Demographics and diversity in Europe: innovative solutions for health

Eurohealth OBSERVER Eurohealth — Vol.22 | No.3 | 2016 18 DEMOGRAPHICSAND DIVERSITYINEUROPE – INNOVATIVE SOLUTIONS FOR HEALTH By: Isabel De La Mata Barranco, Dominik Schnichels, Tapani Piha and Arila Pochet Summary: Whilst still recovering from the economic crisis, Europe’s health care systems are facing the growing challenges of an ageing population and a rise in chronic diseases. A new phenomenon is the migrant challenge. This article outlines various issues related to demography and diversity which affect health systems. It summarises the ways in which the Commission tries to support Member States both through tried and tested methods and through EU cooperation on innovative solutions for health – in particular, eHealth and Health Technology Assessment. Keywords: Health Systems, Ageing, Chronic Diseases, eHealth, HTA, Migrants, Health Workforce Isabel De La Mata Barranco is Principal Adviser for Health and Crisis Management; Dominik Schnichels is Head of the unit “Medical products: quality, safety, innovation”; Tapani Piha is Head of the unit “Cross border Healthcare and eHealth”; Arila Pochet is Policy Officer in the unit “Health determinants and inequality”, DG Sante, European Commission, Brussels, Belgium. Email: Arila.Pochet@ec.europa.eu Introduction Europe’s health systems are facing an ageing population and rise in rates of chronic disease, threatening universal access to health care and the sustainability of health systems. The migration of health care professionals within the European Union (EU), and the consequent shortages in medical personnel in the countries they leave behind, is another predicament. A new phenomenon is the influx of migrants and refugees, which poses challenges for countries on the frontline, particularly Greece, as well as final destination countries such as Germany and Sweden. These challenges are taking place against a backdrop of the continuing effects of the economic crisis and the strain it has placed on health budgets. Whereas the organisation and delivery of health care is in the hands of Member States, this article focuses on the many ways that working together at EU-level can help address challenges related to demography and diversity. Much can be achieved through sharing expertise and best practice and working together in collaborative projects and joint actions. However, we also need new solutions for health, and here we focus on two areas in particular – eHealth and Health Technology Assessment (HTA). The ageing demographic and rise in chronic diseases The ageing trend in Europe is set to continue in the decades to come. Life expectancy has increased for both sexes in all EU countries. The average lifespan has risen from 74 years in 1990 to 80 in 2015, and by 2060 life expectancy will have risen by seven more years for men and six for women. 1 ➤ #EHFG2016 Forum 9: Reality meets Reality ➤ #EHFG2016 Workshop 3: New frontiers in HTA ➤ #EHFG2016 Forum 4: Desperate migration and health Eurohealth OBSERVER Eurohealth — Vol.22 | No.3 | 2016 19 However, healthy life years are not increasing accordingly. Longevity and healthy life years are strongly affected by the cumulative effect of health behaviours and inequities across the life cycle. Large health inequalities persist both between and within EU countries. For example, in 2012 the gap in life expectancy between the Member States at the lowest and highest end of the spectrum was 18.7 years for men and 19.3 years for women. 2 ‘‘ ageing population and rise in rates of chronic diseaseIn parallel, the burden of chronic diseases in the EU is growing, causing drawn out suffering for patients and placing a huge burden on health care budgets: an estimated 70% to 80% of health care costs, representing some €700 billion in the EU, 3 are spent treating chronic diseases. In 2012, EU countries devoted an average of 8.7% of GDP to health spending, up significantly from 7.3% in 2000. 4 The European Commission takes a multi-faceted approach to supporting EU countries’ efforts to deal with an ageing population and prevent, reduce and treat chronic diseases – supporting partnerships, providing fora for exchanging good practice on risk factors, various sources of funding, advice, and more. Three examples include the following: 1. The European Innovation Partnership on Active and Healthy Ageing has, to date, brought together over 3000 partners, 1000 regions and municipalities, and 300 organisations to examine new ways of addressing the challenge of an ageing population. This has led to innovative programmes being rolled out – for example, on adherence to medication, prevention of frailty, chronic disease management and integrated care, and a strategy to scale- up successful practices. 2. In the context of the European Semester, the Commission provides recommendations and advice to a number of EU countries to help them design resilient health systems that can withstand current and future pressures and to continue to provide patients with the best possible care. 3. The CHRODIS Joint Action 5 of 25 countries is among the many projects and joint actions co-financed by the Commission’s Health Programme aimed at preventing chronic diseases and promoting healthy ageing across the lifecycle. Furthermore, there is a growing pace of technological advancement and innovation that has the potential for improving health in Europe. The challenge is to ensure the availability, affordability, cost- effectiveness and safety for products and technologies for patients, whilst preserving an innovation-friendly environment. We would like to highlight two particular areas of innovation that can offer new solutions for Europe’s health systems in terms of providing more care with less expense: eHealth and Health Technology Assessment (HTA). eHealth eHealth and mHealth products and services have already become firmly established within the public health and health care sectors. More and more people use smart-phones and other electronic devices for prevention and monitoring of diseases. And more countries are integrating telemedicine into their health systems, such as consultations over the internet. This promising field is gaining momentum and acceptance across Europe; and the Commission is seizing the opportunities offered by the emerging European Digital Market to create an environment in which practical, innovative, and cost-effective eHealth solutions can thrive. The key to maximising the potential of these various technologies is for EU countries to ensure that their respective eHealth systems can communicate with each other. To this end, the Commission is working closely with Member States to overcome interoperability challenges between EU health systems so that patients can fully benefit from a digital single market in health – for example, through cross-border e-prescriptions or electronic patient summaries. The EU also provides various tools to finance eHealth; for example, the Connecting Europe Facility (CEF) is financing, amongst other things, the building of an EU digital infrastructure for health. To date, 20 Member States have applied for funding under this project in order to build up concrete capacity to exchange health data, e-prescriptions and patient summaries. Such EU collaboration and connectivity in the area of eHealth aims to bring about four big wins: 1) Empowered patients who are able to manage their own health thanks to a better flow of information and interaction with health professionals. 2) Increased sustainability and efficiency for health systems. 3) Greater access to personal health data for patients and health professionals, enabling faster diagnosis, improved monitoring, more effective treatment and better health outcomes. 4) Support for patients’ access to health care services across Europe. HTA In a climate where the challenge for all countries in the EU is to do more with less, cooperation on HTA at EU-level can help decision makers in all 28 Member States formulate safe, effective and cost-effective health policies. HTA answers questions like: Is the technology effective? For whom does it work? What costs are entailed? How well does it work compared to alternative technologies? Such questions are vital for health policy makers and administrators to face the increasing burden on Europe’s health systems. The benefits of a sustainable EU cooperation on HTA are numerous. It can ensure better use of resources in HTA production, contribute to the functioning Eurohealth OBSERVER Eurohealth — Vol.22 | No.3 | 2016 20 of the internal market for health products, ensure that patients have timely access to innovative health technologies and treatments, and improve the sustainability of health care systems. The Commission has supported voluntary cooperation in this area for more than 20 years. In 2013, the voluntary EU-wide network on HTA composed of national HTA bodies or agencies was set up. This work, complemented by three Joint Actions* on HTA, has enabled us to build a solid knowledge base on methodologies and information exchange. Now we are embarking on the next step. Preparatory work on HTA is included in the 2016 Commission’s annual Work Programme. This is a crucial milestone, enabling us to build on our achievements and bring fresh impetus to the efficient use of HTA resources in Europe. We are now working on an inception impact assessment to carefully assess various options linked to continuing the cooperation on a permanent and sustainable basis. The migrant challenge As of the end of February 2016, over 1.1 million people – refugees, displaced persons and other migrants – have made their way to the EU, either escaping conflict in their country or in search of better economic prospects. 7 Migrants entering Europe are, in general, healthy and do not bring diseases with them. However, most have travelled in dreadful conditions to arrive at overcrowded ‘hotspots’ in a state of mental and physical exhaustion. It is a desperate situation for these individuals, and an enormous strain for the countries on the frontline, particularly Greece which is already facing severe economic hardship. The Commission’s immediate concern is providing these countries with the support they so desperately need – e.g., with piecing together migrants’ health records and vaccination history, training staff and volunteers, and, in the longer * EUnetHTA Joint Action 1, 2010 – 2012, EUnetHTA Joint Action 2, 2012 – 2015 and EUnetHTA Joint Action 3, 2016 – 2019: http://www.eunethta.eu/ term, ensuring migrants’ integration into primary health care systems, and protecting against stigma and health inequalities. Concrete actions include: • Producing a Personal Health Record to reconstruct the medical history of incoming migrants and refugees† jointly with the International Organisation for Migration (IOM) and the European Centre for Disease Prevention and Control (ECDC), and an accompanying Handbook for health professionals. 8 • Mobilising the EU budget to help countries on the ground with activities such as health care models for vulnerable migrants, integration of migrants in primary health care systems, and training of health professionals. • Coordinating activities within the Health Security Committee, e.g. – gathering requests for vaccines and other health supplies from the countries most affected, so that other Member States can provide support; – reinforcing surveillance of communicable diseases via the Early Warning and Response System; and – connecting national contact points for health with those in charge of civil protection and asylum, migration and integration funds. • Participating in discussions on the integration of third country nationals, particularly as there are health workforce shortages in the EU, and many incoming refugees and migrants are health care professionals. Migration within the EU This last example leads us to look further at the migration challenge within Europe. The “brain drain” affecting some countries, as doctors relocate to countries with better conditions and remuneration, has led to critical shortages and concerns for access to health care for the patients in the countries they leave behind. † Personal Health Record in English and Arabic, being piloted in Greece with a view to initially extending it to Italy and Slovenia. Available at: http://ec.europa.eu/dgs/health_food- safety/docs/personal_health_record_english.pdf While the mobility of health professionals is a fundamental right under the Treaty, facilitated by the Directive on the mutual recognition of professional qualifications, an EU Action Plan to address challenges to the EU’s health workforce 9 focuses on issues such as recruitment and retention of health professionals. Last year, the Commission published a study on innovative and effective recruitment and retention strategies 10 to assist EU countries with developing policy responses to recruit and retain staff. In addition, a Joint Action on health workforce forecasting and planning, co- financed by the Health Programme and bringing together 28 European countries and 16 stakeholder organisations, has just ended, delivering results such as: • A handbook of good practices and methodologies; • A study looking at the main drivers of changes through to 2035, and implications for the health workforce in Europe; • Data analysis to support improved data quality, availability and comparability, for the benefit of EU countries. There is commitment to continue this work. Indeed, support for cooperation at EU level to address health workforce shortages remains a key priority of the Commission’s Health Programme. Conclusion There are many ways in which the EU can help Member States with the challenges to their health systems – both in emergency situations such as the refugee crisis where the EU principle of solidarity is put to the test, and in serious long-term issues such as increasing rates of chronic diseases and shortages of medical personnel. These include methods with a proven track record, and vitally, ramping up EU collaboration on new innovative solutions such as eHealth and HTA. With the commitment and solidarity of EU countries and stakeholders we can accelerate progress in these areas, which is expected to bring direct benefits to health systems and patients in Europe. Eurohealth OBSERVER Eurohealth — Vol.22 | No.3 | 2016 21 References 1 Annual Ageing Report. Brussels: European Commission, 2015. Available at: http://ec.europa. eu/economy_finance/publications/european_ economy/2015/ee3_en.htm 2 European Core Health Indicators (ECHI) data tool. Available at: http://ec.europa.eu/health/dyna/echi/ datatool/index.cfm?indlist=40a 3 OECD. Health at a Glance: Europe. Available at: http://ec.europa.eu/health/state/glance/index_ en.htm 4 The 2015 Ageing report. Available at: http://www. aal-europe.eu/wp-content/uploads/2015/08/Ageing- Report-2015.pdf 5 CHRODIS Joint Action. Addressing Chronic Diseases and Health Ageing Across the Life Cycle. Available at: http://www.chrodis.eu/about-us/ partners/ 6 ECHO. Refugee crisis in Europe. Available at: http://ec.europa.eu/echo/refugee-crisis_en 7 Handbook for Health Professionals: Health assessment of refugees and migrants in the EU/ EEA (available in English, French, German, Greek, Italian, Bulgarian, Romanian, Slovenian, Croatian and Hungarian), 2015. Available at: http://ec.europa. eu/dgs/health_food-safety/docs/personal_health_ handbook_en.pdf 8 Commission Staff Working Document on an Action Plan for the EU Health Workforce, 2012. Available at: http://ec.europa.eu/health/workforce/ docs/staff_working_doc_healthcare_workforce_ en.pdf 9 Recruitment and Retention of the Health Workforce in Europe, 2015. Available at: http:// ec.europa.eu/health/workforce/key_documents/ recruitment_retention/index_en.htm DEMENTIA: PRESSING POLICY CHALLENGES By: Martin Knapp Summary: Dementia is one of the biggest clinical, social, economic and policy challenges for European health and care systems today. I argue that a collective (policy) response to these challenges must be multi-dimensional. Societal responses to dementia in many countries are already better today than they were ten years ago, but much more needs to be done. There must be earlier and more effective prevention, better care and treatment (although no ‘cures’ have yet been discovered), more support for family and other unpaid carers, and continued investment in basic science to find disease-modifying treatments. Keywords: Dementia, Long-term Care, Prevention, Unpaid care Martin Knapp is Professor of Social Policy and Director of the Personal Social Services Research Unit, London School of Economics and Political Science; and also Director of the NIHR School for Social Care Research, United Kingdom. Email: M.Knapp@lse.ac.uk Introduction Dementia is a major clinical, social, economic and policy challenge across the whole of Europe. It is a devastating, distressing collection of illnesses, the most prevalent of which is Alzheimer’s disease. Recently, I have heard a number of people describe dementia as the ‘new cancer’: a collection of different diseases, some of them highly prevalent, none with a known cure, all of them life-shortening, and all widely feared. Dementia is already very costly, and the costs – both to the public purse and to individuals and families – will get considerably greater over coming decades. Since dementia prevalence has a steep age gradient – fewer than 1% of people aged under 70 have dementia, but 30% of those aged above 90 – one could almost suggest that the policy challenge is actually growing faster than the population is ageing. Recent studies suggest that age-specific incidence rates may be falling in some countries (e.g. England), probably due to better health behaviours earlier in life. 1 However, in reporting similar overall findings from the well-known Framingham Heart Study in the US, 2 Satizabal and colleagues point out that this improvement is only found among the better educated members of the cohort. The otherwise welcome reduction in dementia incidence is therefore far from equally enjoyed across all sections of society. Challenges of the near-future Despite these important (if small and unequal) changes in incidence rates, the total prevalent number of people with dementia will continue to grow considerably over the next few decades. Growth will be especially rapid in low- and middle-income countries. According to Alzheimer’s Disease International 3 ➤ #EHFG2016 Forum 10: The challenges of Alzheimer’s and other dementias