indd 8 15/01/15 09:18 Key poINtS 10 ChapterS 1. A new compact for health 14 2. Action by citizens 34 3. Action across society 68 4. The continuous pursuit of improved quality and the application of knowledge and technology 94 5. A person-centred and team-based health system 120 6. New roles and strengthened leadership 144 7. Financial sustainability 156 8. Recommendations 182 9. The Gulbenkian Challenges 188 appendiceS 1. The Commission: purpose, methodology and membership 196 2. “Me and my ideal health system” from Working Group 2’s report 203 3. Whole of Society Alliance for Health from Working Group 1’s report 206 4. Transparency from Working Group 2’s report 210 5. Patient routes for access to information from Working Group 2’s report 215 6. The evolution of the Portuguese health system from Working Group 1’s report 217 7. Previous reviews of health financing 221 001_224 ING Final_LM.indd 9 15/01/15 09:18 Key points the future for health – everyone has a role to play role a has – everyone health the future for 001_224 ING Final_LM.indd 10 15/01/15 09:18 This report calls for a new compact for health where everyone has a role to play – citizens as well as health professionals, teachers and business people as well as munici- palities and national government. Health is influenced by many different factors – from education, the envi- ronment and the economy to the quality of health services and the skills of health professionals. Looking forward 25 years we can expect enormous change as these factors interact in multiple ways to shape the future. This change and complexity means there is a need to learn constantly and adapt as the future unfolds in order to take advantage of new opportunities and avoid new threats and risks. It also means that everyone must contribute to improving health and that every sector of soci- This report offers ety needs policies which help maintain and improve health. Health cannot be left purely to health professionals or politi- a new approach to cians nor can it be treated simply as a business or a govern- improving health. ment service. Everyone has a role to play. This report offers a new approach to improving health. It places the focus firmly on action by citizens and wider society. It aims to reduce the incidence of chronic diseases such as diabetes and the length of time that people suffer from them – both of which are higher in Portugal than in most Western European countries – and it shows how quality improvement methodologies and better access to evidence improve health services and reduce expenditure. The report envisages a transition from today’s hospital-centred and illness based system, where things are done to or for a patient, to a person-centred and health based one where citizens are partners in health promotion and health care.