2050 A Health Odyssey 2050 A HEALTH ODYSSEY - THOUGHT-PROVOKING2050 A HEALTH IDEAS FOR POLICYMAKING
THOUGHT-PROVOKING IDEAS FOR POLICYMAKING
Health First Europe Chaussée de Wavre 214d 1050 Brussels, Belgium Tel: +32 (0)2 62 61 999 Fax:+32 (0)2 62 69 501 www.healthfirsteurope.org Email: [email protected] 2050: A HEALTH ODYSSEY: THOUGHTNEUROLOGY PROVOKING IDEAS FOR POLICY MAKING
Table of Contents
Introductory note ...... Mel Read 2 (Honorary Chair of HFE)
Reflection on the future of healthcare ...... Maria Rauch-Kallat 4 (Austrian Federal Minister of Health and Women)
1. The future of health “sans cordon sanitaire” ...... David Byrne 8 (Former EU Health Commissioner and HFE patron)
2. Dreaming of a European platform ...... Dr. Maria Siebes, Prof. Dr.Jos Spaan, Prof. Dr.Jos Vander Sloten 12 “engineering for health” – a vision for the future of EU healthcare (EAMBES)
3. The future of healthcare is patient-centred ...... Jo Harkness 16 (IAPO)
4. Looking to the future – the added value of eHealth ...... David Lloyd-Williams 20 (EHTEL)
5. Revolutionising patient care – medical technology of the future ...... Dr. Drago Cerchiairi 24 – the potential, the challenges (Eucomed)
6. EU challenges to safeguard quality ...... Paul de Raeve and Annette Kennedy 28 of care and patient safety (EFN)
7. Access to patient health records - considerations for the future ...... Dr. Milan Cabrnoch 32 (MEP)
8. Medical innovations in the EU ...... Prof. Dr. Günter Neubauer and Philip Lewis 36 – investing in health, value for society (IFG)
9. The future of quality patient care, ...... Dr. Vincenzo Costigliola 40 clinical safety and operational efficiency (EMA)
10. Prevention and detection - the future of diagnostics ...... Christine Tarrajat 44 (EDMA)
11. Patient mobility – what does it mean for the future? ...... Dr. Max Ponseillé and Paolo Giordano48 (UEHP)
12. Health is wealth ...... Prof. Dr. Felix Unger 52 - strategic visions for European healthcare at the beginning of the 21st century (EOM)
13. Invest in healthcare workers ...... Bert van Caelenberg 56 = invest in the future of the healthcare sector (EUROFEDOP)
14. Standards of care for Europe’s ageing population: ...... Prof. Dr. Antonio Moroni and Amy Hoang-Kim 60 osteoporosis in Europe (ISFR)
15. Diabetes - about cure, care and prevention ...... Dr. Wim Wientjens 64 (IDF - Europe)
16. Promoting gender equity in European healthcare ...... Peggy Maguire 68 (EIWH)
About Health First Europe ...... 72
2050: A Health Odyssey
INTRODUCTORY NOTE FROM MEL READ
Dear Reader,
What will healthcare delivery look like in 2050? Do we stand on the edge of a new revolution in healthcare treatment? How will we as patients consume healthcare in the modern age? All of these far-reaching questions and many others are addressed in this collection of thought-provoking essays by leaders in the healthcare field. Exploring sensible approaches to the fundamental challenges in healthcare in the 21st Century is the mission of Health First Europe, (HFE).
Health First Europe was established in March 2004 by a group of organisations representing patients, healthcare workers, academics, policy makers and medical industry experts, concerned about the persisting inequalities in access to healthcare in Europe at a time of demographic and technological revolution.
To date, Health First Europe has grown to include 24 member organisations all willing to devote their energy and professional support to furthering the core aims of our platform. In addition, we have 19 supporting Members of the European Parliament from across the political and geographical spectrum, and two Patrons whose support is greatly valued.
HFE has four core beliefs: • There are weaknesses in European healthcare systems; a rethink is required in order to meet current and future health challenges; • Patients and clinicians should have equitable access to modern, innovative and reliable medical technology; • The development of new and flexible modes of healthcare delivery will benefit both patients and healthcare providers; • "Health equals wealth"; health is a productive economic factor in terms of employment, innovation and economic growth.
The aim of this book is to encourage reflection and dialogue on the future of healthcare in Europe and to stimulate the debate on what can be done between now and the year 2050. The articles that you will read in our Health Odyssey provide a fresh perspective on a variety of healthcare issues from a variety of healthcare experts, but do not constitute an official HFE position per se. We hope that the European policy makers, and everyone who reads this book, will be encouraged to think about the direction in which one policy European health policy is going.
I invite you to share you comments, impressions and remarks with Health First Europe and with individual authors on the future of healthcare. You can do so by posting your observations on the articles on the Health First Europe website: www.healthfirsteurope.org
Happy reading!
2050: A Health Odyssey 3 REFLECTION ON THE FUTURE OF HEALTHCARE
Reflection on the future of healthcare
By Maria Rauch-Kallat, Austrian Federal Minister of Health and Women
Austria will assume the EU Presidency In spite of medical prosperity and the which is the main reason for long- for the second time in the first half of possibility to access this, Europeans term disability and invalidity pension. 2006. Particularly for a small country, have to have a new awareness of the All that will lead to an additional drain this task is both a great challenge value of health. ”Prevention is better on finances. and an opportunity to set political than cure“ and therefore a healthy agendas. lifestyle protects against painful Thus, the promotion of good health operations, long-winded treatments must be more important in European Nowadays, we have to face a major or a strong limitation of health quality. health policy. Prevention against demographic change in Europe. A cardiovascular disease is part and declining birthrate can be seen In fact, lifestyles are changing in parcel of most prevention programs alongside increasing life expectancy. our industrialised society and so are of the European Union. The great The population of many countries is disease patterns. Nowadays, a lack efforts made against smoking are shrinking and therefore most national of exercise, poor nutrition and obesity another example of a strong collective economies are confronted with are the most frequent causes for political initiative. problems in financing social and illness. Accordingly, cardiovascular health insurance systems. For diseases rank at the top of mortality. The Austrian Presidency in the first example, in 2001 we registered 1,72 Every third Austrian complains of half of 2006 will focus on several million people who are over 60 years pain in the musculoskeletal system priorities to continue and improve old in Austria and for the year 2041 we are expecting 2,85 million people in this age bracket. The total fertility rate per woman between 2000 and 2004 was only 1,4 in Austria and 1,6 in the European region. In comparison to that, the African region has a total fertility rate of 5,4. The Austrians are getting older – alongside other Europeans.
In close connection with the demo- graphic change in Europe, the expense factor of scientific progress is also an important factor in financing the best possible healthcare. Today, medical science is able to yield top-performance with unlimited access for every Austrian. To secure high-end medicine now and in the future, we have to make arrangements in financing and legislation, but also and especially in people’s ways of life.
4 2050: A Health Odyssey MARIA RAUCH-KALLAT
efforts at European level. Within the forecasting a gender-specific increase are further focus points of the framework of a varied work programme in diabetes cases for Austria. According Austrian EU Presidency. Particularly with important dossiers, two themes to this, the number of female diabetics in the case of cardiovascular disease, stand out as the main focal points in will increase between 2000 and 2025 women have a higher mortality rate the field of health policy: type 2 by 28% and the number of male than men. More gender sensitivity is diabetes and women’s health. The diabetics will even rise by 49%. required here in order to recognise documentation of gender-specific Alongside age, the risk factors for symptoms and to treat them in good epidemiology is essential, but along- diabetes are primarily socio-economic time. Women are not like men, and side Austria, only few states have a factors, lack of exercise, poor nutrition, this fact also has to be taken into “women’s health report” which a high BMI (excess weight) and consideration in medical training and identifies important fields of action smoking. Clinical studies show that treatment. The objective of the for the coming years. preventive health promotion - measures Austrian Presidency is the initiation of Due to the dramatic increase in new such as a change of diet and regular a European women's health report, cases, type 2 diabetes has developed exercise - are the best possible ways which should document the status of into one of the major medical and of avoiding diabetes. all 25 EU Member States in this field. healthpolicy problems of our time. From 5 to 15% of diabetes cases are In order to underline the significance In Austria, 600,000 to 700,000 people type 1 diabetics and predominantly of this illness also at EU level, diabetes currently suffer from osteoporosis, in children and young people. The remaining 80 to 95% is accounted for by type 2 diabetes, and precisely this type of diabetes is moving away from being a disorder found in old age and is increasingly affecting people in the first half of their lives. Seen on a global scale, there is currently still a majority of female diabetes sufferers by around 7%, but the relative growth rate for men in Europe is markedly higher than that of women.
Austria has also not been spared by this epidemic-like increase of new cases. The current Austrian Diabetes Report, which has been drawn up for the first time, shows that there are presently more than 300,000 diabetics receiving medicinal and dietetic treatment, while the number of unreported cases lies between 50 and 60%. In the case of metabolic syndrome, the precursor of type 2 diabetes, the number of cases is will be one of the two main health one of the most serious and costly impossible to estimate. Although topics during the Austrian Presidency chronic illnesses in Europe. The annual diabetes mortality has been falling of the EU in 2006. European-wide costs resulting from continually since 1991 due to improved fractures due to osteoporosis is early detection and treatment methods, Another important issue is women’s estimated to be over EUR30 billion, there has as yet still been no significant health which should thus also gain in and this figure is expected to double reduction in cardiovascular diseases, significance at European level. The in the next ten years. Successful the most common cause of death for four disorders of endometriosis, therapy is based on seven pillars, of diabetics. Similar to the European- osteoporosis, cardiovascular disease which however only three are within wide perspective, the WHO is also in women and smoking/lung cancer the area of responsibility of doctors.
2050: A Health Odyssey 5 REFLECTION ON THE FUTURE OF HEALTHCARE
account with a plan for a package of measures. Rates of depression among women are two to three times higher than those of men; at least one in five women experiences clinically defined depression in her lifetime. As early as 2020, this will be the leading cause of disabilities caused by illness.
Alongside the abatement of diseases and the difficulties in financing medical care, the whole European healthcare sector is on the cusp of a digital revolution. Telemedicine will turn the usual treatments (upside down) and in the first place we will have to learn More than anything else, a conscious found above all in the field of about the handling of these new lifestyle with healthy and calcium-rich prevention and in forms of treatment information- and communications- nutrition and plenty of exercise leads which are specific to women. technologies in the field of medicine. to significant improvements. New ways of treatment and new In 2002, 39.4% of the European worldwide networks of high-end Endometriosis is a largely unexplained population were smokers, and the medicine will be possible in the near illness, which still requires a great tendency is rising, particularly for future. New medical knowledge will deal of research work in the area of women. In Austria, there are now be developed and distributed faster diagnosis and therapy. Between 7 and almost as many female as there are and new databases of genetic research 15% of all sexually mature women (14 male smokers. In 2004, 46.5% of or virology will be accessible to everyone.
Austria now plays a leading role in “ Alongside the abatement of diseases and the implementing e-Health technologies. The so-called e-Card is just the difficulties in financing medical care, the whole beginning and the key to many new possibilities of information technology. European healthcare sector is on the cusp The Austrian electronic health insurance card provides uncomplicated access of a digital revolution.” to the national healthcare system without the previous paper-based healthcare vouchers. This will eliminate million women in the EU) suffer from women and 48.1% of men smoked. the need to issue and process an endometriosis, and half of them 14,000 Austrians die every year as a annual volume of more than 40 million report noticeable pain. result of smoking, which is considered vouchers. The e-card also incorporates to be the most important cause of the European Health Insurance Card Cardiovascular disease has been a lung cancer and heart attacks. and therefore replaces existing paper central theme in women’s health Whereas the number of men suffering forms used for proving health insurance since the beginning of the nineties. from lung cancer in Austria has fallen entitlement when travelling within the These four disorders are the most slightly in recent years, the comparative European Economic Area. common cause of death for women figure for women continues to rise. and claim more lives than all types of The implementation of the e-Card cancer put together. In Austria alone, Alongside physical diseases, various is one of the biggest European IT 21,296 women and 13,653 men died types of depression are becoming projects. By November 2005, a total of cardiovascular disease in ever more significant for women, and of eight million cards will be sent out. 2003. Possible solutions are to be the EU has already taken this into Furthermore 12,000 doctors will be
6 2050: A Health Odyssey MARIANEUROLOGY RAUCH-KALLAT
connected to the computing centre • The strength of solidly financing composed of 25 members, and to network – all of that largely without health insurance; representing it at an international any difficulties. • The groundbreaking developments level. It will be necessary to be extre- of telemedicine and new ways of mely flexible and to drive forward the Using such digital networks makes using information technologies. decision making processes at both inefficient communication between political and legislative levels. As facilities, insufficient quality assurance These factors stand for growth, Austrians and Europeans, we face and defective transparency in cost dynamics and endless potential, and enormous challenges, and I am very accounting a thing of the past. contribute to the collective good and proud – together with my colleagues the health of all people in Europe. We in the Government and all those In the long run, the future prosperity have made ambitious plans for an EU involved – to be able to contribute of European healthcare depends Presidency which is anything but a towards realising the dream of a on three key factors: routine exercise. For six months, united Europe. • The knowledge, high quality and Austria will make a decisive contri- scientific progress of the medical bution towards steering a course fraternity and nursing staff; for a strong European Union now
Maria Rauch-Kallat Austrian Federal Minister of Health and Women
2050: A Health Odyssey 7 THE FUTURE OF HEALTH “SANS CORDON SANITAIRE”
The future of health “sans cordon sanitaire”
By David Byrne
This article considers EU and international approaches to healthcare challenges.
“ Sympathy for INTRODUCTION suitable federal regulations to support sanitaire) proposed that all ships the health laws of the respective bound for Europe be quarantined at the sufferings of 1 Isolation through means of a cordon States . The response of the U.S. Suez, stating that “questions of our fellow- sanitaire represents only a short-term Senate was as follows: international hygiene reach beyond creatures from solution to an immediate threat to the borders established by politics”. disease, and public health. The future of global “ Sympathy for the sufferings of our Quarantine measures are therefore the important public health planning and preparation fellow-creatures from disease, and inevitable to protect public health is sans cordon sanitaire, as global the important interests of the Union, and are envisaged in the International interests of the health cooperation is the true key to demand of the national legislation a Health Regulations as a legitimate Union, demand combating today’s communicable ready cooperation with the State response to the sudden outbreak of of the national and non-communicable diseases. governments in the use of such means disease. legislation a as seem best calculated to prevent 2 ready co- Globalised public health in an the return of this fatal calamity .” Germs, Globalisation and Global interdependent world requires a Health Governance operation with global policy response and a global As early as 1798 then, the U.S. Senate In today’s interconnected world, the State governance framework involving a acknowledged that cooperation was bacteria and viruses travel almost as governments in multiplicity of actors – international the use of such organisations, private and corporate means as seem actors, and civil society. This article “ Globalised public health in an will suggest possible priorities that best calculated governments, international bodies interdependent world requires a global to prevent the and the ordinary citizen should take return of this into consideration in the future fight policy response and a global governance fatal calamity.” against global communicable and - U.S. Senate non-communicable diseases. framework involving a multiplicity of actors.”
1) GLOBAL COMMUNICABLE the key to solving the scourge of fast as e-mail and financial flows. DISEASES communicable diseases. Dangers to public health anywhere can quickly develop into dangers to Plagued by Yellow Fever Of course, there remains an important health everywhere. In the summer of 1798 an epidemic role for cordon sanitaire in the sense of yellow fever swept through New of quarantine, rather than of isolation. The recent transnational spread of York. A cordon sanitaire was erected Indeed, as the plague began to spread SARS was not only a wake-up call; it around the city. The governor of to Europe via Egypt in the 1860’s, was also a challenge to the existing Pennsylvania proclaimed the need to Dr. Adrien Proust (father of the famous legal and regulatory approaches to suspend dealings and communication novelist and a student of Dr. Fauvel global health governance. The more between New York and Philadelphia. who invented the concept of cordon the world economic order globalises, Later that year, U.S. President John
Adams invited the legislature to 1 Message of December 8th, 1798, cited in U.S. Supreme Court, Smith v. Turner, 48 U.S. 283 examine the expediency of establishing (1849). 2 Quoted in U.S. Supreme Court, Smith v. Turner, 48 U.S. 283 (1849).
8 2050: A Health Odyssey DAVIDNEUROLOGY BYRNE
the more we must address globalisation 2) NON-COMMUNICABLE focus of healthcare will move increa- of the rule of law. Ensuring a robust DISEASES singly out of the acute-care hospital, international legal framework to prevent and closer to the patient. It will shift and protect against global public The public health sector is also facing away from intervening in the acute health threats is precisely what the a number of growing and rapidly phase of the disease, and towards World Health Organization (WHO) has changing pressures in the area of early screening, detection and treat- established through the recent combating non-communicable dis- ment, as well as towards preventing revisions of the International Health eases. The challenges include global- the disease in the first place. Regulations (IHR). isation and changes in disease patterns and demography, as well as A Chronic Challenge: Combating The revised regulations were adopted rising public and political expectations Chronic Conditions by all 192 Member States at the on one side, and limited resources Europe increasingly suffers from World Health Assembly in May 2005 and the need for cost containment on lifestyle-related diseases triggered by and are expected to enter into force the other. These challenges must be an unbalanced diet, physical inactivity, on 15th June 2007. The key provisions viewed as opportunities – for improving smoking or alcohol abuse. Because of the revised regulations demand access, quality, and cost-efficiency people are living longer, they have the better surveillance and increased of care. In particular, advances and opportunity for extended exposure to transparency, leading to a more rapid innovations in science and technology risks that promote the development response mechanism – the three offer opportunities for early and of chronic conditions. The tragedy (or fundamental tools in handling the improved medical interventions. indeed the opportunity) is that the international spread of communicable majority of these diseases can be disease. The regulations require the It is essential for public health practi- eliminated through preventative action, WHO to engage with a Member State tioners to be prepared for a wider such as promoting positive health where there is evidence of an outbreak spectrum of diseases and health determinants. of a public health emergency of concerns; a broader age-range of international concern (PHEIC). The WHO may seek verification and offer collaboration where necessary, and “ The focus of healthcare will move increasingly is empowered to make public any refusal to cooperate, thereby alerting out of the acute-care hospital, and closer to the other States to take any relevant protective measures. patient. It will shift away from intervening in the
At a European level, the European acute phase of the disease, and towards early Centre for Disease Prevention and Control coordinates surveillance screening, detection and treatment, as well as activities across the Union to ensure early identification of potential threats towards preventing the disease in the first place.” to public health.
Other global health accords are also patients, from the very young to the Addressing health determinants is an beginning to emerge, such as the very old; and for a more varied demand important focus of the current European Global Fund to Fight AIDS, Tuber- and expectation of healthcare services. Commission Health Programme. culosis and Malaria. This fund is an Treatable chronic diseases, such as Tobacco provides a particularly acute example of cooperation between diabetes, have highlighted how the example. Smoking-related illnesses governments, civil society, the private hospital represents only one element such as lung cancer, cardiovascular sector and afflicted communities to in a wider healthcare delivery system. disease and emphysema represent raise global finance to fight three of The increasingly important team the single largest cause of avoidable the world’s most devastating diseases. concept in healthcare delivery and death in the European Union, research will mean a blurring of accounting for over half a million boundaries between professional deaths each year and over a million 3 and departmental disciplines. The deaths in Europe as a whole . However,
2050: A Health Odyssey 9 THE FUTURE OF HEALTH “SANS CORDON SANITAIRE”
a number of EU Member States have type 2 diabetes and several other his or her own good health through recently introduced smoking bans in chronic diseases. personal choices. public places. The WHO leads the way on a global scale with the 3) PRIORITIES TO ACHIEVE A Of course, choices are based on Framework Convention on Tobacco FUTURE HEALTH “SANS what people know. Citizens need Control, which entered into force in CORDON SANITAIRE” reliable and user-friendly health February 2005. information about how to stay in Global Cooperation good health. When they fall ill, they Similar action also needs to be taken Cooperation on all levels, from require authoritative information in other areas, for example, against governmental to individual, is the about their condition and the various skin cancer arising from ultraviolet main tool in contributing towards the treatment options available. In the radiation (UV). The European Com- reduction of both communicable European Union, the EU Webpage mission proposed a ‘cover up’ policy and non-communicable diseases. label has helped to assure the quality in the summer of 2005 but was Achieving good health for all is a of health information and the new EU ridiculed by the Mayor of Munich as shared responsibility. Health Portal should help to contribute representing “EU law-making at its to a better understanding of EU 4 most pedantic ”. Such a dismissive Promoting Positive Health health policies. At global level, the approach towards UV protection Determinants Health Metrics Network (HMN) of the within the European Union is bewilde- Prevention is better than cure. A WHO represents a global partnership ring considering that between two recent illustration is the US$4 billion of developing countries, multilateral and three million non-melanoma skin committed by the UK, France, Italy, and bilateral agencies and technical cancers and approximately 132,000 Spain and Sweden to support the experts working to establish better malignant melanomas occur globally work of the Global Alliance for health information. 5 each year . Vaccines and Immunisation (GAVI) 8 over the next decade . But good Prioritising Patient Care Diabetes is another example of a health needs to be defined in much We are living through a period of preventable condition. An estimated broader terms than simply the profound change in the way in which 30 million people worldwide suffered prevention of illness. It includes health services are organised, delivered and experienced. Industrial and technological innovations have “ Good health needs to be defined in much broader both raised healthcare expectations and broadened the scope and nature terms than simply the prevention of illness” of healthcare supply.
from diabetes in 1985. A decade later, ensuring a protective environment The introduction of new technologies 6 the figure stood at 135 million . The (with relevant legislation and services) represents a radical catalyst for fight against diabetes has been and a health promotive mindset, change, with important implications chosen as a priority topic by the empowering individuals and families for healthcare cost, quality and access. Austrian EU Presidency. to make decisions in their best health The e-Health Action Plan adopted by interests. However, while policymakers the European Commission in 2004 Obesity is another global epidemic, can help raise awareness, create shows how these new technologies and is usually associated with poor health-enabling conditions and provide can be used to extend better quality nutrition and a sedentary lifestyle. good healthcare, each and every citizen healthcare Europe-wide, allowing Recent figures from the WHO estimate has an important role to play in shaping healthcare to become increasingly that there will be 1.5 billion people 7 overweight worldwide by 2015 . An 3 http://europa.eu.int/comm/health/ph_determinants/life_style/Tobacco/tobacco_en.htm EU Platform on Nutrition has recently 4 http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/08/03/wdirndl03.xml&sSheet= been created to encourage stake- /news/2005/08/03/ixworld.html holders to take concrete actions to 5 http://www.who.int/mediacentre/factsheets/fs261/en/print.html promote healthy eating, as a raised 6 http://www.who.int/mediacentre/factsheets/fs236/en/index.html body mass index is a major contri- 7 http://www.who.int/mediacentre/news/releases/2005/pr44/en/index.html butory factor in heart disease, stroke, 8 www.vaccinealliance.org
10 2050: A Health Odyssey DAVIDNEUROLOGY BYRNE
decentralised and more citizen- oriented. We are also witnessing a revolution in medical diagnostics, “ There is an increasing awareness among shaping a new age of healthcare in which disease is detected earlier, policymakers concerning the economic and diagnosed more precisely and treated less invasively. social costs which result from an unhealthy
Of course, public demand – supported society, and that longer, healthier, more by the media – will always orientate towards the latest treatment, which is productive lives deliver concrete not necessarily the best one. New health technologies and drugs must economic benefits.” always be properly assessed for their efficacy, security and efficiency. new structural indicator for the Lisbon Strategy. In addition, a report on ‘The The European High Level Group on Contribution of Health to the Economy Health Systems and Medical Care is in the European Union’ has recently a Community body dedicated to been published by the DG of Health developing European cooperation in and Consumer Protection, showing the area of health services and medical that good health is good news for care. On a global scale, the WHO has competitiveness and growth. established a World Alliance for Patient Safety. Conclusion The future of global public health is a Proactive Health at the Centre of future not characterised by isolation, the Policy Agenda but by global cooperation, global There is an increasing awareness governance and global partnership. among policymakers concerning the The benefits of this cooperation in economic and social costs which the future will lead to an overall more result from an unhealthy society, and healthy society, characterised by that longer, healthier, more productive enhanced economic output and lives deliver concrete economic reduced strain on public healthcare benefits. systems. The perception of society will develop into to a more cooperative, Within the EU, the debate about integrative, prioritised and proactive health and economic development is view of public health. currently being shaped by discussions surrounding the Lisbon Agenda on growth and competitiveness. Since the 2005 Spring European Council, ‘Healthy Life Years’ has become a
About the Author
David Byrne is a former EU Commissioner for Public Health and Consumer Protection (1999-2004), and a former Special Envoy to the WHO on the revision of the International Health Regulations (2004-5). He is senior counsel in the Brussels office of Wilmer Cutler Pickering Hale and Dorr LLP advising on European and international law. In summer 2005, he became a Health First Europe patron.
2050: A Health Odyssey 11 DREAMING OF A EUROPEAN PLATFORM “ENGINEERING FOR HEALTH”
Dreaming of a European Platform “engineering for health” - a vision for the future of EU healthcare
By Dr. Maria Siebes, Prof. Dr. Jos Spaan, Prof. Dr.Jos Vander Sloten
This article considers the importance and place of biomedical engineering (Engineering for Health) in healthcare now and in the future.
THE IMPORTANCE OF DREAMS represent, who dream of better possible by biomedical engineering understanding the engineering of activities. Biomedical engineering (or Developments in healthcare are the living systems, and have provocative “Engineering for Health”) is one of the result of the integrated action of ideas for better diagnosis and treat- fastest growing fields of technology many players. Doctors, nurses and ment and for new modalities of and it is coarsely defined as the use paramedics are at the forefront of delivering healthcare, will benefit of principles and techniques of delivering healthcare to the patient. The from a rethink of European healthcare engineering to solve problems in medical device and pharmaceutical policies. This rethink should include biology and medicine. It encompasses industries are in the middle, providing the strategy of providing the means the advancement of fundamental the means to deliver. Research is at to realise those dreams and ambitions concepts in engineering, biology and the foundation for creating new to the benefit of better health and medicine to develop innovative possibilities; it is the cradle of inno- quality of life, and better healthcare approaches and new devices, materials, vation. Research, however, is based delivery. implants, algorithms, processes and on dreams of individuals and dreams systems for: are hard to sell. It is easier to explain Interactions between engineering • prevention, diagnosis, and treatment how something already present can and medicine to improve human health of disease; be improved or how something can be traced back for centuries. • patient care and rehabilitation; already known is lacking in a particular Resulting achievements in medical • assessment and evaluation of technology; • improving medical practice and “ Without the dreams of individual scientists and healthcare delivery.
engineers, it would be difficult to move beyond the Individuals able and with opportunity to convert their dreams into well- horizons that are currently visible.” defined principles remain at the base of technological innovation. Modern circumstance. But without the dreams technology range from early devices healthcare would be unthinkable of individual scientists and engineers, such as crutches, platform shoes, without the numerous engineering it would be difficult to move beyond wooden teeth and limb prostheses, achievements that are based on 1 the horizons that are currently visible. to more modern marvels including these dreams . European Alliance for Medical and pacemakers, the heart-lung machine,
Biological Engineering and Science dialysis machines, diagnostic equip- THE FACTS: SOCIO-ECONOMIC IMPACT (EAMBES) supports Health First ment and imaging technologies of Europe in the quest for equal access every kind, and artificial organs, The EU currently holds the highest to improved care for all in Europe and implants and advanced prosthetics. ‘human development index’ worldwide. stresses that engineering and research In the past 50 years, most quantum This index combines three basic are essential to providing this. We leaps in medicine have been due to indicators of human well-being: leading hope that the many scientists that we technological advancements made a long life in good health, being well-
12 2050: A Health Odyssey DR. MARIA SIEBES, PROF. DR. NEUROLOGYJOS SPAAN, PROF. DR. JOS VANDER SLOTEN
educated, and having access to the for Health’ creates greater efficiency aspects of telecare and independent resources necessary to enjoy a decent and savings in the health system. living devices in healthcare. ‘Engine- standard of living. On the other hand, Already, the use of diagnostic and ering for Health’ also plays a significant Europe has the fastest growing therapeutic modalities of medical role in healthcare technology ass- percentage of elderly in the world. technology brings about improved essment, thereby supporting the The proportion of elderly (≥ 65) in patient outcomes. Enormous benefits implementation of innovative tech- Europe’s population will have doubled have been achieved with respect to nology in the interests of European to reach 28% in 2050, with, for the quality of life and quicker return to citizens. These are vital elements first time, more elderly than young (0- health across a range of chronic with a huge potential for positive 15) people in the EU by 2010, reaching conditions. In cardiac care, prominent economic and employment benefits 40% in some Member States by examples include the use of coronary in an economy facing a predominant 2 2020 . Healthcare expenditures are artery stents, implantable defibrillators demographic shift towards an ageing projected to increase by 1% to 3% of and pacemakers, and intelligent society. GDP over the period 2010-2050. ambulatory heart monitoring systems.
Advances in orthopaedics, minimally THE VISION: ROLE OF ENGINEERING In Europe’s aspiration (the Lisbon invasive surgery, and biomaterials have FOR HEALTH IN THE FUTURE OF EU Agenda) to become the most com- resulted in safer operations, faster HEALTHCARE petitive, knowledge-based economy recoveries and improved end results. in the world by 2010, the continuity of These and other advancements have “Long-range planning does not deal healthcare represents a major chal- significantly reduced mortality rates, with future decisions, but with the lenge for the EU, given the rise of an improved patient quality of life and future of present decisions.” (Peter ageing population and considering freed up healthcare resources by F. Drucker, management consultant) the growing imbalance between the reducing both frequency and length The objective for the future must be EU, and Japan and the US in this of hospitalisations. to contribute to Europe’s exploitation sector. Given the importance of the of the unprecedented opportunities health and well-being of European Although an overall cost-effectiveness for generating new knowledge and to citizens especially in the enlarged EU analysis is hampered due to a lack of translate it into applications that of 25 countries and the wealth gene- harmonisation and coordination in enhance human health. Both funda- ration potential of the medical device the use of evidence-based medicine mental and applied research, with an and pharmaceuticals industry in Eur- and health technology assessment of emphasis on integrated, multidisci- ope, basic research, innovation and Member States and the lack of a plinary, and coordinated efforts will development in biomedical engineering coherent European Database on help to increase the competitiveness and technology are of increasing Medical Devices (EUDAMED), studies of the European healthcare system. socio-economic importance in today’s on specific healthcare areas have The European “eHealth Action Plan” knowledge-based EU society. concluded that enormous net cost aims at delivering better quality 3,4 savings can be achieved . Areas healthcare for European citizens 5 The health sector is driven by scien- where engineering for health R&D while reducing costs , with one of its tific and technological progress, and contributes significantly to enhanced major targets to create a borderless health is a productive economic factor competitiveness in research and European health information space in terms of employment, innovation, innovation include tissue and (by the end of the decade). Engineering and sustainable development and organ engineering, biological and for Health is intimately engaged in growth. The past decades have seen physiological systems analysis, developing the required technological tremendous improvements in the computer-integrated surgery systems, backbone for this ambitious know- provision of healthcare and as a human-environmental interfaces, ledge-based approach to healthcare. result, people are living longer and diagnostic technologies, and all healthier lives. This success is based
on a combination of factors: better 1 AIMBE 2005 Hall of Fame, American Institute for Medical and Biological Engineering, informed patients, skilled clinicians, http://www.aimbe.org scientific discoveries, and techno- 2 Third European Report on Science and Technology Indicators 2003 “Towards a Knowledge- based Economy.” European Commission DG for Research, EUR 20025 EN logical innovation. Through moder- 3 Making the economic case for medical technology, The Medical Technology Group, UK, 2003 nising modalities for prevention, 4 The value of investment in health care: Better care, better lives, Advanced Medical Technology diagnosis and treatments, ‘Engineering Association (AdvaMed), USA, 2004
2050: A Health Odyssey 13 DREAMING OF A EUROPEAN PLATFORM “ENGINEERING FOR HEALTH”
Technological advancements realised 20 to 30%. This staggering number and ultimately arrive at balanced, but through ‘Engineering for Health’ of imprevented incidents highlights flexible long-range planning and priority research and innovation will positively the need for novel strategies to settings. This important task will be and widely affect the quality of life of further improve cardiovascular out- facilitated by the establishment of a EU citizens not only in relation to comes. For example, how sure are ‘European Institute of Health’ and disease, but will extend to tangible we that the forward leap is coming within it, an ‘Institute for Medical and outcomes regarding the efficacy, from the strategies put forward in a Biological Engineering Research’, as safety, ergonomics and comfort in all project submitted under predefined agencies that foster continued aspects of empowering, re-enabling, categories such as ‘Cardiovascular advancement in medical and biological or assisting the human body in normal disease’, ‘Nanotechnology’ or ‘E- engineering. activities (i.e. children, disabled, and Health’? Obviously, these are important
elderly) as well as in exceptional targets for research but it may very WHAT DOES THE FUTURE HOLD 50 activities (i.e. work, sports, security, well be that the real discovery comes YEARS FROM NOW? and the exploration of hostile from a proposal not recognised by the environments). mechanisms put into place to pro- Predicting what the future will bring in mote these specific areas. The solu- this rapidly evolving field is rather At the basis of technological progress tion may follow the example of the difficult. Individual achievements of is fundamental research uninhibited discovery of penicillin, which was a biomedical engineering have changed by priority directives. We strongly feel mere accident, or that of the heart- with the continued development of that Europe needs a platform, ‘Engi- lung machine that was developed to the field. Cardiovascular research was neering for Health’, that is not frag- perform fundamental studies on car- initially based on mechanical aspects mented into particular categories of diac function in an isolated heart involved, e.g., in the development of science, technology or disease, but preparation but later saved so many an artificial mechanical heart and is provides an opportunity where a pro- lives because it made open heart now focusing on studying the mech- posed project is primarily judged for surgery possible. anics and molecular dynamics of its possible contribution to the im- signal transduction in blood vessel provement of health or quality of life. Of course, there needs to be a walls. New discoveries and important Better representation and recognition balance between dreams and reality. new applications for medicine based of this field is so vital for European To advance medical technology, we on ‘Engineering for Health’ have healthcare as dreams are so difficult must have the inspiration and creativity increased exponentially6. to categorise. Consider, for example, of individual scientists while barriers to Substantial steps ahead, particularly in areas such as regenerative medicine, “ The objective for the future must be to contribute nanomedicine, minimally invasive sen- sors and surgical technologies, tissue to Europe’s exploitation of the unprecedented engineering, medical imaging, and telemedicine will revolutionise dia- opportunities for generating new knowledge and gnosis, treatment and rehabilitation; engineered tissues will challenge to translate it into applications that enhance inanimate organ replacement. Natural organs may be regrown after injury or human health.” disease. Molecular nanotechnology may provide microscopic means for targeted delivery of personalised cardiovascular disease, which is the interdisciplinary engineering innovations medications. An all-inclusive lifelong major cause of mortality worldwide. that have the potential to enhance health record may be readily Despite major efforts to reduce car- quality of life need to be reduced. But accessible, on a tiny chip implanted diovascular morbidity and mortality, we must also consider critical needs under the patient’s skin. Gene currently available strategies aimed at lowering individual risk factors have 5 e-Health - making healthcare better for European citizens: An action plan for a European e- Health Area, COM (2004) 356 final only succeeded in reducing the car- 6 Nebeker F. Golden accomplishments in biomedical engineering. IEEE Eng Med Biol Mag. diovascular event rate by a modest 21(3):17-47, 2002
14 2050: A Health Odyssey DR. MARIA SIEBES, PROF. DR. NEUROLOGYJOS SPAAN, PROF. DR. JOS VANDER SLOTEN
transfer may alleviate or correct Europe realise its goal to become a problems resulting from genetic genuinely competitive, knowledge- defects. Treatment at a distance, based economy. Through its activities monitoring and healthcare provision and opportunities, ‘Engineering for at home may become common. Health’ represents a major thrust in policy-oriented research and deve- Public perception and acceptance by lopment and provides European medical professionals are important added-value in important areas Electron microscopic image of a myocardial aspects in the success of these identified as key EU policy targets. capillary in the left ventricle of a rat (Alcian “It will never technological advancements7, and blue 8GX stain). Vascular endothelial cells are shielded from direct exposure to flowing blood come into gen- continued efforts are necessary to by a highly hydrated mesh of membrane- educate public policymakers, the associated sugar like molecules, the glycocalyx. eral use and It was recently hypothesized that this layer media and the general public about forms the first line of defence against vascular its value is the valuable role of medical and disease (see: Circulation. 2000;101:1500-2, Circ Res. 2003;92:592-594, and Curr Opin extremely biological engineering in these en- Lipidol. 2005 Oct;16(5):507-11) doubtful, deavours. For the sceptics, when it comes to the importance of scientific because its revolutions, let us cite a quotation beneficial from an 1834 editorial in The Times application (London) about the introduction of requires much the stethoscope: “It will never come time and gives into general use and its value is extremely doubtful, because its a good bit of beneficial application requires much trouble to both Guide wire equipped with miniaturized sensors time and gives a good bit of trouble to at the tip (arrow) to measure blood pressure the patient both the patient and practitioner and and flow velocity in diseased coronary arteries of patients (Volcano Therapeutics, CA). The and practi- because its human character are wire tip has a diameter of 0.3 mm. These novel foreign and opposed to all our habits tools are used in interventional cardiology to tioner and assess the severity of coronary artery disease and associations.” in the catheterization laboratory and to evaluate because its the outcome of treatment with balloon angioplasty and stent placement. (see: human char- ‘Engineering for Health’ has evolved Circulation 2004;109:756-62, Circulation 2005;111:76-82) acter are for- into a key area supporting the long- eign and term strategic objectives of the EU. The European Commission has opposed to all recently put forward the concept of a our habits and “knowledge triangle” of research, associations.” 7 education and innovation to help Medical and Biological Engineering in the Future of Health Care. Ed. J. D. Andrade, University of Utah Press, Salt Lake City, Utah, 1994 - The Times
About the Authors
Maria Siebes is University Docent, Dept. of Medical Physics, Academic Medical Center, University of Amsterdam, The Netherlands, and Council Member (Academic Division) of EAMBES Jos A. E. Spaan is Professor and Chair, Dept. of Medical Physics, Academic Medical Center, University of Amsterdam, The Netherlands, and President of EAMBES in 2005 Jos Vander Sloten is Professor and Chair, Division of Biomechanics and Engineering Design, Katholieke Universiteit Leuven, Belgium, and President of EAMBES in 2006 EAMBES: http://www.eambes.org/
2050: A Health Odyssey 15 THE FUTURE OF HEALTHCARE IS PATIENT-CENTRED
The future of healthcare is patient-centred
By Jo Harkness
This article considers patient-centred healthcare and why is it so important.
‘A collaborative We live in a time when chronic health outcomes, quality of life and Chairman, Irish Patients Association effort consisting conditions account for over half of cost-efficiency. asserts, “the patient is the key person the global disease burden (WHO, in healthcare and... their needs and of patients, 2004), placing an ever-increasing WHAT IS PATIENT-CENTRED HEALTHCARE? preferences are at the centre of all patients’ burden on health systems originally aspects of healthcare”. This focus families, designed to address acute medical So, what is patient-centred healthcare? should not detract from equality in all friends, the conditions. In order to cope with this, Patient-centred healthcare is a term relationships in healthcare. health systems need to develop so doctors and that is now commonly used but rarely that they are able to address the defined by those using it. As Stewart Interestingly, there is no universally other health ongoing needs of these people. (2001) states, it is often understood accepted definition of patient-centred professionals… by what it is not: ‘technology centred, healthcare but there are a number of achieved This requires a new approach because doctor centred, hospital centred, academic and patient driven definitions through a chronic conditions, such as diabetes, disease centred’. which include: heart disease, asthma and cancer, comprehensive require management on an ongoing The traditional biomedical mana- ‘A collaborative effort consisting of system of basis, often for many years or gement model of healthcare involved patients, patients’ families, friends, patient decades. Health systems therefore ‘paternalistic’ treatment where the the doctors and other health profes- education require the personal involvement and health professional decided the ap- sionals…achieved through a compre- where patients hensive system of patient education where patients and healthcare pro- and healthcare “ The patient is the key person in healthcare fessionals collaborate as a team, professionals share knowledge and work toward collaborate as and their needs and preferences... are at the common goals of optimum heal- a team, share ing and recovery.’ (Grin, 1994). knowledge and the centre of all aspects of healthcare.” ‘Healthcare that is closely congruent work toward with and responsive to patients’ wants, the common commitment of individual patients to propriate course of treatment, often needs, and preferences.’ (Laine & goals of adhere to their treatment and make without significant patient invol- Davidoff, 1996). optimum behavioural changes, if they are to vement in the decision. This situation healing and effectively manage their healthcare. has been changing as, over the years, ‘Patient-centred care is quality health- Aspects of a patient-centred approach many people have become more care achieved through a partnership recovery.’ can be seen in the increase in self- interested in health issues and in between informed and respected (Grin, 1994). management and patient education taking more responsibility for their patients and their families, and a co- initiatives, resulting in a move to more personal healthcare. The significance ordinated healthcare team.’ (National collaborative care. The benefits of of patient-centred healthcare is that it Health Council, 2004). this ‘patient-centred’ approach are moves the healthcare focus from the that they promote greater patient disease to the patient. It can, there- (see IAPO, 2005 for further definitions responsibility and optimal usage fore, be a useful concept to ensure and principles) which ultimately leads to improved that we remember that as Stephen McMahon, IAPO Board Member and
16 2050: A Health Odyssey JONEUROLOGY HARKNESS
Perhaps the essence of patient- which will have an impact on patients’ essential to encourage patients to centred healthcare is that the health- lives. adhere to their treatments (WHO, 2003). care system is designed and delivered to address the needs and preferences BENEFITS OF PATIENT-CENTRED The studies also show that patients of patients. The optimal outcome of HEALTHCARE often want a patient-centred approach. healthcare is a better quality of health There are, of course, times when and/or of life for the patient (as defined There is growing evidence that desi- patients don’t want to actively parti- by the patient). gning health systems with the patient cipate in their healthcare and a balance at the centre is an appropriate and needs to be reached between encou- PRINCIPLES OF PATIENT-CENTRED cost-effective way to address the raging engagement in care and HEALTHCARE needs of people with chronic condi- respecting personal preferences. The tions. A number of research studies results are encouraging but there is Extrapolating from the definitions, key have concluded that there is a still much research to be done to principles of patient-centred healthcare positive link between the practice of develop a significant evidence base can be identified which resonate with patient-centred healthcare in clinical with comparisons and conclusions patients around the world, regardless settings and outcomes (including complicated by the different metho- of the healthcare system, resources Bauman et al (2003), Little et al (2001), dologies and varying definitions of ‘Healthcare patient-centred healthcare often used. available or culture: Stewart et al (1995) and Henbest et al that is closely • Respect and support for the indivi- (1992)). Collectively, these studies congruent with dual patient, their wants, preferences, indicate that the patient-centred DEFINING HEALTHCARE values, needs and rights. approach can lead to a variety of COSTS AND BENEFITS and responsive • Access to the healthcare services positive outcomes including patient to patients’ warranted by their condition. This satisfaction, emotional health, sym- There is a need for more research to wants, needs, includes access to appropriate, ptom resolution, function, physiologic assess the impacts of patient-centred and prefer- quality and safe treatment with the measures (i.e. blood pressure and healthcare and more generally to ences.’ (Laine ability to make an informed choice. blood sugar level), pain control, provide a clearer overall picture of the • Information that is appropriate, engagement and task orientation, costs and benefits of a healthy nation & Davidoff, relevant and timely and information reduction in anxiety, quality of life, by measuring social and economic 1996). exchange between patients and doctor satisfaction and an increase in outcomes in addition to health out- others involved in healthcare to efficiency resulting in fewer diagnostic comes. Health status is important ‘Patient- enable patients to make informed tests and unnecessary referrals. and can be assessed through meas- centred care is decisions and take effective action urement of physiological measures to improve or manage their health. Systematic reviews of self-manage- such as blood pressure and clinical quality health- Information should be presented in ment programmes have shown that assessments such as wound healing. care achieved a format appropriate to the needs self-management training has benefits Healthcare behaviour relating to a through a of individual patients, according to for patients. In addition to improved patient’s behaviour and attitude to their partnership health literacy principles considering health outcomes and quality of life, treatment should also be assessed. their condition, language, age, under- these approaches can reduce hospital This is because changes in behaviour between standing, abilities, and culture. attendances and admission, and time such as adherence to therapies and informed and • Empowerment/motivation of pa- off work or school (e.g. Gibson, 2000, self-management of conditions through respected tients to take responsibility for their Wolpert, 2001) leading to significant diet, lifestyle and/or therapies directly patients and healthcare and be as independent healthcare savings and overall national impacts on other outcomes such as their families, as possible and for patients’ orga- economic productiveness. A major health status and well-being. nisations to be recognised, involved concern in healthcare surrounds the and a coordi- and encouraged to take leadership consistently low levels of patient It is accepted that health is not just nated health- roles. adherence to treatment which can be about the treatment of a condition care team.’ • Involvement of patients in health- less than 50% in some instances. but about social, physical and mental (National care at their level of choice and the Once again, elements of a patient- well-being. But social outcomes are Health involvement of patients and patient centred approach such as effective not always considered and patient- representatives in a meaningful way communication, patient-tailored inter- centred healthcare aims to bring the Council, in all decision making processes ventions, patient support and a holistic focus away from the disease and back 2004). approach have been shown to be to the person. It recognises that a
2050: A Health Odyssey 17 THE FUTURE OF HEALTHCARE IS PATIENT-CENTRED
person’s quality of life does not solely ill-health is more cost-effective than The EU is in a good position to play a depend on the impact of their disease treating ill-health. key role in changing the culture of on their health but also encompasses healthcare towards patient-centred- ness, so that patients can access treatments that are right for them. “ Health is not just about the treatment of The EU is well-placed to facilitate the exchange of good practice, dissemi- a condition but about social, physical and nate information, promote collaboration activities and research and encourage mental well-being.” European countries to value healthcare and recognise the link between good health and economic gain. how the disease impacts on their Accurate representations of the eco-
participation in society, and their nomic, social and health costs and TOWARDS A PATIENT-CENTRED FUTURE physical and mental well-being. benefits of treatments will help us to Assessments of quality of life can determine the most effective and Designing healthcare systems around only be made by the patient and appropriate treatment. In the case of patients, addressing their needs such therefore patients must have the medical technologies, the economic as providing access to appropriate information and decision-making benefits are beginning to be calculated treatment, relevant information and skills to have a choice – to be able to determine what would be appropriate treatments and successful outcomes “ Designing healthcare systems around to treatment for them. Patient satis- faction with healthcare as determined patients will empower people to take by patients, their families and/or carers can indicate their satisfaction with responsibility for managing their health, care which will have an impact on their health behaviour and overall leading to better patient outcomes, health quality of life. outcomes and economic outcomes which In measuring economic implications, there must be full consideration of the will help to relieve the major burden on cost of treatment but also comparisons of the cost of not treating a patient, or of using a different treatment and of health services.” the implications of treatment such as incidence of hospital readmission and (Medical Technology Group, 2004) support, will empower people to take repeat operations. By including these and patients in the EU are finding a responsibility for managing their health, aspects, we will have a better im- voice to talk about the health and leading to better patient outcomes, pression of the overall cost of these social benefits for them. Benefits of health outcomes and economic treatments. In addition to the cost of medical technologies as stated by outcomes which will help to relieve healthcare, the cost to national econo- patients themselves are that they can the major burden on health services. mies of ill health and the benefits of a improve health and quality of life as healthier population are not always they are increasingly less invasive and There are many different starting fully considered when national gover- easy to use, helping people to manage points for patient-centred healthcare nments consider their spending on their conditions and lead longer, more and patient involvement depending health. There are many obvious benefits independent and healthier lives. These on national wealth, culture and of a healthier nation, for example, positive patient benefits are reflected attitudes. What is important is that more people will be at work, resulting in cost-efficiencies with reductions in throughout the EU and the world, in less sick pay and an increase in hospital readmissions and in increased people understand about patient- national productivity improving the national productivity. centred healthcare and patients economy and secondly, preventing and patients’ organisations work in
18 2050: A Health Odyssey JONEUROLOGY HARKNESS
partnership with healthcare profes- REFERENCES http://www.mrc.ac.za/policybriefs/1 sionals, providers and policy makers, polbrief2002.htm helping to shape their health systems Bauman A E, Fardy H J, Harris P G for the future. (2003), Getting it right: why bother Little P, Everitt H, Williamson I, et al with patient-centred care?. Medical (2001), Observational study of effect Journal of Australia, 179 (5), 253-256. of patient centredness and positive Available online at: approach on outcomes of general http://www.mja.com.au practice consultations, British Medical Journal, 323: 908-911. Henbest R and Fehrsen G (1992), Patient-centredness: is it applicable Medical Technology Group (2004), outside the west? Its measure and Making the Economic Case for effect on outcomes. Family Practice. Medical Technology. Available at: Sep 9 (3) 311-7. http://www.mtg.org.uk
International Alliance of Patients’ Stewart M (2001), ‘Towards a global Organizations (IAPO), 2005, Policy definition of patient centred care: The Statement on Patient Involvement in patient should be the judge of patient Health Policy. Available online at: centred care’, British Medical Journal, http://www.patientsorganizations.org/ 322: 444-445. involvement World Health Organization (2002), International Alliance of Patients’ Innovative Care for Chronic Conditions: Organizations (IAPO), 2005, Guidelines Building Blocks for Action. Available for Patient Involvement in Health Policy. online at: Available online at: http://www.who.int/chronic_condi- http://www.patientsorganizations.org/ tions/icccreport/en involvement World Health Organization (2003), International Alliance of Patients' Adherence to Long-Term Therapies: Organizations (IAPO), 2005, What is Evidence for Action. Available online at: Patient-Centred Healthcare?: A Review http://www.who.int/chronic_conditions/ of Definitions and Principles. For further information: http://www.patients- World Health Organization (2004), organizations.org/manifesto World Health Report 2004, Changing history. Geneva, World Health Orga- Lewin SA, Skea ZC, Entwistle V, nization, 2004. Zwarenstein M, Dick J (2002) Inter- ventions for providers to promote a patient-centred approach in clinical consultations (Cochrane Review). In: The Cochrane Library, Issue 1. Oxford: Update Software. Available at:
About the Author
Jo Harkness is Policy and External Affairs Director at International Alliance of Patients’ Organizations IAPO: http://www.patientsorganizations.org
2050: A Health Odyssey 19 LOOKING TO THE FUTURE - THE ADDED VALUE OF EHEALTH
Looking to the future - the added value of eHealth
By David Lloyd-Williams
This article considers the role of eHealth in the future of healthcare.
INTRODUCTION citizen through to the European Social rapidly. The aim here is to consider Model. views of the future which can form eHealth refers to the use of modern inputs to the baseline thinking for information and communication tech- There are three broad streams: policymakers at all levels. nologies (ICT) to meet the needs of • patient and professional mobility;
citizens, patients, healthcare profes- • citizen-centred health systems; SCENARIO ONE – CURRENT sionals, healthcare providers as well • improved quality and efficiency of CONCEPTUAL THINKING TO 2010 as policymakers. It is a shorthand label healthcare availability. for the wide range of uses to which There are two main strands: information technologies are put in This implies change, improvement Costs: governments have to find ways the healthcare setting, encompassing and transformation of current and to contain the remorseless rise in the health-related labels such as Health traditional processes of delivery, taking cost of providing care in the developed Informatics, Health Telematics, Tele- advantage of advances in medicine, world; governments in the developed medicine and Telehealth. eHealth is drugs and treatments, logistics, world have to find affordable ways to not a set of products, tools or appli- research and information technology. provide a reasonable level of care. cations but a range of responses to a This makes the isolation of added value Viability: most governments face the set of requirements in the context of much more than just cost savings huge challenge of existing healthcare improving and transforming health- since these changes are often not a processes and models which over care services. matter of choice but an imperative. the next decade will be unable to cope The effect and value will be reflected with increasing demographic change, The traditional measure of value in in areas of healthcare other than the current demand crises and growth in health for ICT has been cost reduction original process location. expectations. and cost savings; in the current context of a seemingly inevitable rise Looking to the future in health is an Two main focus points emerge: in demand and GDP percentage for inexact science; change takes a long healthcare, this remains a strong time to percolate through to wide- factor for policymakers. However, as spread delivery. The approach is to A) NO CHOICE eHealth has matured, it has become consider three timeframes: clear that this is only one side to the • current conceptual change looking Some of the main process areas added value proposition. at realisation and deployment; under active consideration include • transformation that is necessary or those where there is no option other The three key criteria of the EC Action clearly desirable based on current than radical change: Plan are Access, Quality of Care and thinking (including radical and inno- Cost Containment and these, along vative ideas); • care for chronic conditions; with the overriding need for increased • informed speculation (including • disease management; equity, are the starting points for new global and macro-social and eco- • integration of care including social ways of looking at added value for all nomic thinking). care; levels of healthcare policy from the The time frames used are arbitrary - • surveillance and public health across 2010; 2030, 2050 and precision declines Europe;
20 2050: A Health Odyssey DAVID NEUROLOGYLLOYD-WILLIAMS
• adaptation to demographic changes B) INVESTMENT and electronic health records remains and increasing demands; a serious challenge. • patient safety (including medication This scenario derives from a series of errors); underlying facilities that are funda- The most fundamental challenge is • patient empowerment and mental to achieving the three key the incremental process of imple- involvement; criteria where there is a second and menting electronic record systems at • knowledge support for clinical often more levels of value to be local levels which can form the basis professionals and for other health derived: for a longitudinal electronic health and social care professionals, carers, record. Technology is not the limiting patients, citizens and others; For equity of access, it must be factor – most of what is needed • good practice care profile norms. possible to share information which exists already in some (often imp- is secure, understandable, and avai- erfect) form; what is missing can be As an example, at a recent conference lable to everyone who is entitled to generated by industry in what is one the diabetes scenario in France was see it, irrespective of their location, of the largest global markets. The described: There are 3 million diabetic educational capabilities or socio- mobile phone, the clockwork laptop sufferers in France (of whom 500,000 economic situation. are today’s exemplars and others will are severe cases). Using conservative emerge. practice guidelines this generates the This requires secure access infra- need for 5.5 million clinical hours per structure, common terminology, Added value for eHealth has to be year. There are 1 million hours resource and multi-lingual capability at each based on requirements to change, available and the prognosis is that the level. eHealth has a major added improve and transform health proces- number of diabetics will double within value contribution; the value is ses to provide better or new services ten years. The current process model additive as succeeding levels are consistent with the local, regional, is untenable and transformation is the reached. The rationalisation for the Member State and European action only option. This could mean National Programme for Information plans. These have to be described in harnessing other resources including Technology in England is based on terms of health processes. The metrics “expert patients”, mass access and the overriding need to have a national will vary from case to case. This could education tools to improve know- information infrastructure in place to be simple reductions as per the Call ledge, self management and the enable the sharing of health Centre example (cost per individual sharing of information experiences. information and electronic healthcare care); the capability to increase the This is an “epidemic” where self records. delivery of a required service as per management holds the key to the the diabetes example; a particular reduction of the high costs asso- For quality of care, information about capability to deliver a service using ciated with later complications. care processes are required to be eHealth solutions as per the English The scenario is not unique to France captured, stored, secured, shared, NPfIT; the support of enhanced faci- but is there also for Europe as a whole. monitored and compared – here the lities via eHealth as per access to processes to be incorporated within clinical knowledge systems or remote The patient safety scenario is along the value chain are more complex diagnosis. There will be many other similar lines: the numbers of deaths and diverse. cases but the common factor is that and readmissions through medical added value is holistic and spread misadventure are becoming public For cost containment, these things across a number of institutions or knowledge. The transformation of the have to be done within an overall care delivery services. culture of blame will have to be based context, and the costs assessed not on eHealth responses. Similar “no just for the primary application, but The two principles of subsidiarity and option” scenarios exist for other as part of an overall programme market forces rather than just the Social process areas. which fits into and is supported by Model aspirations should be the drivers the levels above. Some existing for an internal market – these will barriers will have to be tackled, for provide the best combination of full example, sharing of patient data is access to safe, high quality and efficient still illegal in some EU countries, health services within the Union. there is no European pharmacopoeia, and interoperability of health systems
2050: A Health Odyssey 21 LOOKING TO THE FUTURE - THE ADDED VALUE OF EHEALTH
The role and value of eHealth is in • increasing specialisation of acute clinical excellence in dealing with supporting and enabling this combi- care; the failures, the emergencies and nation at all levels and the key criteria • emergence of the “care manager” the unpredictable; for success for eHealth lies within the and “intelligent carer” function; • the most cost-effective investment “So What” test – does it benefit the • ubiquitous access and feedback (on a global basis) remains the patient and citizen in terms of better, environments; education of the young mother group safer, more accessible, higher quality • development of commodity and and access to necessary treatment healthcare services? consumer markets within healthcare; and prevention mechanisms in the • “just in time” and personalised busi- first five years of life not just in the For policymakers there are two key ness models; developed nations but everywhere issues – how will they deal with the • widespread use of care advice, (linked to poverty abolition); “chronic care epidemic” and how will monitoring and treatment compliance • for the developed world, policies they enable ubiquitous access and networks balancing a shrinking which improve quality of life rather self-management. healthcare professional population; than longevity will become the • addition of convenience as a key focus; for the rest of the world the Towards the end of this period, quality criteria to access, quality and first five years of life are crucial, eHealth becomes a redundant label - cost effectiveness; thereafter maintenance of quality of eHealth becomes part of the process, • change in the supply business model life supersedes the need for “failure like the telephone. to a demand-based, prevention- “care. Care rather than Cure has to oriented, self-management directed be the watchword;
SCENARIO TWO - TRANSFORMATION: model; • removing obvious barriers: regu- LOOKING FORWARD TO 2030 • development of synergistic top down lations, terminology, pharmacopoeia, models in terms of public health, access to good practice, patient The label eHealth has become redun- emergencies, pandemics, quality safety cultures, infrastructure, EPR’s dant, though it is still in the process control and comparative assessment. & EHRs, CPOE, ETP, etc; of becoming the norm support me- • vehicles for integrating multi-level chanism – deployment has taken longer Ideas for policymaking: policies for deployment; than expected and other factors have • sharing and consensus of health conspired to extend the realisation. • clear definition of the consequent issues - how policy can help? effects of policy at various levels – • practical incentives to involve all The picture of health has changed – it European policy will only be effective stakeholders – working together for is beginning to become an informed if it contributes to better care on the health. bottom up process – the paternalism ground locally; has gone or morphed into high value • policymakers will need to interact SCENARIO 3 - service offerings. The trends over this with all the stakeholders to ensure LOOKING FORWARD TO 2050 period can be summarised as follows: consistency and avoid conflict and duplication; This is now in the realms of futurism • integration of health information • if citizens are to become more – projections this far forward will be across all segments including social responsible and active then policy fundamentally influenced by non-health care, prevention, education and self must make this easier, more cost / developments – societal development, management; tax effective, less regulation impaired; global economic change, the impacts • the realisation of patient-centred (or • policymakers will need to understand of global warming, other world events rather citizen centred care); trends, supply and demand changes, and many other factors. Within this • removal of distance, location, social, innovation and take these into period, most of what we can see educational and economic status account; ahead, both desirable and undesirable, as barriers to access; • the current business model for will be possible – the developed world • concentration on the effective and healthcare is flawed in many ways; will have at least partially succumbed convenient management of chronic often policy makes this worse, is a to the onset of ambient intelligence conditions; force for conservatism and tradition though this will have taken hold with • personalised care, intelligent data and as such often counterproductive; different emphases. Every one will have sourcing and syntomic profiling; • priority will be simple effective self- access to eHealth. The key issues for management matched by increasing health may no longer be in healthcare
22 2050: A Health Odyssey DAVID NEUROLOGYLLOYD-WILLIAMS
but in the availability of information, efforts to eradicate disease, to simplify healthcare delivery. The emphasis, clean water, food, subsistence within healthcare, to provide a safe, happy the responsibility for policymakers is stable societies; and the prevalence or environment for our children’s children, now to find ways of getting everyone otherwise of corruption, inequality, nature and man’s pattern breaking involved to work together to make it economic exploitation. nature, the momentum of complexity happen, for everyone everywhere. and the normal doses of chaos will Within the context of what we currently continue. The message for policymakers is clear. view as healthcare, the trends can be The stakeholders need help and perceived as: CONCLUSIONS encouragement to work together to make eHealth happen to generate • self-management and self-managed The more we look to the future, the the added value to be secured from prevention become key components more clearly hindsight shows the transformation of health processes to based on personalised profiles; opportunities we have wasted. We deliver safe, accessible high quality • chronic conditions will be an ac- have spent thirty years developing healthcare for all. cepted part of everyday life for a what we now call EPR systems and significant part of the population, considered not as disease but more like stress, pollution and The more we look to the future, the more commuting; “ • acute clinical care becomes specia- clearly hindsight shows the opportunities lised, feeding self-management as its priority with acute treatment linked to self-management failure, we have wasted.” to unpredictable episodes at per- sonal, group and community level; still not everyone has one. We have • genomics, syntomic profiling and spent twenty years talking about other omic advances will also feed standards in healthcare IT and we are self-management; still talking. We have spent ten years • information is everywhere but much talking about telemedicine and got of it will regress to data and only virtually nowhere. We have spent five some will move on to knowledge; years talking about eHealth and still • pharmaceuticals will separate into most people do not know what it is, personalised commodity distribution how it will help them and what the networks, production and research; benefits are. • healthcare will become health; part of everyday life like work. In 2005, eHealth tells us some of the things that can be done now to help This is no utopia. Other challenges, transform healthcare but also that man-made, natural and externally some difficult decisions have to be generated, will present this world made and then acted upon in concert with a similar level of crises, hatred, by the stakeholders. There is no added exploitation, disasters, and political value in talking about eHealth – but incompetence. Despite all our best only in harnessing it to help improve
About the Author
David Lloyd-Williams is a Board Member of European Health Telematics Association (EHTEL) EHTEL: www.ehtel.org
2050: A Health Odyssey 23 REVOLUTIONISING PATIENT CARE - MEDICAL TECHNOLOGY OF THE FUTURE
Revolutionising patient care - medical technology of the future - the potential, the challenges
By Dr. Drago Cerchiari
This article considers the role of medical technology in healthcare today and in the future.
Some exciting medical innovations enabling them to remain in the “grow” with the patient (treatment of are in the pipeline today that will comfort of their homes, even in the children). Tissue engineered blood contribute to better diagnosis and remotest areas, with the people they vessels could be used to replace treatment, from sophisticated home- love. Such new modes of healthcare damaged or blocked natural blood care solutions to organ or nerve delivery and homecare technology vessels. Research is being conducted regeneration and targeted nano scale more generally, have a huge potential in the field of heart muscle tissue eradication of tumours. In many fields for development, not least because regeneration, as well as regeneration of new and emerging technology, they will contribute to optimising the of tissues of the nervous system to Europe is in a leading position. But investment in healthcare dramatically, treat neurodegenerative diseases such bringing that medical innovation to while improving the quality of life and as Alzheimer’s or Parkinson’s disease. the patient can sometimes turn out to preserving the patient’s freedom. In 2050, it could be possible to rege- be something close to an obstacle This is just one field where the medical nerate entire organs. A damaged liver race. In this article, Eucomed chairman technology sector is set to make some or kidney could be replaced with a and CEO of the Sorin Group, Dr. Drago spectacular progress between today bioengineered version, originating Cerchiari, explores the huge potential and 2050. Human tissue engineering from tissues and cells extracted from of the medical technology sector and is another. the patient. It may even become some of the challenges it faces in the possible to regenerate whole limbs European Union. The Scientific Committee on Medicinal one day. Products and Medical Devices of the Just imagine… A heart valve placed European Commission’s DG SANCO, At the same time, progress in under- into the human heart without opening in its opinion of October 2001, defined standing the nano scale properties of the chest... or a damaged cervical tissue engineering as “the regeneration matter will also lead to new therapies disk replaced with an artifical implant of biological tissue through the use of and diagnostic tools. A nanometer is through minimally invasive surgery... cells, with the aid of supporting a thousandth of a millionth of a meter. or one simple mouse click and the structures and/or biomolecules”. This is about as far down in size as it physician is able to access from his Tissue-engineered skin substitutes is feasible to go; a nanometer is own office a whole range of parameters are already widely used for treating equivalent in size to about three to from a patient miles away... severe life-threatening burns and five atoms. Science at the nano scale chronic wounds, for example. New is not new nor is it one specific In 2050, the delivery of health infor- products are under development to scientific discipline. What is relatively mation or medical services through treat a variety of increasingly wide- new, however, is our ability to precisely the use of information technology spread age-related conditions such manipulate matter at the nanoscale could be the norm. Elderly people as arthritis, osteoporosis and heart which enables the creation of new and patients with chronic, lifelong disease. In 2050, tissue-engineered types of materials and the miniatu- medical conditions could benefit heart valves could offer new benefits risation of mechanisms and machines. most from this type of technology to the patients such as the ability to Nanomedical developments range
24 2050: A Health Odyssey DR. DRAGONEUROLOGY CERCHIARI
from nanoparticles for molecular dia- increasingly personalised, with medical a new regulatory framework for these gnostics, imaging and therapy, to technology tailored to the specific products. integrated medical nanosystems, which needs of each individual. may perform complex repair actions If new regulation is required, the at the cellular level inside the body. challenge is to ensure that patient One example of this novel type of therapy is T-lymphocytes that are “ The pace of scientific progress is much faster than the “engineered” to carry, for example, evolution of the regulatory environment, and it is becoming nano scale metallic particles to the site of a tumour where they can be increasingly difficult for the regulator to keep up.” activated magnetically or by using light, thereby destroying the tumour. However, this tendency towards te- safety is safeguarded whilst at the In 2050, such treatments could herald chnological convergence is blurring same time supporting and encouraging a new generation in treating cancers the traditional demarcation between innovation and facilitating rapid and or other diseases in locations that are regulatory frameworks. The pace of equitable patient and clinician access hard to reach by conventional means. scientific progress is much faster to that innovation. The complexity and than the evolution of the regulatory variety of new medical technologies 2050 could also herald an age of true environment, and it is becoming is such that the expertise required to patient empowerment. Well-informed, increasingly difficult for the regulator assess them adequately could become highly knowledgeable about advances to keep up. increasingly hard to find, hence the in healthcare technology, and mobile, need for an EU-wide network of highly patients will increasingly participate Today, some novel technologies may skilled and complementary Health in decisions concerning their health, clearly fit under the scope of existing Technology Assessment bodies, for make choices between treatments directives such as the medical devices example. and technologies, and travel to seek directive (93/42/EC), the active im- care abroad. plantable medical devices directive Next to the need for a harmonised, (90/385/EC), the in vitro diagnostic appropriate and balanced regulatory
BARRIERS TO PATIENT ACCESS medical devices directive (98/79/EC) environment, a second key element TO MEDICAL INNOVATION or the pharmaceuticals directive (2004/ is funding of healthcare systems and 27/EC). However, these directives were reimbursement of new technology. Human cell and tissue engineering, not necessarily conceived with new Falling populations, continuing low telemedicine, robotics, miniaturisation developments in mind. For example, birth rates and continuing increases and nanotechnology… these are just the nanotechnology-based cancer in longevity will bring major societal a few of the fields of intense innovation treatment described above clearly changes in the European Union. in Europe. New medical technologies does not have a metabolic, immuno- Already between 2005 and 2010, the will increasingly combine different logical or pharmacological action, population aged between 65 and 79 disciplines such as engineering, mate- which is the definition of a medicinal will rise by 3.4% (+1.9 million) and rials science, biological science, and treatment (Directive 2004/27/EC). The from 2010 to 2030 by 37.4% (a stag- information and communication tech- mode of action is more device-like gering +22.3 million). In the same nology. They will bring increasingly and would fall rather under the scope period the population aged over 80 will grow by 17.1% (+3.2 million) and “ Treatment will become increasingly personalised, by 2030 it will grow by a staggering 57.1% (+12.6 million)! Healthcare with medical technology tailored to the specific budgets are in dire straits. For example, needs of each individual.” in 2003, Germany had a healthcare deficit of €3.5 billion; France of €11.5 high levels of benefit to the patient of the medical devices directive 93/ billion and Italy of €5.4 billion – up such as greatly improved treatment 42/EC. Neither the medical devices’ from €3.2 billion in 2002. and prognosis; faster recovery times nor the pharmaceuticals’ regulatory and reduced hospital stays; and a regimes are suitable for human tissue Ensuring appropriate reimbursement faster return to an active and contri- engineered products; this is why the levels is essential to enable patients butory life. Treatment will become European Commission is working on to benefit from the most advanced
2050: A Health Odyssey 25 REVOLUTIONISING PATIENT CARE - MEDICAL TECHNOLOGY OF THE FUTURE
therapies and technologies. Whether to patients. There is no doubt that of boundaries between social or not a medical technology will be between now and 2050, EU Member services and healthcare services, and between hospital services and “ The challenge is to ensure that patient safety is homecare services, could contribute to achieving more efficiency in the safeguarded whilst at the same time allocation of resources. supporting and encouraging innovation and HEALTH EQUALS WEALTH: MEDICAL facilitating rapid and equitable patient and INNOVATION IS AN INVESTMENT, NOT A COST clinician access to that innovation.” But one important piece of the puzzle reimbursed by public or private health- States will need to adopt significant is often forgotten: investing in people’s care providers is an issue and a reforms of their social security health today will ultimately reduce dilemma for medical technology in- systems in order to ensure both their the burden on society of disease and novators. There may be many years financial and social sustainability. disability. The development of inno- between the initial concept of a novel Health Technology Assessment for vative medical technology in the product and actually bringing it to example can be a useful tool to make coming decades can greatly contribute market during which time the innovator better choices in healthcare. A more to better health, by helping to achieve has no income from that product. If effective use of resources and faster and more accurate diagnosis, there are uncertainties as to whether rebalancing between public and better treatment and faster recovery. there will be eventual reimbursement, private sources of financing through Increasingly, minimally invasive surgical then this will certainly be an additional the adoption of co-payment techniques are helping to reduce factor for the manufacturer to consider schemes, could be beneficial too. In hospital stays and hospital readmi- and could, at worst, be a disincentive their study on “Medical Devices – ssions dramatically, while improving to investment in R&D. Competitiveness and Impact on Public outcomes and quality of life. For Health Expenditure” (published by example, in many cases, coronary There is a mosaic of reimbursement the European Commission in July heart disease can be treated today schemes within the European Union, 2005), Pammolli et al propose a triple without the extensive surgery required with each Member State having its diversification of expenditure: a reb- by coronary artery bypass grafting own rules in this area. And with alancing of the components of public (CABG). One technique is angioplasty EU governments under growing social expenditure (in many EU Member with a stent; the surgeon uses a balloon pressure to control healthcare States public expenditure is, and catheter to open the obstruction in a spending, reimbursement levels are projected to be, too concentrated on coronary artery, then inserts a small being reduced in some cases and in pensions); a rebalancing between metal scaffold (stent) to keep the artery others, certain types of new medical public and private sources of financing open. The procedure lasts about 90 technology are simply not being through the adoption of co-payment minutes. The patient is typically out reimbursed at all. Financing hospital schemes; and a rebalancing within of the hospital in one day and conva- care on the basis of Diagnostic- the composition of private social lescence lasts one week. There is Related Groups (DRGs) schemes is increasingly appealing to healthcare “ One important piece of the puzzle is often decisionmakers, as it is seen to provide incentives to hospitals to treat forgotten: investing in people’s health today will patients in the most cost-containing ultimately reduce the burden on society of way. On the other hand, DRGs are not without risks for the quality of the disease and disability.” provided care and by no means free from a potential to be manipulated expenditure, in order to strengthen only a tiny scar. CABG is a consi- and abused. In particular, DRG the institutional pillars of pensions derably more expensive and invasive systems do not always have the and healthcare funds. Another factor procedure: the patient’s chest is necessary flexibility to make medical that should be addressed is the so- opened and a heart-lung machine technology innovation rapidly available called “silo-budgeting”: the elimination takes over the heart function while
26 2050: A Health Odyssey DR. DRAGONEUROLOGY CERCHIARI
the surgeon reroutes the blood around such as blood glucose self-tests, can made ten key recommendations to the blockages by attaching vessels considerably reduce the impact of boost medical technology innovation extracted from the patients’ chest or this illness. The study by Pammolli et in Europe. These include establishing leg. CABG requires 2 to 4 hours al referred to above includes some an autonomous network of Medical surgery, a hospital stay of at least 5 striking data relating to diabetes Technology Innovation Centres in to 6 days, and as long as 6 to 12 care. For example, it refers to a trial Member States, coordinated centrally, weeks convalescence. conducted from 1983 to 1993, which whose role would be to “bridge the shows that keeping blood glucose gap” between the innovator and the Non healthcare costs must also be levels as close to normal as possible patient. Making Europe more attractive taken into consideration. Production slows the onset and progression of to the best researchers and innovators losses due to illness, death, and the eye, kidney and nerve disease caused is essential. EU Framework Program- informal care of people with the by diabetes. The trial revealed that mes should better support Small to disease contribute greatly to the intensive control of glucose levels Medium Medical Enterprises and overall financial burden of disease. can lead to a reduction of 76% in medical technology innovation. Two For example, it is estimated that in new eye disease risk; 54% in early other key recommendations are to 2003, production losses due to cardio- kidney disease; and 60% in nerve create an EU Community Patent and vascular disease associated mortality damage risk. Another trial completed establish a system of financing and and morbidity cost the EU over €35 over a period of 20 years revealed improvement of capital conditions for billion, €24.4 billion of which was due that heart disease risk could be medical technology innovation, espe- to death and €10.8 billion to illness reduced by 56%, and stroke risk, by cially for SMEs. amongst those of working age. The 44%. The authors conclude among cost of informal care for people with others that “When measured in the “ Health equals wealth.” CVD in 2003 was over €29 billion. long-term and considering patients’ quality of life as a relevant effectiveness As stated by Health First Europe patron The ageing of the population will measure, the introduction of different and former EU Health Commissioner, naturally increase the prevalence of innovations in medicine and in vitro David Byrne: health equals wealth! chronic conditions, which are parti- diagnostic can prove to be asso- Not only can innovation in medicine cularly expensive to cope with. The ciated with lower costs”. In 2050, a contribute to making healthcare International Diabetes Federation cure for diabetes is likely to be systems more efficient. Medical estimates that diabetes accounts for available. R&D efforts are already technology innovation contributes between 5% and 10% of a nation's producing some promising results in to better health and well-being health budget. Today there are 194 the field of transplantation of pan- which, in turn, brings wealth and million people with diabetes worldwide. creatic islet cells (from the patient or productivity, employment, exports If nothing is done to slow the epidemic, a donor). and improved European attractiveness the number will exceed 333 million by in an increasingly competitive and 2025. Diabetes patients suffer from an If the fantastic progress in medicine globalised market. Improving patient increased risk of cardiovascular dis- achieved to date is to continue, the access to medical technology inno- ease, kidney failure, blindness and European Union must improve the vation should therefore also be a amputation. Combined with the environment for and support to inno- strategic priority to achieve the goals promotion of healthy lifestyles, the vation. Eucomed, the European Medical set out in the Lisbon Agenda. use of innovative medical technology, Technology Industry Association, has
About the Author
Dr. Drago Cerchiari, Chief Executive Officer of the Sorin Group, is the Chairman of the Board of Directors of Eucomed, the voice of the medical technology industry in Europe.
Eucomed: www.eucomed.org
2050: A Health Odyssey 27 EU CHALLENGES TO SAFEGUARD QUALITY OF CARE AND PATIENT SAFETY
EU challenges to safeguard quality of care and patient safety.
By Paul De Raeve and Annette Kennedy
This article considers current and future challenges faced by European healthcare systems and the role of nurses in tackling these.
INTRODUCTION as the free movement of patients or maintain or improve equity. Many new the patenting of pharmaceuticals, Member States and even future EU Europeans wish for a Europe that is have been driven by the priorities of Member States have clearly chosen for secure and stable with a strong social the internal market . This agenda has a public-private mix. In many new EU dimension. They want sound economic also been influenced by the Directive Member States private clinics have performance, healthy living and wor- on Mutual Recognition of Professional built a bridge to the public hospital. king conditions and a Europe which Qualifications, the proposed framework Nurses have much higher salaries in ensures that basic goods and services Services Directive and the Working these private clinics (so are no longer in healthcare are available to all Time Directive. Other areas, such as living below the poverty line) and are members of society, at a fair price. the European Centre for Disease supported with continuous professional These values relate to the Lisbon Prevention and Control, and action developments, in the most sophisti- goals which are an attempt to respond on healthy lifestyles, are attempts to cated and technological ways, which 1 to the challenges of globalisation . establish a European public health aren’t even available in the EU 15. 2 Europe is part of globalisation and in policy. Furthermore, the European The nurses average salary has risen strengthening the European health Court of Justice has also issued a from 250 Euro to 750 Euro a month. policy agenda, patient safety and quality series of significant judgments on Physicians and nurses are working in 5 of care need to be embedded within a health policy which have had a far partnership to get the best outcome philosophy of ‘European Standards of reaching impact on Member States. for patients and health ministers when Care’ and ‘Health Services Review’. Together, these initiatives have had presenting the new health system an important effect on the policies, reforms based on these models.
IMPACT OF THE EUROPEAN UNION structures and processes of national Although politicians and policymakers 6 HEALTH POLICY ON MEMBER STATES health systems . have been tackling the challenges of higher expectations from patients, Health is increasingly a global matter, Within the European Member States, and the changing demographic and and it is not surprising that the reform of healthcare systems has, for epidemiological profiles of their popu- European Community is developing a the last two decades, been high on lations, Europe keeps on struggling Europe-wide health policy. At European the political agenda. Governments are to find its identity in the European level, the nature of health policy is rethinking the sustainability of health Social model. Susan Gorden, an showing clear signs of going beyond systems amid concerns about cost American journalist, is very clear in creating a single free market of goods, containment. Reforms have focused her position: “Do not take the American 3 persons and services . Although on reviewing the financial basis of the model”. We have the evidence it is healthcare is the responsibility of EU system in order to control costs, not working, especially in relation to Member States, globalisation is driving achieve greater efficiency, and quality of care, sustainability and health system reform throughout the enlarged Europe. Through its Directo- 1 Presidency Conclusions (2000) Lisbon European Council rates, particularly DG Sanco, DG 2 Giddens, A. (1999) Globalisation The Reith Lectures No.1, BBC London Employment, DG Education and DG 3 Byrne, D. (2004) Enabling Good Health for All. A reflection process for a new EU Health Strategy. 4 European Commission Internal Market , the Commission has 4 European Commission (2001) The Internal Market and Health Services. Report of the High Level created a body of legislation which Committee on Health impacts on the health systems of 5 The cases of Kohll & Decker, & Smits and Peerbooms Member States. Some policies, such 6 European Commission (2003) High Level Reflection Process
28 2050: A Health Odyssey P AUL DE RAEVENEUROLOGY AND ANNETTE KENNEDY
equity.” Although the 25 (28) Member In order to obtain healthcare system to efficiency in work, quality in service States want to keep their individual reforms based on criteria such as and working conditions, (are needed) social model and realise that this is harmonisation, competition, account- as well as continuing training modules. not providing any sustainability at ability, effectiveness and solidarity, Prescribing medicines in nursing is a national, nor European level, we need different stakeholders need to develop very good example within the context to come up with a better solution. strategies for the construction of valid of health system reforms and a few partnership relations. Exploring these Member States have evidence that
CHALLENGES FOR partnerships requires the identification their system is working well, but it is THE NURSING PROFESSION of effective leaders who are skilled in very difficult to ‘sell’ at European developing and implementing policies level. Member States, professional As free movement of persons is one of the fundamental freedoms gua- “ In order to obtain healthcare system reforms ranteed by the European Treaty, we need to make sure that EU standards based on criteria such as harmonisation, in care, standards in education and standards in health outcomes are competition, accountability, effectiveness and met at EU level, to comply with global challenges. Current European trends solidarity, different stakeholders need to develop in health system reform, with their overarching concern for cost contain- strategies for the construction of valid ment, have had a downside for nursing in many European countries. This is partnership relations.” reflected in cuts in nursing budgets, the loss of a nursing voice in govern- in different areas of the health system. organisations should constructively mental decisionmaking processes, History tells us that existing models share their positive outcomes to increases in nursing workloads, and are not successful. It is important to be constructive in the acknowled- serious concerns about patient safety develop effective strategies where all gement of the existing challenges in 7 and the quality of care. A shortage of partners have equal opportunities and partnership. nurses worldwide has led to sub- equal authority. These partnerships stitution of nurses with minimally need to focus on outcomes, in a way Having the opportunity to perform is trained unlicensed assistants provi- that will lead to improving the health an important ingredient for strategic 8 ding direct patient care . Nurses are gain of patients/clients. The equation change and reform. Nurses may lack highly qualified and competent and of partnership relates to the capacity this opportunity not because of poor their roles should expand in line with of the stakeholders, the opportunities equipment or outdated technology, changes in the delivery of care and they have and their willingness to but because of poor decisions and the European Working Time Directive. drive the policy agenda. outdated attitudes within leadership, which is the key to successful out- Furthermore, nurses are caught up in Capacity relates to the degree to comes. In relation to other healthcare the problems of the socio-economic which a nurse or doctor possesses professions, 80% of nursing care situation of their country, hampered task-relevant skills, abilities, knowledge relates to patient care. Unfortunately, by old prejudices and customs and and experience. Unless they know only 45% goes directly to the patient are still very much under the authority what is supposed to be done and due to administrative and ‘outsourcing’ 9 of physicians . Therefore, we believe how to do it, high levels of outcomes activities by other health professionals. that our future European Social model are impossible. Clear occupational Therefore, it is essential to include can only be safeguarded if we look at profiles, job descriptions and changes nurses and nursing in decisionmaking the health system outcomes, the in new occupational profiles in relation in order to get the full picture on care clinical, social, political and financial outcomes. 7 EU Luxembourg Presidency (2005) Conclusions and recommendations on “Patient Safety – Making it happen” Conference Luxembourg Presidency 8 Buchan, J. & O’May, F. (1999) Globalisation and Health care Labour Markets: a Case Study from the United Kingdom. Human Resources for Health Development Journal, 3 (3), 199-209 9 De Raeve P. (2004) The Free Movement of Nurses: A win-win situation if based on ethical recruitment guidelines. EuroHealth
2050: A Health Odyssey 29 EU CHALLENGES TO SAFEGUARD QUALITY OF CARE AND PATIENT SAFETY
which comply with well-established global frameworks whereby there is evidence of validation of standards and transparency of the processes. Many countries worldwide are in the process of developing bilateral, international and regional mutual recognition agreements whereby pro- fessionals, their qualifications and credentials are recognised across borders. There is increased interest in streamlining the accreditation stan- dards, processes and mechanisms to facilitate ease of movement of competent professionals holding and to be able to facilitate a paradigm • To implement a holistic and tran- transferable credentials. However this shift. sparent system of accreditation raises many issues which need to be which is easily recognised across resolved, not least the issues of Finally, the willingness to change relates borders. cultural and language competence to the degree to which an individual and the role and responsibility of key both desires and is motivated to exert The increasing mobility of nursing stakeholders and having a shared effort towards attaining particular and the healthcare workforce and the understanding of the term accre- levels of outcomes. This concerns willingness of individuals to seek ditation. Accreditation is a means of the personal choice of the individual, healthcare and health services beyond assuring quality and protecting the but the motivation is influenced by their national borders have provided public by confirming that individuals, factors such as low pay, stress, an impetus to health service providers programmes, institutions or products workload, poor image and working to secure national and international meet agreed standards. Accreditation conditions. In building these partner- accreditation for their services. This is more and more commonly used in ships, different stakeholders expect a has led to an increasing number of the EU whereas credentialing is used lot from the nurses, and most of it is players becoming involved in the in the East, Canada, America, Australia taken for granted. Only strong partner- regulation and credentialing processes. and Africa. ship, with equal rights and obligations, A multiplicity of terms is applied to will guarantee a high quality and safe Quality and Safety, such as standards Whatever the term we choose, doing healthcare system in Europe. of care, peer review, benchmarking, the right things, to the right citizens, regulation, licensure, accreditation, in the right way, at the right time, PEER REVIEW AS A VEHICLE credentialing, etc. The emphasis, ir- using the right resources, in the right TO FACILITATE CHANGE respective of terminology, should be place every time and delivering the on evidence-based practice and right services even better the next The main driver of a high quality and assessment of outcomes in relation time, equals quality. safe healthcare system must be to established standards. Therefore, 10 based on better health for everyone . there is an urgent need to explore the And we do not have to reinvent the The aims to guarantee this high current context of professional prepa- wheel! Colleagues in other fields quality and safe healthcare system in redness in Europe. This, to deliver a have given evidence of successful Europe is threefold: consistent standard of healthcare to reforms and concrete outcomes by individuals in all countries within the establishing an accreditation system • To deliver a consistent standard of EU in terms of education, competence, within their organisation. In 2003, the healthcare to individuals in all of the codes of practice and clinical out- International Planned Parenthood EU; comes. There is a need to develop a Federation (IPPF) began accrediting • To develop a European Accreditation European accreditation mechanism, whereby all of its members (over 150) Mechanism based on national based on National developments, are reviewed to ensure complete developments which comply with 10 Kennedy, A. (2005) How can we meet the aims of a high quality and safe health system in well-established global frameworks; Europe? Health Services workshop, Open Forum, European Health Policy Forum
30 2050: A Health Odyssey P AUL DE RAEVENEUROLOGY AND ANNETTE KENNEDY
compliance with IPPF membership and maintaining accreditation is a system outcomes. This mechanism standards. Successfully addressing rigorous process that ensures certain should be consistent with a European issues of quality, effectiveness and standards are met and provides means framework of agreed standards in accountability are key to the future of benchmarking different schools, areas such as education and compe- viability of IPPF and its members. At nationally and internationally. This is tencies of professionals, codes of the national level, the accreditation likely to be a stepping stone towards practice, clinical outcomes and equity process has helped individual asso- a globally recognised veterinary degree. of access. Achieving this goal will ciations to identify the areas where it Europe needs to make up its mind, necessitate a new way of leadership needs to improve in order to better especially when we want to become within the European health system serve its clients. the most competitive continent accor- reform. ding to the Lisbon targets. At both national and international level, the accreditation process can be seen as a tool to ensure that CONCLUSION international best practice is met in quality service provision as well as in As Europe manages its integration the management and governance of into the global economy and strives associations. Other organisations, to become the world’s most competi- such as the European Union of Medical tive and dynamic knowledge-based Specialists have a well-established society by the year 2010, heathcare system of reciprocal exchange of stakeholders need to develop policy Continuing Medical Education credits and practice strategies. Health profes- between the participating countries. sionals can no longer shirk their Peer review, visitation of practices, responsibilities for developing mecha- outcome measurements, portfolio nisms to safeguard patient safety and overview and translation into credits quality of care. Exploring the mecha- are key components of successful nisms of health services review at 11 outcomes . Although the Directive of regional, national, European and Mutual Recognition of Professional international level will provide Europe Qualifications didn’t take the amend- with safe standards of care, in ments on a European Accreditation comparison to the rest of the world. System into account, due to the sub- Therefore all EU countries should sidiarity principle, the Federation of have a nationwide mechanism for the Veterinarians of Europe (FVE) and the continuous monitoring and develop- European Association of Establish- ment of the quality of its healthcare ments for Veterinary Education (EAEVE) have jointly established a Europe- 11 Maillet, B (2004) CME Around the World: The European Perspective. Presentation Health wide system of evaluation of veterinary Professionals Meeting www.uems.net 12 schools at European level . Getting 12 De Briyne, N. (2004) Joint EAEVE/FVE Evaluation system of Veterinary Schools. Presentation Health Professionals Meeting http://www.fve.org
About the Authors
Paul De Raeve, RGN, MSc, MQA, Mphil, EFN Secretary General, President INGO Council of Europe Health Grouping Annette Kennedy, RGN, RM, RNT, BSc, MSc, EFN President
European Federation of Nurses Associations (EFN): http://www.efnweb.org
2050: A Health Odyssey 31 ACCESS TO PATIENT HEALTH RECORDS
Access to patient health records - considerations for the future
By Dr. Milan Cabrnoch
This article considers issues surrounding facilitating effective access to patient information and privacy in the age of the Internet.
AVAILABILITY, QUALITY AND cations of medical personnel stem information is of course meant for FINANCIAL STABILITY from their education and experience. different users. Information regarding It is necessary to bear in mind that preventive care is meant for the In healthcare, we talk about availability the medical care is not only given by general public and is a part of the of care for all, about financial stability the doctor. The quality of care depends support for health promotion and of systems and about the quality of on the quality of the whole team of health education. This includes infor- healthcare. Quality, availability and doctors, medical nurses and other mation about healthy lifestyles, disease financial stability were set as the main cooperating personnel, including tech- prevention and treatment as well as a goals for the development and reform nicians and other specialists who lot of other information. The volume of healthcare systems in a European work with machines and complex of this information continues to in- Commission report titled, “Modernising technology. crease. Beyond the question of how social protection for the development to navigate though this large amount of high-quality, accessible and sustain- GENERAL INFORMATION of information, there is the more 1 able healthcare and long-term care ”, important question of judging the and were approved by the European Let us return to information. A whole quality of this information. With this in 2 Parliament in April 2005. The three range of information, (both general mind, the European Commission interlaced parameters cannot be and individual) is useful and necessary prepared a report on the quality of 3 separated. If we were to concentrate to provide quality healthcare. General websites related to healthcare . The only on quality, the costs would information is the summation of every- second group of information related increase and the availability of health- thing known about humans. It includes to healthcare, which cannot be found care would decrease. Likewise, if we all information from the area of medi- on the Internet is usually meant for were to concentrate on financial stabi- cine and related sciences, is the subject doctors and other medical personnel. lity, there is the danger of decreasing of studies, is contained in books and The Internet is an ideal setting for not only availability but also the quality journals and access to it is made circulating the newest scientific of the available care. easier through modern technology. findings. The use of the Internet as a source of QUALITY = QUALIFICATIONS, general information is already common- INDIVIDUAL INFORMATION EQUIPMENT AND INFORMATION place providing both medical care and preventive care. Indeed, the Individual information is always related In order to have quality healthcare, it Internet is a very good setting for the to a specific person and is sensitive is important to have qualified medical sharing and exchange of general personal data. Individual information personnel, who provide the medical information regarding healthcare. The is acquired by doctors during a care, quality medical equipment, through which the care is provided, 1 Commission Communication COM(2004) 0304 and information, which the distributor 2 European Parliament resolution on modernising social protection and developing good quality of healthcare has at his disposition healthcare (2004/2189(INI)): Social protection and good quality healthcare. P6_TA-PROV(2005)0152 when making a decision. The qualifi- 3 Commission Communication : eEurope 2002: Quality Criteria for Health related Websites, COM(2002)0667, 29.11.2002
32 2050: A Health Odyssey DR. MILANNEUROLOGY CABRNOCH
consultation. In their first years of SHARING OF INFORMATION detailed information (for example, study of medicine, medics are taught young children who are not accom- how to acquire information through It is clear that it is beneficial to share panied by an informed guardian). anamnesis, physical check-up and and filter individual medical information. laboratory inspection. Anamnesis is It is not possible, nor correct, to gather Another source of information is the the acquisition of information from a all the information every time a decision written report from a doctor, who patient, which relates to not only the needs to be made. It is therefore neces- provided previous treatment. This infor- identification of the patient, but also a sary that each piece of information, mation can contain the anamnesis as description of his or her problems once it exists, is made available for well as recommending treatment. and their development. It includes the making of the next decision. The However, we often come across previous diseases, treatments under- most common source of information patients who do not have previous taken and their results. A whole is the patient on his or her own history, recommendations from another doctor individual chapter of anamnesis is but the patient does not usually re- and who do not have any report with family anamnesis, which lists the member all the necessary information, them. Even if they do have a report, it diseases that have occurred in the does not recognise the importance of does not always contain all the patient’s family. Other examples are the individual information and does necessary information, but is better work anamnesis and social anamnesis. not understand all the information than nothing at all. The results of A correctly recorded anamnesis is an and as a result does not give it in an laboratory tests, imaging methods or important source of information and accurate form to the doctor. In some invasive tests are all considered as often the most important factor in cases, the doctor meets a patient medical reports in this context. A deciding treatment and predicting that is capable of giving little, if any, medical report can be either in paper the outcome.
Physical check-up is another important source of information gained through physical contact and includes in- formation on height, weight, blood pressure and temperature. As more technology infiltrates into medicine, the volume of information gained through the technology increases. This information includes the results of laboratory tests, such as blood tests. Also included in this category are the results of so-called imaging methods, usually X-Ray, ultrasound, tomography or magnetic resonance tests. Another chapter is the infor- mation gained through invasive tests.
A completely distinct group of infor- mation is that obtained from actual treatment. This information is created gradually as the treatment occurs. It includes, for example, information gained during operations or reactions to medicine, the effectiveness of medicine and any possible negative side effects, all of which is used when deciding the next medical treatment, investigations, or treatment regimes.
2050: A Health Odyssey 33 ACCESS TO PATIENT HEALTH RECORDS
patient, the patient remembers it and conveys it to another doctor. This method is simple, but the least reliable. The transfer of a written report is another classical method whereby a report is sent by mail to the doctor who will be providing the next care to the patient. A written report can be be sent by the mes- senger, most likely by the patient himself/herself. If the patient has the report with him/her, it is sure that the information will be available where the patient is and where the next series of care is being provided and or electronic form sent by email. This need to know the medical centre in decisions being taken. However, if latter option is without doubt favour- which the previous medical treatment the report is being carried by the able on the condition that there is was provided, with the data storage patient, there is quite a high risk of proper security of sensitive personal where the information is archived. If the messenger failure – the patient data against unauthorised access. the patient has received care from may forget, lose or destroy the report. many medical centres and the Information systems of medical centres patient’s information is saved in many THE HEALTH BOOK are becoming the main sources of different data storages, then locating medical information. In these systems, this information becomes unbearably The health book is the tool for sharing there is the amalgamation of a large complicated. an individual’s health information. quantity of individual medical infor- The health book belongs to the patient. mation and if the next medical THE INFORMATION Individual doctors make their health treatment is provided at the same BELONGS TO THE PATIENT records into the health book. The centre, then the availability of this patient can make himself/herself data is excellent and the decision There is a very interesting debate familiar with the information recorded regarding the proposed treatment is emerging about who this individual in the health book and can then show much more accurate if the information health information belongs to, who is the book to other healthcare providers is correctly used. We now find infor- eligible to access it and use it. It is the according to his/her decision. The mation technology is facilitating the author‘s opinion that despite argu- patient has all the information with sharing of individual medical infor- ments to the contrary, information him/her, thus the information is usually mation between individual information must ultimately belong to the patient, always available. The idea of the systems. Medical information details and only the patient can decide to health book is not new, for example, of individual patients can be stored in whom it is accessible. Doctors do not it was used in the Czechoslovak databases. Authorised personnel can have the right to transfer among Army for several decades. The health access these databases and use this themselves sensitive citizens‘ personal book can have various technological information, which is a very convenient data, which undoubtedly the individual designs. The classical form is a paper form of sharing information when health information is, without their booklet, notebook, into which the appropriate security measures against consent. What remains to be resolved doctors write the individual information. unauthorised access are taken. The is the method and the shape in which Such design has its own limits. The main question arising is the agree- the patient will obtain information, paper form of the health book has a ment of the patient to allow a third how it will be recorded and how it will limited capacity and may be forgotten, person, such as another doctor, to be further transferred to doctors lost or destroyed. Moreover, information access the information. The patient providing treatment in future. The first stored in the paper health book is not does not always automatically agree and the oldest method used for com- protected against unauthorised access to his doctor having access to all his municating this information is verbal in any way. An increasingly popular medical information. The main problem transfer. The doctor conveys the technology is the chip card which has with this sharing of information is the result of the examination to the many advantages compared to the
34 2050: A Health Odyssey DR. MILANNEUROLOGY CABRNOCH
paper health book. The information real time. Through Project IZIP, every CONCLUSION can be more easily written into the Czech Republic citizen can request chip card by means of the information the establishment of a health book on Healthcare needs fundamental change system used by the doctor and can the Internet (free of charge). Within a and should have a deeper focus on be easily read. Information is far couple of days, the book is established the patient. Healthcare is the system better protected against unauthorised and the citizen obtains exclusive of services from professionals to access. Along with individual health access rights to it. All doctors who patients, the purpose of healthcare information the chip card can also have applied can access the system as a service is to fulfil the expecta- carry other information, for example free of charge. The doctors however, tions of the patient. The decisive role identification data readable optically cannot read the information without in healthcare and its reform cannot be and electronically or secured electronic the right being first granted to them made by the state, nor the health signature. However, even the card has by the citizen. insurance companies, nor doctors a limited capacity, it may be lost or nor hospitals. The decisive role must forgotten and the use of chip cards is The information in the health book of be played by the citizen. The citizen conditioned by technical equipment. the patient is accessible through the who really gets the actual, not just a Internet and the browser of the web formal, right to choose will be equip- IZIP SYSTEM pages without any further restrictions ped with sufficient clear and correct from any computer in the world con- information for decisionmaking and Project IZIP, started in 2000 in the nected to the Internet. Thanks to this will bear real responsibility for his/her Czech Republic, selected a new tech- feature, the individual health infor- decisions. The providers of the nology for the health books of the mation of the patient is available healthcare services in such a system patient. The health books are placed on the Internet, are not limited in “ The decisive role in healthcare and its reform volume amd cannot be lost, forgotten or damaged. The writing and reading must be played by the citizen.” from the Internet health book is done through a personal computer con- nected to the Internet, and there is no without any restriction anytime and will be professional advisers to need for any special software or anywhere. System IZIP has been citizens and administer their respon- hardware equipment for access. The used already by 800,000 citizens in sible decisions. They will be in protection of the sensitive personal October 2005 in the Czech Republic; competition with each other as data is secured at a much higher level more than 8,000 doctors have written competition is the guarrantee of than with paper books or chip cards. about 2 million health records (in their continuous increase in the quality of Another advantage of the health health books). The system is debugged, the service. The target is nothing else books on the Internet is the possibility verified and ready to be expanded than the quality, availiability and long- to write from several places simulta- into other countries. term financial durability of healthcare. neously without physical presence of the patient. The laboratories can thus record the individual results in the Internet book online and practically in
About the Author
Dr. Milan Cabrnoch is a Doctor of Medicine (pediaterician). From 1994-1997, he worked as Director of Health for the insurance department of the Ministry of Health and in 1998 as Deputy Secretary of Health for health insurance and legislative area. As a member of the Czech Parliament, from 1998-2002, he worked as chairman of the Subcommittee for drug policy and refund of medical care, and was the vice-chairman of the committee for social policy and healthcare service. Since 2004 Milan has been a Member of the European Parliament and works on the Committee on Employment and Social Affairs.
2050: A Health Odyssey 35 MEDICAL INNOVATIONS IN THE EU
Medical innovations in the EU - investing in health, value for society
By Prof. Dr. Günter Neubauer and Philip Lewis
This article considers the exisiting approval system and reimbursement systems for medical innovations in Europe and the future implications.
1. THE FUNDAMENTAL ECONOMIC menting health expenditure (through 3. INNOVATION AND SYSTEMS PROBLEM OF HEALTHCARE the development of global morbidity) OF REIMBURSEMENT IN INDUSTRIALISED COUNTRIES and health receipts (limited by national economic development) lead to an Section 1 described the general funda- By using the example of medical increased scarcity of resources in mental economic problem in health innovations in German hospitals, the healthcare. economics. This problem is particularly following article describes the current pronounced in the field of medical
situation of medical innovation and 2. EVALUATION OF technology. The economic pressure how innovation finds its way into the MEDICAL INNOVATIONS faced by health service providers healthcare system. To begin with, this such as hospitals, is typically in part section places the situation into a Medical innovation means medical- passed on to the medical industry. global healthcare perspective. technical progress whenever this Due to low short-term rationalisation progress generates greater benefit/ potentials, hospitals’ acceptance to Developments in healthcare expendi- efficacy relative to conventional treat- introduce higher-quality medical in- ture are influenced by factors both on novations is typically low. Thus, the cost-benefit analyses described in “ Increasing divergence between augmenting health section 2 are an important factor in expenditure and health receipts lead to an determining the efficiency of medical innovation. increased scarcity of resources in healthcare.” We shall look at the means of the demand side and the supply side. ment methods. In order to answer introducing medical innovation into Supply side factors such as medical- questions on economic as well as the German hospital landscape. technical progress and increased medical-technical progress, the costs Medical innovation is henceforth healthcare capacities are driven by of an innovation must also be taken demographic change of an ageing into account. Costs and benefits are population as well as increased set against each other in order to individual preferences for healthcare. establish the efficiency of an innovation. These mutual influences between Medical-technical and economic demand and supply lead to increases progress is guaranteed with higher in health expenditure which outpace efficacy plotted against lower or else increases in health receipts. As regards constant costs/expenditures. However, health receipts, the financial amount the most typical scenario consists of generated for healthcare is determined higher costs and higher benefits of an by financing parameters as well as the innovation. In this case, it must be defined catalogue of health services. analysed whether the supplementary Overall, limits to increases in health costs justify the additional benefits, receipts are set by economic growth thus enabling economic progress. as well as the employment situation of a national economy. To summarise, increasing divergence between aug-
36 2050: A Health Odyssey PROF. DR. GÜNTER NEUROLOGYNEUBAUER AND PHILIP LEWIS
defined as new medical products or view of the supplementary benefits, a specialist organisations to work toge- methods with a proven medical cost-reducing innovation will auto- ther in order to document a high benefit towards conventional methods matically always be economically enough patient number. of treatment. The examples stated efficient per definition. In the case of below consist of medical innovation cost-increasing innovations, the cost- Once the question concerning the applied to frequent and highly benefit ratio needs to be tested from procedure code has been addressed, relevant medical problems. With the view of individual patients as well it needs to be clarified whether an medical-technical progress as the as for the national economy as a appropriate diagnosis-related group starting point, up to five levels need whole. already exists, into which the medical to be passed in order to successfully innovation in question can be intro- establish medical innovation in At a third level, the reimbursement duced. If this is not the case, an German hospitals, as illustrated in system relevant for the medical tech- application must be made to the figure 1. nology in question is taken into Institute for Reimbursement Calculation in Hospitals (InEK). Deadlines for appli- Fig.1: Steps of introducing medical innovation into the German hospital landscape cations are set at the end of March of each year, for consideration starting the following calendar year.
At a fourth level, once it has been established that coding and grouping allows for the introduction of medical innovation, questions on costing and pricing need to be addressed. While costing deals with the issue of whether a DRG is appropriately calculated, pricing establishes whether or not this allows for appropriate reimbursement, covering the cost of the innovation.
In the case of a cost-reducing At a first level, a medical innovation consideration. In the case of German innovation, applications in German is classified by innovation type, either hospitals, this is the German system hospitals are unproblematic from the as a product or process innovation or of diagnosis-related groups (DRGs). view of service providers due to higher else as a hybrid form between the As regards to coding, it needs to be hospital profits (or else lower losses), two. Process innovations describe new clarified whether an operations and assuming constant revenues. Even diagnostic and therapeutic methods procedure code (OPS) already exists, cost-increasing innovations may for without the use of a new medical describing the use of the medical one be outweighed by direct increased product. A typical example would be innovation in question. If this is not patient benefits. They might however the implantation of a knee prosthesis the case, an application needs to be also indirectly strengthen a hospital’s with the help of new, computer- sent to the German Institute for position through higher quality patient animated procedures. Drug eluting Medical Documentation and Infor- treatment and image improvements. stents are a typical example of a pure mation (DIMDI). Specific aspects Resulting increases in patient numbers process innovation. such as relevance, frequency applied, then lead to reduced costs per patient. costs per case and independence of Further examples of rationalisation At a second level, the efficiency of a the procedure all need to be addressed potentials are reductions in lengths of medical innovation is evaluated. From in this application. In order to acknow- patient stay or longer-term substitutions the viewpoint of the health service ledge a new procedure code, DIMDI of personnel. Social health insurance provider, the cost-revenue situation is requires around nine months for data funds may also be persuaded to of primary importance. From the view- processing. Having to document the finance cost-increasing innovations, point of social health insurance, medical frequency of the procedure applied if these lead to longer-term savings benefits must be compared to addition- typically makes it necessary for hospital potentials. Taking into account that ally incurred health expenditure. In and medical associations as well as patients also benefit from medical
2050: A Health Odyssey 37 MEDICAL INNOVATIONS IN THE EU
innovation, a win-win situation may case of a product innovation, the innovation, since the type of prosthe- result for all parties involved. Institute for Reimbursement Systems sis remains unchanged (level one). in Hospitals (IneK) is directly respon- Computer-based support when In the case of cost-increasing inno- sible for possible evaluations. implanting a knee prosthesis is cost- vations, a hospital needs to clarify increasing, since the operation with the contractual partners (the In what follows, two examples of medi- period is increased by around 15 umbrella organisation of the statutory cal innovations are illustrated in order minutes. Tangible benefits can only health insurance sector, the national for the reader to better understand be evaluated once longer-term results federation of private insurance and the individual steps necessary for become visible over the next 10 to 15 the German Hospital Federation) at a introducing a medical innovation into years (level two). A procedure code st national level by October 31 of each German hospitals. (e.g. 5-822.: Implantation of an endo- year on whether or not an innovation prosthesis at the knee joint) already reimbursement is granted under DRGs. A first well-known example is the exists and codification into a DRG is This necessary step is stipulated in drug-eluting stent (DES). This substitute possible (level three). Due to cost the so-called “innovation clause” of innovation towards conventional stents increases, appropriate reimbursement the Hospital Remuneration Act, can be classified as a pure product is not accounted for. A hospital thus KEntgG, § 6(2), in combination with innovation (level one). Drug-eluting has to inform itself with the self- nd the 2 Fee Per Case Amendment Act, stents lead to increased direct costs, governing body at a national level on article 2, point 4. but also cause reduced follow-on whether the innovation could be costs through a reduction in re-stenosis reimbursed under existing DRGs In the case where innovation rates, thus being cost efficient (level (level four). An evaluation by the reimbursement is not provided for two). Since procedure codes originally Hospital Committee may optionally under DRGs, supplementary payments only existed for conventional stents, a be authorised, in order to establish ‘Zusatzentgelte’ may be agreed upon codification within the DRG system the cost-benefit ratio of this medical between hospitals and social health was not possible. An application was innovation. insurance funds. In the case of no then sent to DIMDI in order to achieve
consensus, the federal state arbitration a DES- and non-DES differentiation 4. THE ROLE OF PRIVATE INSURANCE board may call for the so-called within the OPS-system. The new Hospital Committee to evaluate the OPS could then be mapped onto ap- The triangular picture in figure 2 des- case for the following calendar year. propriate DRGs. However, since no cribes three layers of supply provision In this case, a literature-based review appropriate cost differentiation was of medical technology. The ground for the upcoming calendar year established within these DRGs, a layer depicts basic healthcare provi- however seems unlikely, due to the further application for a DRG split sion accessible to the general public. short time remaining. needed to be made (level three). If Patent-protected innovations do not this DRG split is not granted, there yet form part of basic healthcare, but The Hospital Committee ‘Ausschuss will finally be no appropriate costing are also accessible to everyone. On Krankenhaus’ is one of several com- (and hence pricing) of this medical the other hand, new innovations have mittees of the Concerted National innovation (level four). In this case, a not yet found their way into social Committee ‘Gemeinsamer Bundes- possible evaluation can be undertaken health insurance. Instead, they first ausschuss’, GemBA. It instructs the by InEK, responsible for product need to go through a process of Institute for Quality and Efficiency in innovations (level five). Until then, medical evaluations by institutions Healthcare ‘Institut für Qualität und supplementary payments can be such as NICE (National Institute for Wirtschaftlichkeit im Gesundheit- agreed upon between hospitals and Clinical Excellence) in the UK, and swesen’, IQWIG to undertake scientific social health insurance. GemBA in Germany. During this time, evaluations of medical innovations, private self-financing is the only means where appropriate. Thus, at a fifth A second good example of a medical through which such innovations are level, a medical innovation may be innovation is the implantation of a knee able to enter the market for medical evaluated by the Hospital Committee prosthesis with the help of computer- technology. in the case of a process or hybrid animated navigation programs. In this innovation. Such an evaluation is case, conventional implantations however optional and not a prerequisite describe the conventional method of for usage in German hospitals. In the treatment. This is a typical process
38 2050: A Health Odyssey PROF. DR. GÜNTER NEUROLOGYNEUBAUER AND PHILIP LEWIS
Fig. 2: The fundamental economic problem of healthcare in the context of industry, making cost-benefit analyses medical innovation of medical innovation increasingly necessary. Introductions of new medical technology into the healthcare system may take a long time and must be planned well, as the example of innovations and German DRG hospital reimbursement has shown. As introduction of new medical technology becomes increasingly difficult, new methods of private self- financing will have to be established in order to allow individual access to
Figure 3 describes this feature in the Fig. 3: Private self-financing of medical innovation case of a substitutive innovation. The conventional method/existing medical product provides a basic benefit paid by social health insurance through material in-kind cost reimbursement of €1.500. A substitutive innovation is typically more expensive, however providing supplementary benefit. A possible way of enabling this medical innovation into the healthcare system, is to allow an individual free choice over whether or not to opt for this supplementary benefit. While the basic benefit would continue to be financed by social health insurance, the supple- 5. THE OUTLOOK FOR THE FUTURE FOR supplementary benefits of medical mentary benefit would be paid for INNOVATIONS WITHIN THE EU technology. from an individual’s own pocket. The underlying article described the fundamental economic problem of scarcity, which also particularly applies to the health sector. Cost pressure is typically passed on to the medical
About the Authors
Univ.-Prof. Dr. Günter Neubauer, Professor for economics and social policy at the University of Federal Armed Forces (Universität der Bundeswehr) Munich Director of the Institute for Health Economics (Institut für Gesundheitsökonomik) Munich Philip Lewis (MPhil Economics): Research Assistant at the Institute for Health Economics (since 2002) With thanks to Manfred Beeres and Mr Olaf Winkler from BVMed for reviewing the article.
The Institute for Health Economics (Institut für Gesundheitsökonomik, IfG): http://www.ifg-muenchen.com
2050: A Health Odyssey 39 THE FUTURE OF QUALITY PATIENT CARE, CLINICAL SAFETY AND OPERATIONAL EFFICIENCY
The future of quality patient care, clinical safety and operational efficiency
By Dr. Vincenzo Costigliola
This article considers actions that must be taken by all stakeholders to safeguard the provision of quality healthcare in 2050 and beyond.
Making predictions is not an exact surgeons, IT-based techniques and from country to country and depend science. It is desirable that medicine telemedicine enable increasingly mini- on several factors including the eco- is available to everyone and provides mally invasive therapeutical solutions nomic, political and working culture concrete solutions to acute and with great impact. of the country, its economic situation chronic problems. Medicine should and demographic trends. In the add more quality to life and seek to As mentioned in the Health First Europe European Union, health systems are win the battle against pain. Even the core messages, there are weaknesses organised in: most complex and costly therapies in European healthcare systems and • Bismarkian systems; should be available to anybody that a rethink is required in order to meet • Beveridge systems; needs them, regardless of their social current and future health challenges. • Mixed systems. status. Genetic therapies provide A brief overview of healthcare systems hope. Thanks to biotechnologies and in Europe may help us understand The Bismarkian system was establish- immunology, we expect solutions the differences that exist between ed in the 1880s, as a social insurance. which will treat the majority of our EU healthcare systems. Health It consists of obligatory professional pathologies. The use of robot- systems in practice vary considerably social assistance, financed by a tax
40 2050: A Health Odyssey DR. VINCENZONEUROLOGY COSTIGLIOLA
have changed. The organisation of healthcare is undergoing changes as well. Medical treatments have to meet management and efficiency criteria. In order to succeed in this changing environment, we have to redefine roles and decide what we intend by economic assessments.
ACTIONS TO BE TAKEN
Firstly, those responsible for taking political decisions at European and national level, in order to ensure high level standards of healthcare in 2050 and beyond, should aim to reduce on salaries paid by the worker or the motivated than in the past. Patients health inequalities. This approach employer. It covers social risks are more and more demanding in could include: (accident, sickness, old age) through terms of medical performance. They • consideration of the need for health- obligatory contributions to distinct want treatment in shorter times and a care and cost containment; schemes of support. reduction in the occurrence of medical • defining professional roles and tasks errors. The patient expects higher for doctors; The Beveridge system was established levels of safety in clinical operations. • supporting patients’ and healthcare in the immediate post-war period, as professionals’ mobility ; a national health service. It is based Demography is changing: we are • supporting and promoting under- on the principles of universality (all facing the phenomenon of an aging standing among Ministries of the population is covered), uniformity and multi-ethnic population and at education responsible for universities of coverage (regardless of the amount the same time the number of people and Ministries of health responsible contributed) and unity of management suffering from chronic diseases is for medical practice; (given to a public service). It is wholly growing. • promoting quality assurance; financed by the state (tax-based). • supporting the development of new Medicine is changing. The main actors’ and flexible modes of healthcare The mixed system provides for health- needs, namely patients and doctors, delivery; care provision and foresees obligatory have changed. Roles, strategies and • promoting the concept that "Health professional social assistance interventions by national healthcare equals wealth", in that health is a institutes and insurance companies productive economic factor in terms Although a lot of progress is being made in the domain of economic and political union, there is still no common healthcare system in Europe. Special agreements among Member States do exist which confer upon European citizens the right to be treated in all Member States.
THE CURRENT SITUATION
Access to medical treatment is every- body’s right and is embedded in European legislation. Generally, today’s patient is more informed and more
2050: A Health Odyssey 41 THE FUTURE OF QUALITY PATIENT CARE, CLINICAL SAFETY AND OPERATIONAL EFFICIENCY
of employment, innovation and strategies which make it easier to • provide continuing medical education; economic growth. access complex medical treatments. • reduce asymmetry of information; Although unfortunately, in some • ensure that patients and clinicians In order to ensure high level standards instances this has lead to health have equitable access to modern, of healthcare in 2050 and beyond, inequalities. innovative and reliable medical doctors specifically should: technology. • take part in the management of the As such, insurance companies and social and healthcare system; professional structures, together with Finally, medical schools are particularly • manage resources (which are often academic authorities and patient involved because of their educational insufficient); organisations, must: role during the pre-graduate, post • respond to and deal with new social- • set the implementation and control graduate phase and in Life Long economics needs; criteria for quality patient care; Learning. This involvement demands • be able to use innovative techno- • set quality standards in basic medical that medical schools: logical solutions provided by industry; education; • take into account the aims of the • make full and appropriate use of all • set quality standards in clinical safety ; Bologna process and Declaration diagnostic and therapeutical • set quality standards in operational and incorporate them in pre-graduate resources; efficiency; courses; • apply all possible systems available in order to avoid and reduce the occurrence of errors; • be constantly up to date with deve- lopments and support improvements in the quality of treatments; • be ready to work in multicultural societies and handle intercultural dialogue.
Meanwhile, national governments must - in conjunction with healthcare organisations - seek to control rising costs, whilst improving quality of care. The scarcity of resources and the funding of healthcare does not always make the allocation of necessary resources for investment in European healthcare systems possible. Tendancies have traditionally been to reduce healthcare costs and at the same time try to maintain high quality patient care. Healthcare needs to be considered as an industry which delivers patient care services and products that affect the quality of human lives and which needs tech- nology development. In a globalised world, governments must take into account geostrategic changes in politics and medical ethics. In recent years, private insurance companies have become increasingly present on the healthcare market, offering additional services and developing
42 2050: A Health Odyssey DR. VINCENZONEUROLOGY COSTIGLIOLA
• educate MDs to respond to the different initiatives are being carried The quality of patient care, clinical needs of the changing healthcare out at all levels. A new approach for safety and operational efficiency, is a requirements and the challenges of tomorrow’s medicine is to plan new legitimate aspiration which can be news technologies; strategies, taking into consideration achieved. All the points mentioned • respond to demands for new new social determinants of health above should be discussed and specialities; such as: life expectancy, stressful analysed in more detail so as to turn • propose opportunities to respond circumstances (anxiety, depression), this aspiration into a reality by 2050. to the increasing demand for Life mothers and young children, poverty Long Learning; and social exclusion, environmental • promote student and professor factors and workplace, job security, mobility; social support, abuse of alcohol and • promote the diversity of teaching- drugs, food supply and nutrition learning; culture. These factors need to be • create networks which enable the addressed not only from a medical recognition of foreign diplomas. point of view but also in terms of organisation, social legislation and At present there is little harmonisation financial commitment. across the EU, despite the fact that
About the Author
Vincenzo Costigliola is President of the European Medical Association. European Medical Association (EMA): http://www.emanet.org
2050: A Health Odyssey 43 PREVENTION AND DETECTION - THE FUTURE OF DIAGNOSTICS
Prevention and detection - the future of diagnostics
By Christine Tarrajat
This article looks at in vitro diagnostic testing and what potential it holds for the future of healthcare.
Turning the clock back 50 years, most of today’s life-threatening pathogens such as HIV/AIDS were not yet discovered and cardiology and oncology were in their infancy. While such diseases and health conditions have developed and come to the fore, medicine has also come a long way over the course of the last five decades. In vitro diagnostics in particular has been an area of constant innovation.
In vitro diagnostics provide information of value that forms the basis for better decision in healthcare. The results of in vitro tests are a unique source of objective information about your state of health or disease. Valuable information about your state of health, about your body and how it functions can be obtained by taking samples (e.g., blood, tissues or urine) from the body and performing tests on these samples. These tests include measuring the concentrations of various chemical and biochemical components, counting cells, measuring physical properties of the sample, microscopic examination of cells and other structures or making biological cultures. Healthcare professionals refer to these tests as in vitro diagnostic While many medical laboratory tests after a medical examination is often (or IVD) tests because many were are used in diagnosis, perhaps in to take a blood sample and to request originally performed in a test tube (in connection with an infection or an the medical laboratory to carry out a vitro is Latin and means literally "in accident, in vitro tests are increasingly number of in vitro tests. The results of glass") and because they are mostly being used to monitor the treatment the tests are used in disease mana- used to help determine (or diagnose) that is given. One of the first steps gement to assist the doctor (in the what is wrong with a patient.
44 2050: A Health Odyssey CHRISTINENEUROLOGY TARRAJAT
hospital or in general practice) in diverse, complex and often at the of a large number of samples. User- making the best decisions about cutting edge of development. friendly devices can be used by treatment. Laboratory tests are also medical professionals (Point of Care widely used in prevention of disease, Recent developments of diagnostic testing) or by the patients themselves for example, to screen populations or tools (e.g. tests based on molecular at home (self-testing). The samples groups for hidden disease or risk biology) offer devices with better taken are smaller and less traumatic factors and some tests are being sensitivity, specificity and reliability, (other body fluids than blood are used increasingly in health mana- providing an increasing amount of more often used), and the results are gement to check personal health information (such as phenotypes, obtained faster (in minutes instead of status. The results of these in vitro genotypes), allowing us to identify a days or weeks in the past). Infor- tests provide objective information to disease earlier, at pre-symptomatic mation technology further helps to help establish the state of health of stage of an illness, and minimising reduce potential errors in test re- individuals, as well as to indicate the the risk of misdiagnosis. The analyses questing, sample identification and state of health of the general population produced are now highly automated, transmission of the result to the as a whole. The technology used is reducing labour and allowing screening doctor.
In the future, these trends will be reinforced, in that the general po- pulation will be more educated and knowledgeable in the field of medicine. Such knowledge will increase the demand for diagnostic testing. Better and more accessible information will create higher demand. Advances in molecular testing and automation will result in an increased demand on the education and training of lab personnel. The standards and quality of diagnostic tests will become global and not regional. US and European Union IVD regulations may be replaced by new worldwide standards and regulations. With the possibility of travelling and living in space, a new field of dia- gnostics will develop: space medicine!
The application of new techniques from the electronic industry have enabled the miniaturisation of bio- sensor(s) (sensor containing a biological element, such an enzyme, recognising and informing about the presence of a molecule) used in IVD tests ("Nano- diagnostics"). Ultra-sensitive biochips will provide a full medical diagnostic from one sample. Several analytical tests will be incorporated into "lab- on-a-chip" devices. Some diagnostic nanobiodevices called "gene-chips" will be available to measure parts of the genome. 'Cells-on-chips' will be available for pathogen or toxicology
2050: A Health Odyssey 45 PREVENTION AND DETECTION - THE FUTURE OF DIAGNOSTICS
screening. Combined techniques bet- of injection less frequent. In parallel, or the diabetes centre in real time. It ween in vitro (probes and markers) insulin pumps will continue to be will therefore be possible for the and in vivo diagnostic (imaging developed for better patient com- physicians to monitor their patients technology) can be envisaged, as pliance or adherence to treatments. remotely and intervene if necessary advancement in in vivo diagnostics Self-monitoring systems will become (e.g. by regulating insulin quantities) will offer minimally invasive implantable less painful and more precise. Continual or to give them instructions. devices. monitoring systems will eventually substitute the ones currently used Close iterative cooperation between Combined techniques between dia- today that provide patient with "spot diagnosis and intervention will have gnostic and therapy, known as data". The patient will therefore receive resulted in vast pharmacogenetic "theranostics" could be one of the real time information on his glycemic know-how translating individual meta- major healthcare tools in the future level. The parallel development of bolic fingerprints for use in personalised (the "Find, Fight and Follow" concept self-monitoring instruments with medicine, tailored to individual needs of early diagnosis, therapy and therapy continuous measurement and insulin as the broad common standard. All control) and will allow for personalised micro-pump systems will make cancer therapy will be based on therapy. Nanoparticules carrying thera- "artificial pancreas" available that could individual molecular fingerprints. The peutic agents into disease cells will "self-regulate" insulin infusion, taking increased understanding of genomic check for over dosage before becoming into account the glycaemia concen- information will have subdued the active, thus preventing drug-related tration that is continuously measured. impact of cardiovascular and other poisoning. Furthermore, advancements in com- multi-morbid metabolic diseases as munications means will allow the well as mental illnesses. The evolution In the control of diabetes, the evolution glycaemia and insulin micro-pump of information technology for health- of new insulin will make the necessity values to be transferred to the physician care applications will have potentiated
46 2050: A Health Odyssey CHRISTINENEUROLOGY TARRAJAT
effectivity and speed from emergency settings and hospitals, right to people's homes, providing enhanced safety on the one hand and greater flexibility for those affected by the remaining chronic diseases, on the other. As a result, life span will have increased, also based on improved diagnosis of predispositions and the possibility to effect gene therapy and germ line gene therapy, as far as the ethical consensus permits.
In 2004, the European IVD Market was estimated at €7.803 million (based on 14 EU countries - EDMA source). It can be expected that by the year 2050, the contribution of diagnostic tests, procedures and knowledge will have had significant impact on the delivery of healthcare in all important areas, such as disease detection, administration of therapy, monitoring of therapy success, as much as effecting an optimised less than €20 per capita and per utilisation of healthcare resources. annum). IVDs provide critical health
By 2050, European healthcare systems “ By 2050, European healthcare systems will face will face the difficult challenge to achieve a status quo between affor- the difficult challenge to achieve a status quo dable technologies and treatments, possible waves of infectious pathogens between affordable technologies and treatments.” such as SARS or Bird Flu through Europe and the needs of a relatively information. In the future, greater healthy but aging population. There is appreciation and appropriate spen- a great potential for healthcare to ding on IVD would have a positive benefit from the revolution in dia- impact on healthcare. gnostics technology. However, these benefits will only be achieved if the resources are allocated differently. Today, the IVD Market represents generally less than 2% of the total healthcare expenditure in Europe (i.e.
About the Author
Christine Tarrajat is the Director-General of European Diagnostics Manfacturers Association (EDMA) EDMA: www.edma-ivd.be
2050: A Health Odyssey 47 PATIENT MOBILITY – WHAT DOES IT MEAN FOR THE FUTURE?
Patient mobility – what does it mean for the future?
By Dr. Max Ponseillé and Paolo Giordano
This article looks at the place of patient mobility in the future provision of healthcare.
Patient mobility is regarded as a that benefit from a monopoly that often, and will, instead chose to major challenge in a Europe that does not work efficiently and that create centres of excellence in the wishes to be considered closer to its raises the public debt and by conse- different Member States in agreement citizens. The future of patient mobility quence taxation. Free competition with national healthcare authorities. looks bright: globalisation will certainly and liberalisation of services is nec- As an example, a Member State can drive patient mobility into a great essary to improve the European specialise in a certain field while expansion. Integration in health matters economy. The private sector can play another one can provide services in a completely different discipline. This is “ The future of patient mobility looks bright.” already seen in practice areas like cannot go without upgrading to a an important role by investing and dentistry and hip replacements. In European level what, up to now, has choosing to specialise in those sectors the future, there will be a greater been regarded as a simply national where it feels more comfortable. For mobility of patients across the EU. matter. The European Union’s functi- instance, a country could specialise This will extend beyond the EU as onal approach is moving in the same in a particular branch therefore ensuring well. Nowadays, much of the cross direction: since the beginning, the the best quality care. However, there border mobility is outside of the EU. EU’s most ambitious projects have are checks such as competition An example would be the agreements had a bottom up structure, arising regulation and price controls. These concluded between England, Tunisia from solutions to real issues. In light types of barriers create further risks and India for sending English patients of the above, in 2050 patient mobility for independent investors which can to those countries for lower cost will surely be more developed restrict their investment in new healthcare treatment. compared to today. The health capital expenditure like hospitals. achievements that Member States Because of this reason, investors wish to reach are more likely to happen if healthcare is not confined to national boundaries but becomes a European issue clearly based on a good funding sustainability linked to best quality. In Commissioner’s Byrne words: “The future economic growth and sustainable development of the entire Union depends on investment in health – investment that will be doubly important for the new Member States to reduce the gap with the rest of the Union.”
Financial sustainability has become a basic concept in the field of healthcare. There are too many public structures
48 2050: A Health Odyssey DR. MAX PONSEILLÉNEUROLOGY AND PAOLO GIORDANO
The process on patient mobility began a long time ago. Thanks to the Euro- pean Court of Justice, this matter has gained importance and relevance to national healthcare systems. The ECJ cases have been very proactive in the healthcare field, particularly compared to governments who have lagged behind for various political reasons. Social and health-related questions are always difficult to address at the European level, because of the Member States’ competence when it comes to organising those services. A clear example of this is point 5 of article 152 stating that “Community action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care.”
This article has remained through all subsequent treaties. Even in the draft Constitution it has continued intact.
Consequently, acting independently and in accordance with the Treaties, the European Court of Justice started the process with several famous decisions such as Kohl-Decker, Smits et Peerbooms, Vanbraekel, Inizan, Leichtle. Despite some of these groundbreaking cases, the different European Councils needed almost two years to modify Regulation commendations and substantially Member State, this may also be 1408/71 on the social security improves the outlook for improved sought in any other Member State schemes’ coordination which were patient mobility. The European without prior authorisation. That is affected by these cases. Parliament has also contributed to the general picture. European insti- the debate with several resolutions in tutions or Member States still have to However, the lack of clear EU policy that field during the past years. define all the particular aspects of in light of these judgements eventually this new regulation. The European forced the hand of the EU to address The current situation can be described Court of Justice stated that in order the issue of patient mobility. A High as follows: if a patient cannot get to benefit from hospital healthcare, Level Group on patient mobility was hospital care in his country of resi- the patient needs pre-authorisation created within the European Com- dence, he is entitled to receive the from his social security. But this must mission to investigate in which way same treatment in another Member be given if the treatment cannot be the EU could codify these cases in State and his national social security provided in the patient’s country of policy while at the same time exploring system is obliged to cover all the residence. the value of patient mobility to the costs. Concerning non-hospital care cross-border EU health market. This to which one is entitled in his/her own High Level Group lists several re-
2050: A Health Odyssey 49 PATIENT MOBILITY – WHAT DOES IT MEAN FOR THE FUTURE?
The High Level Group has focused on the information that should be given to patients in relation to the care across borders. Nowadays, patients do not even know their rights derived from these ECJ judgements, which is why so very few patients consider the opportunity to be treated abroad.
Following the process of open method of coordination, Member States should give all requested information such as: • the way reimbursement works; • how much they are obliged to re- imburse (according to the rights prevailing in the country of origin, it seems that the reimbursement could not exceed the costs which would normally be charged in the patient’s country of residence for the same treatment); • whether travel costs are reimbursed or not; • the existence of information centres for patients, etc.
Community regulations have formed a very important instrument of co- ordination, and the new health card replacing the old E111 document goes in that direction. However, the level of coordination is still at a minimum and one should improve the freedom of movement for patients. The regulation must state that the patient has a free international choice as to his service provider and hospital. The only public health restriction that could be justified is the requirement of a high level of quality that is comparable among treatment providers. This level is guaranteed by the mutual recognition of degrees, equipment and medical devices, as well as medicine.
Mobility of patients is linked to the principle of free movement of goods that respect the right of patients to private sector is at the same level as and services that must be applied to choose the place of treatment, inter- the public health service. It has been all social security systems. The Com- nationally or nationally and to use all decided to establish agreements munity authorities do not have to the available establishments, public between the private sector and the standardise a treatment or payment and private. In many countries such public social security. Patients who, system, but rather lay down principles as France, Italy and Germany, the for instance, choose one of those
50 2050: A Health Odyssey DR. MAX PONSEILLÉNEUROLOGY AND PAOLO GIORDANO
private hospitals do not have to pay long waiting lists. The concept of will have its own place and function anything. It is their social security European citizenship must be thought within the national and international system that will pay for them, just as through i.e. what rights are recognised hospitals network and would be if they went to a public structure. to patients. A “Patient rights Charter” involved in the social dialogue, is indeed being discussed: every intended to promote the hospitals The competence of the EU covers citizen has the fundamental right to sector within the framework of a the coordination of: receive healthcare services. This shall global health policy. • non–discriminatory conditions of not be an obstacle for citizens. In the access; same way, patients need all the • coverage by each country of services necessary information to remove freely chosen in another EU country; administrative difficulties. There is still • mutual and minimum guarantees of a lack of information about available quality and qualification; treatments. • Member States’ limitations or obstacles, without actually choosing In the light of this, it would be useful a system or rules or programmes. for the future if the European Com- mission could approve a decision Unlimited freedom of movement of which enforces and underlines all the patients can be envisaged in the European Court of Justice decisions short-term. It would sound absurd and all the recommendations of the not to allow citizens to seek a High Level Group. Eventually, this fundamental medical treatment decision should foresee funding wherever a better quality or quicker opportunities to help Member States service can be dispensed. Citizens to build up the required information of new Member States must be able system. This in accordance with the to enjoy the same quality of health- principle of subsidiarity. care as citizens of the original fifteen Member States. The quality of their But what of patient mobility in 2050? healthcare systems should be Undoubtedly the strains on healthcare improved but they should also have systems will rapidly rise given the the possibility to choose what they ageing population. Given that many consider the best structure for them systems provide “guaranteed” delivery without discrimination. of healthcare to patients, this will call for increased efficiency as costs rise. Statistical data shows that there is The result will be a rationalisation of not enough patient movement between how medical treatment is provided, Member States to undermine national not if it is provided. healthcare. Patients have the right to take advantage of all the healthcare Patient mobility in 2050 will see a services provided by their Member large percentage of treatment outside States and beyond in order to avoid of the home country. The private sector
About the Author
Dr. Max Ponseillé is the President of UEHP Paolo Giordano is the General Delegate of the UEHP
European Union of Private Hospitals: http://www.uehp.org
2050: A Health Odyssey 51 HEALTH IS WEALTH
Health is wealth - strategic visions for European healthcare at the beginning of the 21st century
By Prof. Dr. Felix Unger
This article looks at the future of healthcare delivery in the EU.
Delivery of healthcare is now a matter are included, this is estimated to Europe demands a new comprehensive for serious public discussion and the increase to 20 – 25% of GNP. However, European healthcare system to over- future of European healthcare is public contributions to the costs of come national barriers and to foster based on the patient’s own respon- healthcare via insurance premiums greater mobility in an open market. sibility in a free market. Old national and taxes cannot sustain unlimited The European Academy with its structures are seen to have failed and growth while the working population Institute of Medicine sees this as a this has resulted in growing public is shrinking. The potential for cost great opportunity to consolidate the frustration coupled with exploding reduction has to be quickly realised different national models and inherited costs. People react angrily if they are by redefining healthcare packages systems in a European Healthcare denied access to care or services and that can be provided from public Market (EHCM) and consequently to in many countries healthcare is funds based on the levels of solidarity stimulate clinical leadership to achieve considered as a part of social in European society. The private sector sustainable reforms. The goals of welfare, and is generally a high will cover any additional costs not EHCM are the following: political priority. This combination covered by public funds and sub- • healthcare for all; gives rise to national state-monopolies sequently will gain more importance. • health resource allocation based on with few private exceptions. This in Finally, young people have to be evidence and efficacy; turn has proved to be a source of advised today about providing for • cost control; mismanagement and discomfort to their health coverage of tomorrow. • transformation of healthcare from patients. Against this backdrop, national monopolies to a European Europe is ripe for a European market market. for healthcare with the essential prerequisite “Health for All”. The development of this market will depend on clinical leadership. Key challenges are posed by progress in therapy and diagnostics, which make healthcare more and more specialised and expensive in an environment of an ageing population compounded by declining birth rates.
In Europe, medicine expenditure represents approximately 14% of GNP. When all other health markets such as wellness, para-medicine and all related structures in health and care
52 2050: A Health Odyssey PROF. NEUROLOGYDR. FELIX UNGER
The common concern is the increasing cost of provision. Stabilising costs in an environment of a decreasing working population is very challenging. By modernising systems there is potential for controlling costs, the processes for which have still to be identified. Most national reforms have failed due to massive political influence especially where healthcare together with welfare is operated as a state-monopoly.
My strategic vision for the future of healthcare is based on the following goals: • To provide healthcare for all European citizens; • To transform healthcare from national state-monopolies to an open Euro- pean market allowing mobility and B. MEDICAL ARTS and providers of finance. Research, better use of resources; development and industry play • To identify potential for cost control. The optimisation of Medical Arts and indispensable parts in developing Sciences is an essential prerequisite the medical arts. Europe has to This strategic vision has four mutually of the strategic vision. The focus here encourage and promote innovation in dependent parts: the patient is in the is on the basics of diagnosis, therapy new therapies and diagnostics. centre, and surrounded by the Medical and prevention. Conservative, invasive Arts, the Medical Organisation and and prophylactic principles cover the C. ORGANISATION IN MEDICINE Financing. It is structured in 4 segments whole range of possibilities including (A-D below) which represent the corner the prediction and prevention of Greater effectiveness in the organi- stones for establishing a real European diseases. To use Outcome Related sation of healthcare can be achieved healthcare market. Medicine (ORM) as a measure of by the alignment of best practices effectiveness, medical conditions have and in boosting synergies in access A. THE PATIENT to be classified. The capacity for and quality. The main nucleus of the purchasing has a direct effect on the EHCM is that healthcare is delivered There is a change in today's paradigm: access of patients and clinicians to all by doctors for in- and out-patients in the patient has become the focal point. therapies and diagnostics. It is neces- acute, chronic and long–term condi- tions. New educational concepts on There is a change in today's healthcare provision will have to be “ introduced at universities and schools for nurses and paramedics. It will be paradigm: the patient has become essential in the future to create and to foster sustainable clinical leadership. the focal point.” There will be no sustainable reform in the future without a solid core of sary to monitor the effectiveness of medical professionals. eHealth will The patient of today is increasingly healthcare provisions, to perform play a major role in medicine for well-informed and motivated. The quality control checks and to measure information, transfer of findings and patient is at the centre of all efforts, therapy by means of health technology avoiding duplication of effort. A and all healthcare provisions are assessment and outcome indicators. patient's "Health literacy" will gain in constructed around the patient. The Assessment can be done by patients, importance. It is foreseen that 80% of patient is both a consumer and a clinicians, healthcare organisations patients will perform “self-care” actions contributor to the EHCM.
2050: A Health Odyssey 53 HEALTH IS WEALTH
without the involvement of healthcare ness and to demonstrate fairness in In summary healthcare of the 21st professionals. financing. Surveying Europe shows Century must have the patient as the that there are a variety of systems in central fulcrum of all stakeholders.
D. FINANCING OF HEALTHCARE operation: including the Anglo-Saxon This approach will drive necessary (Beveridge) universal state-centred, changes at both EU and national Healthcare financing must be patient tax-based social security system, level, as well as at the level of the oriented and make use of several and the continental "Bismarck" model private sector, including insurance, instruments: insurance premiums, co- financed by social insurance and medicine, and eHealth. Health policy payment systems, capitation, taxes, corporate elements (Chassard and relating to EU citizens will no longer voluntary payments, out-of-pocket Quintin 1992). The private sector will be the remit of government alone, but expenses etc. Covering healthcare gain increasingly in importance and rather a nature mix of investment by costs will need a combination of in the future copayment systems will all stakeholders. national healthcare allocations and be unavoidable, and the methods of individual contributions to provide all financing by solidarity contributions citizens with equal access, responsive- will need to be redefined.
Fig. 1: Overview of the European Healthcare Market
National • Funding the European Healthcare Market Tasks • Providing equal access, broad population coverage and high quality • Setting reimbursement standards
European Tasks
• State-of-the-Art in Medical Sciences • Organisation of medical service providers • Prediction, prevention, diagnosis, therapy • In- and out-patient services • Development of medical standards • For acute, chronic and long-term conditions • Efficacy and volume monitoring • Medical and paramedical education • Quality control • eHealth • Research and development
54 2050: A Health Odyssey PROF. NEUROLOGYDR. FELIX UNGER
Fig. 2 Structural Reform for European Healthcare
Current: National monopolies Future: European HC Market
Cost explosion National cost control and solidarity Rigid public structures Health for all in open EU market Unequal access to Healthcare coverage Market arbitration of resources Resource mismanagement Responsible patient = decider Patient dissatisfaction Evidence-based standards Unsatisfactory outcomes • The responsible and informed patient is at the centre • No holistic view of the patients and their role in HC and drives the European HC market • Diverging funding systems (public/private) • Funding systems aligned but maintained as national • Each country has specific, regulated HC organisation task • Different principles of HC regulation • HC organised as a European open market – State-run • European HC regulation standards – Self-administration with national regulation – Standards for state participation – Mixed forms – Standards for self-administration • Unclear distinction between healthcare and social • Clear separation of HC and social welfare tasks welfare • Common European medical classification based on • Diverging medical usages efficacy and evidence
About the Author
Univ. Prof.Dr.Dr.h.c. Felix Unger, is President of the European Academy of Arts and Sciences European Academy of Arts and Sciences: http://www.european-academy.at/en/
2050: A Health Odyssey 55 INVEST IN HEALTHCARE WORKERS
Invest in healthcare workers = invest in the future of the healthcare sector
By Bert Van Caelenberg
This article looks at the role to be played by healthcare workers in the future of healthcare.
INTRODUCTION 1. THE HEALTH OF HEALTHCARE WORKERS (7% in hospitals). Precisely because “health” is one of the main pillars of In the course of the last decade, the A recent study of the Austrian “Ludwig our economic growth and develop- healthcare sector has been confronted Boltzmann Institute for the Sociology ment, makes the healthcare sector 1 with ongoing problems as regards of Health and Medicine ” has shown such an interesting one.
The problem is that workers of the “ 10% of Europe’s working population healthcare sector are under heavy health pressure. Indeed, it is widely works in the healthcare sector.” known that this sector is one of the most hazardous to work in, patho- healthcare workers, and indeed the that 10% of Europe’s working popu- logically speaking. Both physical future of healthcare workers may not lation works in the healthcare sector problems (e.g. infections, MRSA, be so bright. By throwing light, in a constructive manner, on some of the most pressing problems in this field, this article should provide European policymakers with suggestions for solutions.
Threats to European healthcare workers are of a diverse nature and are in such a way interrelated with each other that they can have an influence on all actors in the sector. Employers and workers, trade unions, industry, authorities, schools and universities may undergo the consequences of this. In order to effectively deal with these problems, we need to invest in the sector’s biggest capital: its workers. This will be even more important in 2050, when there will be more people who need healthcare, but less people who can help them.
56 2050: A Health Odyssey BERT NEUROLOGYVAN CAELENBERG
AIDS, sharps’ injuries) and psycho- logical problems (e.g. burn-out) are very frequent in this sector. That is why health and health promotion have to be seen as a real management task for the institutions. On the one hand, because these institutions depend on the health of their staff for their own continuous functioning (absenteeism, mistake risks, early departure of collaborators, etc.). On the other hand, because they are themselves (co-)responsible for this promotion and maintaining the health of their workers.
Therefore, it is necessary to establish a basis for strategies, programmes and measurement instruments to improve the health of the workers in the next fifty years and practise bench- marking between various organisations and units.
2. THE EUROPEAN WORKING TIME REGULATION FOR EUROPEAN HEALTHCARE WORKERS
The work in continuous shifts with permanently staffed services and the shortage of healthcare workers in this sector mean that workers in this sector are confronted with having to perform far too many hours consecutively. Therefore, it is of great interest that a good working time regulation is 2 designed and implemented .
3. MIGRATION OF HEALTHCARE WORKERS
The testimonies given by Poland and This migration is mostly an eco- 4. TRAINING AND SKILLS OF HEALTHCARE Slovakia at the final conference of the 4 nomic migration to Western EU WORKERS IN EUROPE NEXT-Study exceeded all imagination. Member States, the USA, Canada Migration has become such a great and Australia. The problem has to be There is a great variety of training and problem in Eastern European countries tackled. It also shows itself in African certificates in Europe. The permanent that it risks putting a real threat on and Asian countries. Furthermore, evolution of health science requires public health. Some hospitals even these migrants are often exploited in that all healthcare workers permanently have to close doors on certain days Western countries, where they may do improve their skills. Therefore, it is in because they do not have enough the job well but are paid as a cheaper the interest of everybody (employers, healthcare workers. workforce. workers, industry, patients) that healthcare workers acquire the
2050: A Health Odyssey 57 INVEST IN HEALTHCARE WORKERS
necessary skills on the work-floor, in 5. DEMOGRAPHIC PROBLEMS AND THE job, lack and cost of housing, older accordance with new developments, EARLY EXIT OF HEALTHCARE WORKERS age at which people have their first rather than super-specialise themselves child, occupational choices, study without any guarantee for the future. The demographic changes in today’s choices, etc. More permanent training on the units society are the result of a few basic 5 within the framework of lifelong developments : These demographic developments learning is required instead of super- • continuing increases in longevity as will have the effect of increasing work specialisations. a result of considerable progress pressure and putting even more made in healthcare: the age of the strain on working conditions in the population will continue to increase; healthcare sector so that even less • continuing low birth rates as a result people will be urged to choose a job of a number of social and economic in this sector. factors such as difficulty in finding a
58 2050: A Health Odyssey BERT NEUROLOGYVAN CAELENBERG
Furthermore, as regards training, it is increasingly assumed that younger people today are better trained and, so, are more productive and more capable of working with flexibility. But people should become aware that flexibility also has its borders. It is precisely because the pressure put on healthcare workers as regards flexibility has reached such a high level, that they are not capable of flexibility anymore.
Europe should invest in better demo- graphic developments for the future.
FINAL OBSERVATIONS
1. Healthcare must be a political priority! Healthcare should get a better place in the political mainstream. “ It is necessary to establish a basis for strategies, programmes and measurement instruments to improve the health of the workers in the next fifty years...”
2. Monitoring of the problem: Public authorities and government 1 must be key players in eHealth. Ludwig Boltzmann Institute for the sociology of health and medicine and the Institute for Sociology, HUSO university of Vienna : “Health of the Healthcare Workers” by Sonja Novak- 3. Healthcare as action programme: Zezula. Healthcare must have a place in 2 Amendment to 2003/88 the future European health action 3 Opt out concept = worker can agree to deviate from the working time regulation by signing an programmes. opt-out. 4 4. Invest in healthcare workers: NEXT-Study : “Nurses’ Early Exit Study” - htpp://www.next.uni-wuppertal.de/download/ NEXTscientificreportjuly2005.pdf Healthcare as one of the biggest The NEXT-Study is a European research project investigating premature departure from the sectors in Europe must be able to nursing profession in European healthcare. It is being financed by the European Commission develop itself in the future. (QLK6-CT-2001-00475). European NEXT-Study coordination by Hans-Martin Hasselhorn, MD, PhD & Professor Bernd Investment in the healthcare workers Hans Müller. Department of Safety Engineering, Division of Occupational Safety and is a long-lasting responsibility. Ergonomics, University of Wuppertal, Germany. 5 See COM(2005)94
About the Author
Bert Van Caelenberg is the Secretary General of EUROFEDOP. European Federation of the Public Service Employees: http://www.eurofedop.org/index.html
2050: A Health Odyssey 59 STANDARDS OF CARE FOR EUROPE’S AGING POPULATION
Standards of care for Europe’s aging population - osteoporosis in Europe
By Prof. Dr. Antonio Moroni and Amy Hoang-Kim
In this article the effects of osteoporosis on an aging European population are considered, and possible strategies for improved care are put forward.
According to the 2002 UN World fracture even when the radiographs of fixation failures and poor functional Population Prospects, by 2045- appear normal. People with broken outcomes. Furthermore, surgery should 2050, the average life expectancy in bones suffer severe pain and disability, be kept simple to minimise operative Europe is expected to rise to 80.5 resulting in a loss of quality of life and time, blood loss, and physiologic years from the currently estimated independence. There is also an in- stress. 73.2 years. There will also be more creased risk of death, as a result of
elderly people as one-third of Europe’s osteoporosis not being diagnosed in SOCIAL COST population will be at least 60 years time. Unless osteoporosis prevention and “ By 2045-2050, the average life expectancy in treatment becomes a priority for government and healthcare providers, Europe is expected to rise to 80.5 years from this growing number of osteoporotic fractures will have a serious impact the currently estimated 73.2 years. on society, not just in terms of people’s ” quality of life, but also in regard to increased expenditure for healthcare, old by 2050. As Europe’s population rehabilitation and nursing care. In fact, ages and becomes more sedentary, Pneumonia, congestive heart failure, patients with osteoporotic fractures the number of people affected by thromboembolic disease, decubitus are among the highest risk patients osteoporosis will increase significantly. ulceration, and further generalised for further osteoporotic fractures, often Hip fractures, which are a severe musculoskeletal deterioration are within one year of the fracture. consequence caused by weak porous frequent complications in bedridden bone, are expected to double in the elderly patients. A comprehensive WHAT ACTION CAN BE TAKEN? next 50 years. working knowledge of diagnostic modalities, medical therapeutics, and Although fractures of the spine, hip Osteoporosis is a chronic, progressive, the special needs of the osteoporotic and wrist are most typical of osteo- mostly asymptomatic disease. The surgical patient will become more porotic condition, fractures of other fact that osteoporosis is asymptomatic important as the population continues bones, such as the ribs, humerus, and may mean that patients find it difficult to age. Furthermore, widespread insuf- pelvis are not uncommon. Compared to appreciate that treatment is ne- ficiency in calcium and vitamin D to individuals with no history of fracture, cessary or understand the benefits. It intake as well as lack of exercise a patient with a prior vertebral fracture is unfortunate that only after a throughout Europe will have an impact is nearly five-times more likely to suffer fracture occurs the patient realises on bone health and on the number of future vertebral fractures and up to a that treatment is necessary. It is people with osteoporosis in the future. six-times more likely to suffer hip and important that the orthopaedic surgeon, The majority of fractures of the long other non-vertebral fractures. The risk who is the first to encounter these bones in elderly osteoporotic patients of any osteoporotic fracture increases cases, considers the special needs of are best managed by early surgical exponentially with aging in both men the osteoporotic fracture patient and fixation. These fractures are fixed with and women of all races. recognises that osteoporotic patients surgical implants which have been who describe pain at specific skeletal designed for healthy bone fixation. sites may be experiencing a stress This often leads to a high incidence
60 2050: A Health Odyssey PROF. DR. ANTONIONEUROLOGY MORONI AND AMY HOANG-KIM
Bone mass can be determined with THE ADHERENCE GAP: pendence and increased mortality. dual energy x-ray absorptiometry (DXA). TARGETING TREATMENT Worryingly, 70% of doctors acknow- The rate of active loss can be assayed ledge that they do not know why so by the detection of bone collagen The survey conducted for the Inter- many patients spontaneously stop breakdown products in the urine. national Osteoporosis Foundation by taking their bisphosphonate medi- Strategies for the prevention and IPSOS Health, aimed to understand cation. While 90% of women view treatment of osteoporosis are directed the reasons why women with osteo- osteoporosis as a serious condition at maximising peak bone mass by porosis do not stay on treatment. It they don’t fully appreciate all the optimising physiologic intake of cal- showed that 34% of women inter- benefits of their treatment. Three- cium, vitamin D therapy, exercise, viewed either didn’t know what the fifths of patients questioned felt that and maintenance of normal menstrual benefits of their medication were or focussing on the positive outcomes cycles from youth to adulthood. Cou- wrongly thought there were no benefits of treatment - such as knowing they pled with drug therapy should be a at all. Drawback of treatment identified were doing something to help them- comprehensive approach to exercise by women were predominantly related selves - provided the greatest and fall prevention. Stretching, strength- to inconvenience and side effects. motivation for continuing their therapy. ening, impact, and balance exercises 85% of doctors prescribed a bis- Conversely, 41% of physicians are effective. phosphonate, the most commonly focussed on negative motivators prescribed osteoporosis treatment, such as fear, believing the best way
IS GENERAL BONE HEALTH NEGLECTED and patients stopped treatment too to motivate patients to continue BY EUROPEANS? early to get full benefit. Evidence treatment is to explain or remind them suggests that the communication about the risks and complications of 65% of women past the age of gap between doctors and patients fracture if they abandon treatment. menopause have varying degrees of threatens effectiveness of long-term lactose intolerance and by preference treatment. Stopping treatment leaves avoid lactose-containing dairy pro- ducts. There is also constant pressure “ Evidence suggests that the communication gap on the public to slim, and calcium- containing products, most notably between doctors and patients threatens milk, are perceived to have high caloric densities. Consequently, whether by choice, habit or design, most Euro- effectiveness of long-term treatment.” peans have calcium intakes below the recommended level, particularly patients at greater risk of fracture and In addition, while doctors agree on in the elderly years. Even with detailed associated disability, reduced inde- the importance of long-term treatment instruction and guidance, it is difficult for individuals to obtain adequate amounts of calcium (specifically, 1,500 mg daily) strictly from their diet. Therefore, supplements are required if age-corrected physiologic calcium intake is to be achieved. Established recommended daily levels of calcium intake indicate that calcium is most effective when taken throughout the day, with no dose being larger than 500 mg at a given time. Dietary sources of calcium include dairy products, broccoli, tofu, and rhubarb.
2050: A Health Odyssey 61 STANDARDS OF CARE FOR EUROPE’S AGING POPULATION
‘Ringing the and 82% said they told patients to both in-patient and out-patient, and vities in the Northern Ireland report stay on therapy for a minimum of one providing the evaluation process. An ‘Ringing the changes: a strategy for changes: a to two years, just over half of patients efficient system includes a competent older people’ include ways in which to strategy for could not recall being told how long orthopaedic ward staff maintaining a reduce the severity of osteoporosis older people’ they should continue their medication. list of fracture admissions between and also recommendations for safe- - Northern The survey shows that where doctors visits by the nurse, using general proofing the home for the prevention Ireland Report and patients do agree is in relation to hospital IT systems to track patients, of falls. how treatments could be improved. and working with the clinical secretaries
Eight out of ten doctors believe in the orthopaedic departments to IMPROVING MEDICINES MANAGEMENT improvements in osteoporosis treat- obtain copies of all reports relating to ment are necessary for effective new in-patient and out-patient The work of ISFR and partners is disease management and three- fracture attendances that are routinely encouraging the local planning and quarters of those interviewed felt that sent to primary care physicians from provision of a range of additional or altering the dosing frequency of bis- the orthopaedic consultants. In this reconfigured services delivered by phosphonates would have a strong setting of a nurse-led clinic, recom- healthcare practitioners and by influence on adherence. Patients mendations would be made to the specialists in the care of people with concur, citing reduced side effects primary care physician to commence these conditions. These initiatives and having to take treatment less calcium and vitamin D without further have been aimed at further improving often as the top two things they think assessment. At the time of bone older patients’ access to proper would improve adherence. A Canadian density measurement, the risk factors diagnosis of osteoporosis. Older study followed patients with a fragility for osteoporosis and fractures are people often need multidisciplinary fracture from five community fracture identified and discussed. These results assessment which has to date not clinics. It would appear that patients and their implications would be dis- been available. The coordinated who understand the clinical implication cussed with the patient. Educational improvement action is to ensure that of low bone mass are more likely to material about osteoporosis and no osteoporotic fracture patient seek treatment. Therefore, promoting reduction of fracture risk would be spends more time than necessary in patient information and patient edu- given to the patient. Risks and benefits the hospital ward. The development cation are vital to the success of any of possible treatments including ap- of services both in the hospital and future fracture prevention strategy. propriate lifestyle modifications would the community should provide one- be agreed upon. This DXA report on-one assistance in order for the HEALTHCARE STRATEGY FOR THE ELDERLY would then be sent to the general patients to fully understand their practitioner after the DXA assessment. condition and subsequent treatment Because the primary objective of the A computerised database is necessary modality. Therefore, a top priority for orthopaedic surgeons is treatment of for the management of osteoporosis reducing pressure on emergency fractures, they have not wished to including fracture history, past medical services is the development of assume central responsibility for history, risk factors for osteoporosis, improved management of chronic evaluation and management of the risk factors for fracture, current conditions in the community. Further- underlying chronic disease. Identi- medication use, DXA results and more, older people would benefit fication of these patients through interpretation, lifestyle recommen- greatly from increased hospital capacity primary care practices has to date dations, osteoporosis treatment for elective surgery, particularly in been unreliable and incomplete. The recommendations and arrangements relation to orthopaedics, where inter- development of a fracture liaison for follow-up. The lead advocate, vention makes a big difference to service can and should assume the who may be from Primary Care, their independence and quality of life. responsibility for assessing and Secondary Care or a Nurse Consultant, performing diagnostic evaluations is the driving force of a fracture By 2050, these prescriptions for (including the use of DXA scans) and liaison service. better treatment and prevention will making specific treatment recommen- be well advanced as personal clinical dations for the secondary prevention PREVENTION OF FALLS AND FRACTURES and out-patient care grows increas- of osteoporotic fractures. This is a ingly sophisticated on the back of service in which specialised nurses Action should be taken to prevent modern technology. This will slowly have primary responsibility for identi- falls and other injuries in older people. follow the main trends in patient fying fracture patients at all sites, Recommended health promotion acti- healthcare – i) the issue of personal
62 2050: A Health Odyssey PROF. DR. ANTONIONEUROLOGY MORONI AND AMY HOANG-KIM
management of treatment and pre- REFERENCES: selective oestrogen receptor mo- vention through increased knowledge dulators (raloxifene) and parathyroid of their vulnerability and steps that a 1) Gunnes M, Mellstrom D, Johnell O. hormone (teriparatide) for the patient can personally take to decrease 1998 How well can a previous secondary prevention of osteo- their risks of disease or injury; ii) rise fracture indicate a new fracture? A prootic fragility fractures in and adoption of wellness programmes questionnaire study of 29,802 postmenopausal women. Techno- in which the patient is incentivised to postmenopausal women. Acta logy Appraisal 87. January 2005. pursue proper health management Orthop Scand 69 (5): 508-12. and; iii) specialisation of clinical 8) Northern Health and Social Services functions to deliver centres of 2) Hawker G, Ridout R, Ricupero M et Board. Ringing the changes: A excellence around a specific condition al. The impact of a simple fracture strategy for older people. December or injury. clinci intervention in improving the 2002. diagnosis and treatment of osteo- porosis in fragility fracture patients. 9) Riggs BL, Melton LJ III: The Osteoporos Int 2003; 14: 171-178. prevention and treatment of osteo- porosis. N Engl J Med 1992; 327: 3) IPSOS Health, European Survey of 620-627. Physicians and Women with Osteoporosis, January-April 2005. 10) Scottish Intercollegiate Guidelines Sponsored by Roche/GSK. Network. Management of osteo- porosis SIGN 71. June 2003. 4) Lane J, Nydick M. Osteoporosis: Current Modes of Prevention and Treatment. J Am Acad Orthop Surg 1999, 7:19-31
5) Lucas T, Einhorn T. Osteoporosis: The Role of the Orthopaedist. J Am Acad Orthop Surg 1993; 1: 48-56.
6) McLellan A, Gallacher S, Fraser, M, McQuillian C. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 2003. 14: 1028- 1034.
7) National Institute for Clinical Excellence. Bisphosphonates (alen- dronate, etidronate, risedronate),
About the Authors
Antonio Moroni is Professor of Orthopaedics and an ISFR Board Member and Osteoporotic Fracture Campaign Steering Committee Amy Hoang-Kim (BSCH, MA) sits on the ISFR Osteoporotic Fracture Campaign Steering Committee and is Research Coordinator
International Society for Fracture Repair (ISFR): http://fractures.com/isfr/duportal/default.asp
2050: A Health Odyssey 63 DIABETES - ABOUT CURE, CARE AND PREVENTION
Diabetes - about cure, care and prevention
By Dr. Wim Wientjens
Copyright Loura Kok Fotografie This article looks as diabetes as a growing concern in the healthcare sector and how this epidemic should be approached so as to ensure best care and containment in the 21st Century.
Nowadays, diabetes is still an incurable This poses fundamental economic notable, complications from diabetes disease and a very serious disease. and productivity problems for remained a serious health risk. That’s the bad news. The good news governments and individuals alike. is that diabetes is a treatable disease Prevention or at least delay of any Diabetes is a chronic condition that and a manageable disease. resulting complications has been arises when the pancreas does not proven very cost effective and help produce enough insulin, or when the There will be more than 300 million sustain a longer and more active body cannot effectively use that persons in 2025 with diabetes and working life. However, this rising insulin. In general, we are talking now this will increase further to more than problem will not be countered unless about two types of diabetes. Diabetes 500 million in 2050 if we don’t succeed we adopt a new view on patient type 1, in which type of diabetes the in changing our lifestyle. In many of treatment, not just for diabetes but production of insulin by the body our modern societies our lifestyle is completely stops. Diabetes type 2, in which type of diabetes there is still “ There will be more than 300 million persons in insulin production, but the working of insulin is not good. Insulin is necessary 2025 with diabetes and this will increase to get glucose into the cells of the body. Common symptoms of diabetes further to more than 500 million in 2050 if we type 1 include excessive thirst, constant hunger, frequent urination, sudden weight loss, extreme tiredness, blurred don’t succeed in changing our lifestyle.” vision. People with diabetes type 2 may have the same symptoms but one of the major causes of diabetes. for all chronic and dehabilitating they may be less apparent. Many The composition of what we are conditions. have no symptoms and are only eating and drinking contributes to diagnosed after several years with this rising epidemic. Too many From the moment insulin was the condition. calories, too many wrong fats and discovered (more than 80 years ago) obesity are growing risk factors in the one could survive by receiving spread of diabetes. “ Every 30 seconds a leg is lost due to For people with diabetes, the de- velopment of one or more serious diabetes somewhere in the world.” complications is, of course, personally very dramatic. Blindness (10%), kidney injections with insulin. This major The amount of people with diabetes failure (30%), neuropathy (45%), breakthrough help millions to survive type 2 has increased tremendously in amputations (every 30 seconds a leg the traumatic ramifications of the the last couple of years. The expec- is lost due to diabetes somewhere in disease. However, while survival of tations are that the amount of people the world), and heart failure are all diabetes itself was becoming more with diabetes in the world will increase follow-on conditions from diabetes. from about 130 million people in
64 2050: A Health Odyssey DR. WIMNEUROLOGY WIENTJENS
2003 to more than 300 million people Second, there is the process of patient solutions and home care. This in 2025. About 10% of these patients education, in which the person with will cut across the previous “doctor will have diabetes type 1 and about diabetes plays the role of a pupil or a knows best” approach to treatment 90% will have diabetes type 2. This student who has to learn to manage and involve a new layer of complexity disease has the capacity to cripple diabetes in their daily life. A very to patient decisions. health systems as they are today. good self-management of diabetes is From 1922 (the year insulin was “ The amount of people with diabetes in discovered) up to now, much more is known in the diabetes field. Since the world will increase from about 130 then many innovations have taken place regarding medicines against million people in 2003 to more than the disease itself, including medicines against several follow-on complications, 300 million people in 2025. This new blood glucose monitoring and monitoring of other important blood parameters, new methods of education, disease has the capacity to cripple especially regarding psychosocial aspects and new approaches to diet health systems as they are today.” and exercise.
often necessary and in most cases is In many countries, National Diabetes When a person is diagnosed with now possible. This trend towards self- Programmes exist with a range of diabetes, three processes start in treatment has been around for years, modern possibilities of treatment and that person and he/she will play three but technology and medicine are now including many guidelines and roles according to these three pro- releasing new methods of patient standards. However, the implemen- cesses. These processes will become own-care. Increasing homecare solu- tation of these programmes are very more prevalent for patients over the tions and ease of use will allow poor. This mainly concerns the quality next few decades and serve as a patients to increasingly self-treat, and the availability for everyone of guide to what will happen with thus avoiding hospital visits and proper medicines (including insulin), patient care. They are not exclusive radically changing the way patients lack of a critical mass of healthcare to diabetes patients. seek assistance. This will have a professionals, not enough reimbur- major impact on how healthcare is sements for cutting-edge technologies First of all, there is a process of good delivered as it will no longer simply and a lack of investment in new treatment and care, in which process be the doctor - hospital nexus which methods of treatment. the person with diabetes plays the drives treatment. role of a patient - getting medicines Therefore, the first step in the coming and devices, diagnosing the condition Third, there is the process of being a decades must be the proper imple- and understanding any possible full member of society, in which the mentation of good diabetes care for complications. This is indicative of person with diabetes has to play the everyone anywhere in the world. This one of the major trends in treating role of a patient with interests, with all includes the millions who already chronic disease - the informed patient. the rights and duties as everyone have diabetes but are still not As the array of treatments increase, else in this world. This may seem diagnosed. Late diagnosis can leave patients will seek information on not only the most appropriate treatment, “ Patient rights will no longer be about demanding but the cost and availability of such treatment. Information will unleash a in-patient treatment, but equally seeking out- whole new set of patient demands with assessment and preliminary patient solutions and home care.” diagnosis being shared between patient and doctor, if not challenged obvious, but patient rights will no diabetes undiscovered for up to 5 – by patients. longer be about demanding in-patient 10 years. Complications are already treatment, but equally seeking out- present before the diagnosis takes
2050: A Health Odyssey 65 DIABETES - ABOUT CURE, CARE AND PREVENTION
place and this requires a whole new Not only are life saving medicines The second main step in the coming level of treatment. and medicines against complications decades will be prevention. In this necessary, but also treatments which respect we have to talk about pre- Good implementation of existing improve all the aspects of having a vention of diabetes itself and about knowledge means also the willing- normal quality life without unnec- prevention of diabetes complications. ness to change treatments, when it is essary limitations and unjustified This step involves the two aforemen- necessary. Many patients with discrimination. So in the coming years tioned approaches – self-education diabetes type 2 start with tablets, but implementation of good diabetes care of the patient and training for self- change far too late from tablets to and diabetes education will also be treatment. One of the biggest problems insulin injections or to combinations characterised by a goal of leaving the is tackling those who are undiagnosed of several tablets and insulins. This patient with a good future quality of for diabetes, particularly type 2. A increases the propensity for further life. No longer should treatment be major thrust will be to diffuse complications. about mitigation of symptoms, but information and self-testing as soon making continued health a priority. as possible. Like annual tests for automobiles for roadworthiness, there
66 2050: A Health Odyssey DR. WIMNEUROLOGY WIENTJENS
will be a new regime for health the 1990s, St Vincent became a real (humanitarian, social and economic), prevention involving regular scheduled concept in the diabetes world. Euro- to increase the chances of diabetes tests for major diseases, particularly pean meetings for the Implementation to become a health priority in indi- those affected by lifestyle. of SVD were organised (Hungary vidual nations, to promote strategies in1992, Greece in 1995, Portugal in for the prevention of diabetes compli- The third and ultimate big step for 1997, Turkey in 1999). The European cations (in particular cardiovascular diabetes this century must be a Association for the Study of Diabetes disease), to promote public health cure. Unfortunately, there are too few (EASD) joined the St Vincent move- strategies for the prevention of signs of exploratory research work in ment, and IDF/EASD co-operation diabetes itself, to recognise the the field of curing diabetes. Of continues to thrive today. For several special need groups (diabetes in course, these kind of breakthroughs reasons, including the organisation of children and adolescents, the elderly, cannot come from practicing doctors, SVD, the outcome of improved pregnancy, migrant populations, people but dedicated R&D departments. Real recording of diabetes itself and of the in developing nations, indigenous breakthroughs must come from other complications (as mentioned in the peoples). disciplines. From immunology, gen- SVD targets), and the access to good etics, stem cell research, and information about the progress of the In conclusion, 2050 will need to bring vaccination research amongst others. national action plans were very about a revolutionary change in the The costs of this research are far difficult. But at the same time, WHO way we address chronic diseases below the costs of the treatment of Europe, IDF Europe and EASD such as diabetes. The patient-centric diabetes patients nowadays. Costs realised how important the concept model will be the main driver for analysis finds that investment in finding of the St Vincent Declaration still is. treatment involving a large preliminary a cure for diabetes and its subsequent Even stronger: SVD is more needed stage of prevention and self-education. pay-off in terms of the general well- than ever. It is still used as a guide to The result will be less later stage being of diabetes patients is far below national diabetes service deve- treatment and a reduction in expensive the costs of getting people to the lopments. In addition, the epidemic complications which require time- moon for instance. The fear of course growth of diabetes and the trem- consuming and costly treatments. is that delay will further saddle later endous increase of complications Such a model can be developed but generations with the bill for not and of the very serious socio- without proper nurturing we may find addressing chronic disease. economic impact of diabetes in the ourselves talking about the same many countries of the European thing in 45 years time. Representatives of governmental Region of IDF and WHO, demand a health departments and patients' response at national and regional organisations from all European levels. countries met with diabetes experts under the aegis of the WHO Europe Coupled with the SVD, IDF is seeking and the IDF Europe in St Vincent a United Nations Resolution on (Italy) in October 1989. They un- Diabetes in 2007. The possible animously agreed on general goals outcome of such a UN Resolution for people with diabetes and on many would be to increase global awareness five-year targets in the framework of of diabetes, to increase the reco- the St Vincent Declaration (SVD). In gnition of the burden of diabetes
About the Author
Dr. Wim Wientjens is President of the International Diabetes Federation European Region (IDF Europe)
International Diabetes Federation Europe: www.idf-europe.org
2050: A Health Odyssey 67 PROMOTING GENDER EQUITY IN EUROPEAN HEALTHCARE
Promoting gender equity in European healthcare
By Peggy Maguire
This article considers the inequities in healthcare treatment between men and women and recommends strategies to deal with this.
2 Women comprise no less than 50% for the Health of Women in Europe . age, more attention must be paid to 1 of the population in any EU country , For example: the healthcare needs of women who and as half of the population women • mental health statistics often conceal have a higher life expectancy, and are ought to be entitled to the same level considerable differences in preva- known to spend, at all ages, greater of healthcare as their male counter- lence and disease manifestation at proportions of their life in states of parts. This must become a reality by different stages in the life cycle chronic illness and disability. 2050. The last twenty years has seen between women and men; a growing debate about the links • the causes of higher rates of de- HEALTH ISSUES MORE PREVALENT between gender and health, and pression and mental illness in AMONG WOMEN gradually a consensus is emerging women remain unknown; on the broader economic and social • cardiovascular disease is a lead Some diseases are more prevalent gains to be made from promoting the killer of women but the vast majority among women, though both sexes health of women. The promotion of of research has been based on can be affected. Although men can gender equity has been a long- long-term studies of men, making get breast cancer too, this condition standing theme in the philosophy and the findings not always applicable is typically associated with women. It operations of the EU (mainstreaming to women; is estimated that 1 in every 12 women of gender was formalised in the • the risk of HIV infection during will develop breast cancer at some Treaty of Amsterdam, in articles 2 unprotected intercourse is two to point in their lifetime. Risk factors for and 3, and by inclusion of a four times higher for women than breast cancer can include genetic statement to the effect that human men, yet much of the research is predisposition, hormonal effects and health should be protected in ‘all gender blind, women have been age, but many women develop breast Community policies and activities’). excluded from clinical drug trials cancer without any of these factors However, improvements to date have and are frequently diagnosed at a present. not gone far enough in respect of the later stage in the disease than men; creation of equitable and inclusive • most pharmaceutical research is Statistics on mental health disorders European healthcare systems that still carried out on men, even when often conceal the considerable diffe- realistically and pragmatically identify it is known that the disease in rences that exist between men and and address the needs of women. question is more frequent in women; women in the prevalence of specific • recent studies suggest the health types of mental disorders and at Inequalities between the sexes are risks associated with alcohol abuse different stages of the life cycle. further compounded due to the lack may be greater for women than Depression and depression-related of disaggregated information on a men. problems are today amongst the sex and gender basis, and for which most pressing public health concerns. the relevant statistical data is urgently Furthermore, as an increasing pro- The causes of the higher rates of required. Indeed, these necessities portion of the population reach old depression and mental illness are not were at least partially identified in 2001 in the World Health Organi- 1 World Development Indicators (2002): http://www.genderstats.worldbook.org.home.asp sation’s (WHO) Strategic Action Plan 2 World Health Organisation Regional Office for Europe (2001) Strategic Action Plan for the Health of Women in Europe Copenhagen: WHO Regional Office for Europe
68 2050: A Health Odyssey PEGGYNEUROLOGY MAGUIRE
known. However, we do know that smear in the previous year. A major brovascular disease. Cardiovascular risk factors prevalent in women barrier to addressing and treating this disease is an important cause of pre- include poverty, violence, self harm, wholly preventable, disease has been mature mortality in the accession sexual abuse, family responsibilities the lack of resources available to countries where rates are higher than and the role of the carer. One implement national and/or regional the EU average. Much of the re important consequence in relation to cancer screening guidelines and search on cardiovascular disease has mental disorders is suicide and cervical cancer screening programmes. been based on long-term studies of attempted suicides. Risk factors for men, and the findings are not always suicide and para-suicide (attempted The EU has recognised the potential applicable to women. Yet, cardio- suicide with higher rate among women) of population-based cancer screening vascular disease remains a lead killer include alcoholism, depression, and programmes in its Council Recom- of women in most developed countries. socio-economic problems. Women mendation adopted in 2003 (Official There is increasing evidence from all with eating disorders, such as anorexia Journal of the EU L327, 16.12.2003). It fields of medical research, suggesting and bulimia, are also at higher risk of remains to be seen whether the that on both the biomedical and committing suicide and para-suicide. Recommendation for breast, cervical social side, the risk factors, biological Statistics also show that women who and colorectal cancer screening will mechanisms, clinical manifestation, have attempted suicide are much be implemented in the 25 Member causes, consequences and mana- more likely to try again. Women are States. gement of disease may differ in men twice as likely to be diagnosed as and women. In such cases, prevention, depressed, yet doctors often do not HEALTH ISSUES AFFECTING treatment, rehabilitation and care- take women with depression seriously. WOMEN DIFFERENTLY delivery need to be adapted according Elderly women have the added to gender. Consequences for not disadvantage suffering the stereotype Cardiovascular disease causes 1.9 doing so impinge on the health of that depression is a normal part of million deaths a year in the 25 countries both women and men. For example, ageing. Specialists point out that of the EU. The most common cardio- emerging research on gender women have different symptoms vascular diseases are hypertension, epidemiology has revealed the when they suffer depression. ischaemic heart disease and cere- serious shortcomings of applying
HEALTH ISSUES SPECIFIC TO WOMEN
The existing healthcare system has historically underestimated the importance of the differences bet- ween women and men in terms of the impact on morbidity and mortality and on public health. Also less money has been invested on research into women-specific illnesses and diseases. Women’s reproductive capacity brings them into the healthcare system more often than men. This increased contact provides opportunities for such preventive measures as screen- ings for breast cancer and cancer of the reproductive organs, fertility control and support during pregnancy. Cancer of the cervix is the second most common female cancer in the EU. Early screening and detection can improve survival rates, but only about 40% of all women over the age of 15 report having had a cervical
2050: A Health Odyssey 69 PROMOTING GENDER EQUITY IN EUROPEAN HEALTHCARE
”male-based” diagnostic techniques norm especially when it comes to women, and to ensure effective public and treatments to female patients. treatment of heart disease. health policy and strategies for all by This stems mainly from the increased 2050. All healthcare services in all EU
recognition that symptoms of heart WOMEN AS BETTER INFORMED Member States need to be sensitive attack differ significantly between PATIENTS AND CARERS to women’s health needs, and to ensure men and women and that life- gender mainstreaming in health, to threatening delays in diagnosis (via Women have a keen interest in health make explicit how women’s physical, EKG) of women may occur because information. Easily accessible and psychological and social health of lack of awareness of the unique easily understandable, high-quality, should be addressed. nature of female symptomatology. accurate, reliable and up-to-date health and disease information to patients Quite simply, to begin to redress the An important increase in the number and the general public is an essential structural, and resulting policy and of HIV positive women reflects their step towards achieving a high level of delivery, deficits in healthcare, a greater biological vulnerability to this health protection. Today’s information revision of the parameters for data illness. Biologically, the risk of HIV technology has the potential to em- collection and analysis is necessary, infection during unprotected inter- power and support women as patients, as these determine subsequent policy course is 2-4 times higher for women guardians and carers of family health. and programme delivery. Additionally, than men. Women are also more Appropriate information can improve using both morbidity and mortality likely to have other STD’s (sexually communication between patients rates (rather than just mortality rates), transmitted diseases), which can and their doctors, lead to improved to inform public health policy would increase the risk of HIV infection by health status and a sense of being in go some way towards addressing 3-4 times. This is because women control. For these reasons, women gender imbalances. It will also broaden are biologically more vulnerable, and are rightfully viewed as protagonists health targets for diseases with high because 50-80% of STD’s have no for positive change. In fact, the WHO mortality (such as cancer and heart symptoms in women. If a woman acknowledges that women are one of disease) so as to include diseases becomes infected with HIV, she may the strongest means for improving with high morbidity (such as arthritis also suffer inequalities during the health in families and communities. and osteoporosis). treatment. As such, women should be central to future EU health policy and their ACCESS TO HEALTHCARE The WHO acknowledges that women are There is now considerable evidence “ of differences in access to health- care. Despite the fact that women one of the strongest means for improving use medical services more often than men do, it has emerged that care health in families and communities. As provisions are inferior for women who belong to another underprivileged such, women should be central to future group, such as black, migrant and ethnic minority women. There are EU health policy.” consistent indications that gender divisions can be a causal factor perspective must be included from In relation to research and policy, full limiting the quality of care women the start of the formulation process attention to women has only been receive. This is especially evident in rather than as an afterthought. given in the area of reproductive reproductive health services where health and even there, many gaps still exist between women’s health providers are often too concerned ACTIONS TO BE TAKEN with controlling women’s fertility needs and healthcare provisions. Ignorance of womens’ health needs, especially when it concerns margi- It is the belief of the EIWH that there may indeed contribute to generating nalised groups of women such as are obvious first steps to take towards life-threatening conditions for women. disabled, poor and/or minority and remedying the disparities in health- It is a fact that women consume more migrant women. Furthermore, different care encountered across Europe by treatment for women than men is the medicines than men, but most
70 2050: A Health Odyssey PEGGYNEUROLOGY MAGUIRE
pharmaceutical research is still carried to focus on their reproductive functions, from the fields across the world, out on men, even when it is known neglecting other needs including those resulting in a large depository of that the disease in question is more before or beyond reproductive age. information on women’s health. This frequent in women than in men. Conversely, men’s reproductive health will be available at the fingertips of needs are often inadequately met by women patients and thus make them Determinants of women's health, healthcare policies and services. The more knowledgeable about preven- drawn from both gender differences means to help public health pro- tion and treatment. and interdisciplinary research, are fessionals to consider gender issues necessary to tackle ways of reducing in their work are limited. In order to Finally, women’s health in 2050 will the present health gaps for women. demonstrate that a gender perspective centre around the patient-centric At its most simplistic level, this requires does improve the health of women model of delivery. Women will be the disaggregation of all health and and men, information about good better able to understand their specific healthcare statistics by sex to practices needs to be widely needs and be empowered to argue provide a more complete picture of available to public health staff and for those. All of society stands to gain women’s health. Interdisciplinary wider stakeholder groups. by an intelligent and appropriate use collaborations to analyse existing of scarce healthcare resources. The data sources are also necessary: Current and future European policy issues I have taken up in this article – research on women’s health generates initiatives must be targeted at women creating gender sensitive healthcare a wide variety of data, ranging from essentially qualitative assessments, through to epidemiological and clinical “ Women’s health in 2050 will centre around the trials. Scientific data that reflects the state of health of different population patient-centric model of delivery.” groups and divided along gender lines is an essential tool for improving the state of health of the population in as well as at men in order to harness for women will then become achie- Europe. the benefit of better health outcomes vable in the overall framework of by 2050. good health for all. It is of utmost importance that the health professions develop a gender WHAT WILL WE SEE IN 2050? sensitive approach and that the relevant teaching institutions such as The mainstreaming of women’s health medical schools, begin to integrate a will result in an increased focus on gender perspective into their curricula. appropriate health services and lead The different health needs of men to two dramatic steps in healthcare and women need to be met in an delivery. The first is the rapid rise in equitable manner in prevention, information which allows for a critical treatment and care services. Medical mass of evidence in more narrow or care and services often do not neglected sectors such as women’s respond adequately to the specific health. Information technology is needs and concerns of women and bringing information and evidence men. Health services for women tend
About the Author
Peggy Maguire is Director General of the European Institute of Women’s Health
European Institute of Women’s Health: http://www.eurohealth.ie/
2050: A Health Odyssey 71 ABOUT HEALTH FIRST EUROPE
Health First Europe (HFE) is an alliance of patients, doctors, nurses, academics, experts and industry that aims to ensure that equitable access to modern, innovative and reliable medical technology and healthcare, is regarded as a vital investment in the future of Europe.
The core messages of HFE are the following: • There are weaknesses in European healthcare systems; a rethink is required in order to meet current and future health challenges. • Patients and clinicians should have equitable access to modern, innovative and reliable medical technology. • The development of new and flexible modes of healthcare delivery will benefit both patients and healthcare providers. • Health equals wealth. Health is a productive economic factor in terms of employment, innovation and economic growth.
Since our launch in March 2004. HFE has been involved in numerous activities (awareness-raising events, position papers, press releases, etc.) aimed at encouraging Europe to lead the way in developing a truly patient-centred healthcare, where every European citizen is able to benefit from the best medical treatments available. For full details of our activities, please see our website: www.healthfirsteurope.org
HFE MEMBER ORGANISATIONS Heart EU Paul Rübig, Austria Institute for Health Economics (IFG) Ria Oomen-Ruijten, the Netherlands Aktion Meditech International Alliance of Patients Orga- Dr. Thomas Ulmer, Germany European Academy of Science and nizations (IAPO) Karl von Wogau, Germany Arts / EOM - European Institute of International Diabetes Federation –
Medicine Europe Region (IDF-Europe) HFE PATRONS European Alliance for Medical and International Organization for Stan- Biological Engineering and Science dardisation (ISO) David Byrne – Former European (EAMBES) International Society for Fracture Health and Consumer Protection European Brain Injury Society (EBIS) Repair (ISFR) Commissioner European Diagnostics Manufacturers The Medical Technology Group (MTG) Professor Dr. Dietrich Grönemeyer – Association (EDMA) The European Federation of Nurses Institute for Microtherapy European Federation of Crohn’s and Associations (EFN) (Associate member) Ulcerative Colitis Associations (EFCCA)
European Federation of Public Service HFE MEP SUPPORTERS Employees Unions (EUROFEDOP) European Federation of National Dr. Adamos Adamou, Cyprus Associations of Orthopaedics and Dr. Irena Belohorská, Slovakia Traumatology (EFORT) John Bowis, UK European Health Telematics Asso- Martin Callanan, UK ciation (EHTEL) Alejandro Cercas, Spain European Institute for Womens’ Health Brian Crowley, Ireland (EIWH) Dr. Dorette Corbey, the Netherlands European Medical Association (EMA) Avril Doyle, Ireland European Patients Forum (EPF) Christofer Fjellner, Sweden European Society of Cardiology (ESC) Karin Jöns, Germany European Union of Independent Malcolm Harbour, UK Hospitals (UEHP) Stephen Hughes, UK European Medical Technology Industry Liz Lynne, UK Association (Eucomed) Dr. Miroslav Mikolasik, Slovakia © HFE
72 2050: A Health Odyssey 2050 A Health Odyssey 2050 A HEALTH ODYSSEY - THOUGHT-PROVOKING2050 A HEALTH IDEAS FOR POLICYMAKING
THOUGHT-PROVOKING IDEAS FOR POLICYMAKING
Health First Europe Chaussée de Wavre 214d 1050 Brussels, Belgium Tel: +32 (0)2 62 61 999 Fax:+32 (0)2 62 69 501 www.healthfirsteurope.org Email: [email protected]