In health, Europe must be in the business of change and mean business

Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 18 IN HEALTH, EUROPE MUST BE IN THE BUSINESS OF CHANGE AND MEAN BUSINESS By: Tamsin Rose Summary: The big challenges for health are clear: the need for a major paradigm shift by transforming health care institutions from sickness treating systems to promoters of wellbeing. We need to get better health outcomes for less resource. Health needs to be a central part of all policy-making and an explicit outcome of government action. Consumption patterns and behaviour need to change radically to reduce the burden of chronic disease. Brussels-based think tank, Friends of Europe, sees the new European Commission mandate (2014 – 2020) as an opportunity and convened health stakeholders to develop recommendations for a new, improved EU approach to health. Keywords: Strategy, Health Policy, Change, Leadership Tamsin Rose is an independent health advocate and adviser to Friends of Europe, Brussels, Belgium. Email: tamsin.rose@ gmail.com Friends of Europe – Les amis de l’Europe – is a leading think-tank that aims to stimulate thinking on key global and European political challenges. It promotes the confrontation of ideas that is vital to policymaking and encourage wider involvement in Europe’s future. www.friendsofeurope.org Introduction During the summer of 2014, there was intense political horse-trading behind closed doors between the new European Commission President and national capitals on the allocation of portfolios. Before the new Commission College takes office, now is a good moment to reflect on what a strongly committed European Union (EU) Health Commissioner could achieve for health in Europe. Friends of Europe, a Brussels based think tank, convened a Health Working Group and brought together a diverse group of stakeholders from across Europe representing policy-makers at EU and national level, international organisations, academia, health-related industries and non-governmental organisations. The Working Group sought to define coherent messages from the health community to the new Parliament and Commission on how they could support positive change for health in Europe. The Group met four times throughout 2013 and 2014 under the Chatham House rules which ensured a frank exchange of views and allowed some out-of-the-box thinking. The consistent theme that emerged was that the EU could be the catalyst for some of the major transformation that is needed for public health and health care but change needs to be an explicit EU goal for health. Another red thread through the discussions was the need to focus on prevention both in terms of serious political commitment and financial resources. Strengths and weakness of health in Europe Health is a significant asset for Europe. The universal access health care systems that exist in all EU countries are a unique feature of the region. Life expectancy Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 19 has steadily risen as living and working conditions have improved and most citizens can expect to enjoy long periods of good health, accessing care when they need it. 1 Europe hosts a thriving life sciences industry with world leading companies that are producing new drugs, medical devices and diagnostic tools. There is a well-educated workforce readily available and funding for health research has been ring-fenced, contributing to the growing body of scientific knowledge. The diversity of health care systems across Europe presents opportunities for shared learning and exchanges of experiences. EU level data collection gives insight into the operational efficiency of different health systems and allows benchmarking and realistic target setting. The EU could and should capitalise more on its health assets to achieve better health outcomes. 2 3 ‘‘ non-communicable disease burden consumes up to 80% of all health care costs With all good news, there tends to be bad news. The societal challenges ahead are well understood – demographic change has profound implications for health and social care costs, chronic diseases consume most health care resources but are largely preventable. Health care systems are still heavily invested in expensive hospital- based curative services which deliver acute care, but are not adapted to provide patient-centric care in community settings. The poaching of health care staff from one health system to another contributes to brain drain and both shortages of skilled health care workers and skills mismatches across Europe. Chronic diseases are interrelated, are largely preventable and have common risk factors – tobacco use, poor nutrition, physical inactivity, alcohol consumption, and environmental factors. Among the six World Health Organization (WHO) regions in the world, Europe is the most affected by non communicable or chronic diseases. It has the highest smoking rates in the world for both men (38%) and women (19%). Europeans drink more alcohol (12.5 litres of pure alcohol per year) than in any other part of the world – almost double the global average. Only North America has a higher proportion of obese citizens (26%) than the European region (22%) where more than 50% of men and women are overweight. In terms of physical activity, 35% of the people in Europe are insufficiently physically active. So Europe scores highly on all the key risk factors for chronic diseases. Unsurprisingly the resulting non-communicable disease burden consumes up to 80% of all health care costs in Europe. 1 Can the EU be an agent of change for health? Change is not easy to achieve and there are formidable barriers: the complexity of health and care systems, strong vested interests and power imbalances in the system, information asymmetries between users and providers of care, silo thinking within health care, short term crisis management rather than long term strategic planning and legacy health care institutions that are out of date and unsuitable for modern care models. The health care sector has also been slow to adopt new technology and therefore has not achieved the efficiency gains and productivity increases that other sectors have benefitted from. Change takes a long time in health care; new approaches often take ten to fifteen years to become enshrined in clinical guidelines and ineffective treatment is hard to amend or eradicate. Entrenched attitudes by health care professionals protecting their own interests often block attempts to open up areas of care for other types of skills and qualifications. The policy environment can also be slow to respond when the evidence for change is strong – it took three decades for politicians to act on the link between smoking and cancer. Despite the terrible toll that alcohol takes on society and the WHO guidance that raising the minimum price is an effective way of reducing consumption, 4 only Scotland has attempted to regulate this and has faced strong opposition from drinks companies and other governments under EU internal market rules. There are significant health inequalities in Europe which reflect broader inequities in society but are exacerbated by prejudiced attitudes and poor quality care within health care services. The 2013 European Commission report on Corruption in Healthcare identified problems in some EU countries with fraud and informal payments, etc. all of which undermine the efficiency of the health care system and make it hard to reform. 5 The economic crisis has heightened the sense of urgency and sharpened the focus on reform of health systems. The dramatic drops in Gross Domestic Product (GDP) experienced by many countries post 2008 has led to deep cuts in public spending, including health and social services. 6 The new economic governance framework gives the EU, and particularly the Directorate-General for Economic and Financial Affairs (DG ECFIN), an unprecedented right to critique national investment and spending plans. 7 In the past, Member States have fiercely defended their exclusive right to manage health care systems and therefore have been reluctant to actively engage at EU level on broader health issues. This, in turn, led to health being a low profile portfolio within the European Commission, and the Directorate-General for Health and Consumers (DG SANCO) faces many obstacles to being seen as a major player in policy discussions. Raising the profile of the EU Health Commissioner For health to get a seat at the European Commission tables where the big picture of public financing and health care spending is being discussed, it needs to have a strong figurehead within the European Commission. The ideal candidate would be someone who has credibility, having served as a Minister of Health, and with experience of negotiating with Finance Ministries and other departments. If they have seniority within the Commission, for example a Vice President post, they would be in a good position to convene groups of Commissioners where health is the linking theme; for example, consumption/ production patterns, consumer behaviours and climate change. To really deliver on the disease prevention agenda, the Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.20 | No.3 | 2014 20 European Commissioner for Health needs to take on some big battles. There are powerful industries that have shaped the environment for consumers, influencing behavioural decisions on smoking, drinking alcohol or soft drinks and eating patterns. They have an economic interest in maintaining the status quo and their business models would be threatened by significant shifts in these consumption patterns that are essential to boost disease prevention. Other parts of the Commission responsible for trade, the internal market, industry policy, etc. act as champions for these interests and have in the past undermined efforts to regulate on the basis of public health. The Commissioner for Health would need to get fellow Commissioners to buy into the vision of health as the key outcome of EU actions, bringing them alongside when the external lobby pressures to block change start to mount. There are some useful policy developments that would assist the Health Commissioner in making the case for change. The utility of GDP as a measure of societal progress is being questioned. The Organisation for Economic Cooperation and Development (OECD) is developing the Better Life Index, which is a more nuanced basket of eleven criteria to measure performance – ranging from income and housing to health and work- life balance. 1 The incoming Commission President has promised to invest more in social Europe, marking a shift from the economic growth driven austerity measures. Given the close linkages between poverty, social exclusion, unemployment and health, this is an important development. Poor health and chronic illness can be both a driver of unemployment and a result of being out of the labour market. Health should rightfully claim a central space in future social Europe initiatives. Health is also increasingly acknowledged as being at the nexus of climate change, as a contributor to the problem (the sector uses resources intensively and produces high levels of waste) and a consequence of global warming as extreme weather events affect health and shifting climate patterns bring new disease patterns to Europe. Climate change will continue to be a headline policy priority at EU and global level and health should be a central part of the debate on how to address it. Stakeholders’ recommendations for EU action on health Reflecting on these challenges and opportunities, a new report from the ‘Friends of Europe’ think tank (due to be published shortly) distils the thinking of their Health Working Group’s into a list of 23 recommendations on what the EU should ‘Start’, ‘Stop’ or ‘Do Differently’ during the next mandate. This approach was designed to make sure that the report did not create an unfeasible list of new tasks for the over-stretched European Commission staff to take on. The ‘Start’ recommendations set out some positive steps that the EU could take to reinforce efforts to effect positive change for health. The recommendations on what the EU should ‘Stop doing’ reflects a certain frustration with the prior lack of coordination and inconsistent follow up of initiatives. The ‘Do Differently’ recommendations outline how the EU could use greater focus and simplification with more joined up thinking across policy areas to end silo working. The Working Group was undaunted by the size of the challenges facing health in Europe and felt that the timing is right for a more proactive Commissioner for Health who would find allies in the Parliament and among Health Ministers that want Europe to be a friend to health systems. If stakeholders get a clear message at the beginning of the mandate that Europe is in the business of change for health – and it means business – they will find ways to align their strategies and activities to this agenda. This might be the trigger that is needed for the paradigm shift for health. References 1 OECD. Health at a glance, OECD indicators. Paris: OECD, 2014. Available at: http://www.oecd. org/health/health-systems/health-at-a-glance.htm 2 Mackenbach J, Karaikolos M, McKee M. Health policy in Europe: factors critical for success, BMJ 2013;346:f533. 3 Friends of Europe. Why health is crucial to European recovery? Report of European Policy Summit. Brussels: Friends of Europe, 2012. Available at: http://www.friendsofeurope. org/Portals/13/Documents/Reports/2012/ FoE_Report_Health_2012.pdf 4 Increasing excise duty and value added tax on alcohol. Copenhagen: World Health Organization Regional Office for Europe, 2012. Available at: http://tinyurl.com/kzatetz 5 European Commission – Directorate General Home Affairs. Study on corruption in the healthcare sector. Luxembourg: Publications Office of the European Union, 2013. Available at: http://tinyurl. com/ll6wgbv 6 Karanikolos M, Mladovsky P, Cylus J, et al. Health in Europe: financial crisis, austerity and health. The Lancet 2013; 381:1323 – 1329. 7 Council of the European Union. Council conclusions on the economic crisis and healthcare. Luxembourg: Council of the European Union, June 2014. Available at: http://www.consilium. europa.eu/uedocs/cms_data/docs/pressdata/en/ lsa/143283.pdf