Abstract Background Health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities. Methods This paper originated from a workshop entitled ‘Health systems for the future’ held at the European Parliament. Experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely: (i) increasing citizens’ participation; (ii) the importance of primary care in providing integrated services; (iii) improving the governance and (iv) fostering better data collection and information channels to support the decision making process. Results In the parliamentary debate, was discussed the concept that, in the near future, health systems’ effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems. Conclusions Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue. It is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges. health systems, primary and integrated healthcare, European Union, health promotion, health governance, big data Introduction Over the last 2 decades, health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities. For example, (i) an epidemiological transition where chronic conditions and complex patients require integrated services pivoting around primary care, that contrasts with the prevalence of specialized, rather fragmented care, mainly provided by hospitals;1,2 (ii) a pervasive idea that more care is always better than less care, when there is a widespread evidence of inappropriate use of treatments and technologies;3 (iii) the rising promise of personalized medicine, that eclipses the efforts in promoting healthy lifestyles;4 or (iv) the increasing demand of information and transparency with respect to services’ quality and safety, that contrasts with serious flaws in the good governance of health services.5 Underlying these challenges is a profound transition in the medical knowledge paradigm, from the traditional and prevailing heuristic approach to the development of data-driven learning systems.6 Along these years, several official documents, reports and communications have highlighted potential strategies to deal with those, and other, challenges.7–12 The idea of this paper originated from a workshop entitled ‘Health systems for the future’ held at the European Parliament in Brussels, Belgium in June 2017.13 In this meeting, experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely (i) increasing citizens’ participation in health promotion and disease prevention (HPDP); (ii) the importance of primary care in providing integrated services; (iii) improving the governance of the EU health systems; and (iv) fostering better data collection and information channels to support the decision-making process. The event was organized by the Science and Technology Options Assessment (STOA) Panel, which is the European Parliament’s in-house source of independent, balanced analysis of public policy issues related to science and technology.14 Public health research provides scientific evidence on which to build public policy. However, there is often little correlation between the quality of the science and the quality of the policy derived from it.15 In this context, STOA provides the means for the scientific community, policy makers and key stakeholders to exchange thoughts and views. In the current 5-year legislative term (2014–19), STOA is focusing on five priority thematic areas: (i) eco-mobility; (ii) natural resources; (iii) information society; (iv) health; and (v) science policy. The workshop, and subsequent debate, was based on four underlying assumptions: (i) community participation is a key principle of health promotion practices, stemming from an ideological position that shifts from a bio-medical paradigm towards a social model that creates conditions where people are active participants in their own healthcare;16 (ii) strengthening primary care is one of the major challenges facing EU healthcare systems as they reduce fragmentation in care provision. Decision makers are searching for models that are able to increase the whole pathway of care: primary, secondary and tertiary, long-term care and eventually social care;17 (iii) threats to good governance—lack of appropriate competences, the existence of conflicts of interest, bureaucratic rigidity—translate into a lack of transparency, poorly thought-out policies and the prevailing use of the ‘low-hanging fruit’ strategy;18 and (iv) finally, the generation and reuse of health data (administrative, clinical, environmental, etc.) are essential in embracing the change in the knowledge paradigm towards learning health systems and subsequently toward more sustainable health systems.19 Stemming from some of the key insights that arose during this parliamentary conversation between researchers and policy makers, the present article seeks to contribute to the public dialogue on the health systems of the future, reflecting on those specific topics (citizens’ involvement in HPDP, primary care governance, and data collection and data reuse) and, ideally, shedding light on potential avenues for future policy making. Health promotion, disease prevention and citizen participation There are many socioeconomic determinants of health. Smoking, harmful consumption of alcohol, unhealthy diets and sedentary lifestyles are risk factors that can be effectively addressed by government regulation, taxation and pricing, especially when working in tandem with other measures such as labelling, smoke-free environments, banning advertising and ensuring access to healthy foods. Interventions that promote physical and mental health and early childhood development are more cost-effective than downstream measures that address harmful behaviours and treat problems only once they have developed.20 Investing in prevention and public health services is strongly recommended by different actors,20,21 and reallocating resources from treatment to prevention can increase the cost effectiveness of spending in healthcare. Unfortunately, the impact of such investment is difficult to measure and quantify. Expenditure on prevention and public health is defined by the OECD as expenditure on services designed to enhance the health status of the population as distinct from curative services.22 European countries continue to lag behind, spending only 2.4% of their healthcare budgets on prevention and promotion (~0.2% GDP) (Fig. 1). One reason for this trend is the fact that political cycles do not match with the long-term vision needed for the effect of prevention policies to become evident.11 Fig. 1 View largeDownload slide Public expenditure on preventive as a percentage of the health expenditure among the EU 28 MSs (2005–15). Source: European Parliament Research Service computations based on Eurostat and OECD health data. Note: All EU-15 MSs (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom) were represented with only 7 MSs from EU-13 (Czech Republic, Estonia, Hungary, Latvia, Poland, Slovak Republic and Slovenia) being represented, due to the lack of data. Fig. 1 View largeDownload slide Public expenditure on preventive as a percentage of the health expenditure among the EU 28 MSs (2005–15). Source: European Parliament Research Service computations based on Eurostat and OECD health data. Note: All EU-15 MSs (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom) were represented with only 7 MSs from EU-13 (Czech Republic, Estonia, Hungary, Latvia, Poland, Slovak Republic and Slovenia) being represented, due to the lack of data. The pace of innovation in health is fast, and there are growing opportunities to encourage citizen’s participation in HPDP. New technologies (such as ICTs, social media and mobile tools) can produce better health outcomes and increase citizens’ involvement in different stages of health service development.23 They could have a direct influence on co-creation practice, making a stronger partnership between citizens, health professionals and other health actors, and potentially affecting the future appearance of new forms of healthcare organizations. In the STOA workshop, front-line examples were provided of innovations for healthier lives that were driven by users and care givers.24 However, these types of innovations need to be integrated with measures to increase digital and health literacy.25 A major challenge for improving HPDP in Europe is the implementation of integrated policy making, as mentioned in the ‘Health in All Policies’ strategy. This strategy is defined as ‘an approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity’.26 The Health in all Policies strategy aims to improve the accountability of policy makers at all levels with regard to health impacts. It also seeks to improve health through mechanisms and actions accomplished mainly by sectors other than health. While inter-sectorial governance is needed for an effective Health in All Policies, this requires participation and co-creation and has been proven difficult to establish. Greer et al. found that the difficulty of establishing inter-sectorial governance is due to two major factors. The first is the lack of coordination that encourages different parts of government to work together towards a defined health objective. The second element is durability, which undermines the ability of inter-sectorial health policy to persist over time due to political and bureaucratic change.27 Greer and Lillvis27 also noted three strategies by policy makers approaching issues of coordination and durability: (i) direct leadership with specific plans and targets; (ii) bureaucratic changes and reorganization; and (iii) data publication and support from outside groups to influence future policy.27 The de-institutionalization of health services offers new opportunities for HPDP and connecting citizens with services in their communities. Co-creation with citizens and engaging them in policy and decision-making are vital to understanding needs and developing local solutions. Greater involvement of citizens and associations also requires a shift from small-scale community health projects to mainstream community programmes, expanding the capability to engage with a wider audience. Successful community mobilization is itself a subject deserving of further research.16 Improving the primary and integrated healthcare services In many health systems, integrated care is seen as a possible solution to the growing demand for improving health outcomes of long-term care patients, and in the last decades, different models of integrated care have been widely applied in Europe.28 Integrated healthcare services is defined by WHO as ‘an approach to strengthen people-centred health systems through the promotion of the comprehensive delivery of quality services across the life-course, designed according to the multidimensional needs of the population and the individual and delivered by a coordinated multidisciplinary team of providers working across settings and levels of care’.29 This definition adopts a health system perspective, acknowledging that integrated care is achieved through the alignment of all health system functions and effective change management.28 Promising EU integrated care programmes already exist, consisting of a mixed package of interacting patient-, provider-, organizational- and financial-oriented interventions, tailored to the context in which they are designed.30 In many of this promising programmes, primary care plays a significant role. At the EU level, primary care is defined as ‘the first level of professional care where people present their health problems and where the majority of the population’s curative and preventive health needs are satisfied’.31 Kringos et al.,31 described good primary care as having four main characteristics: accessibility, comprehensiveness, continuity and coordination. Although the combination of disciplines that make up the primary care workforce may differ in different EU MSs, general practitioners (GPs) and family physicians are the most common primary care providers in Europe.32 In the EU, strong primary care is associated with better population health, lower rates of unnecessary hospitalizations and relatively lower socioeconomic inequalities in health. It is important to note, however, that overall health expenditure is higher in countries with stronger primary care structures.33 Improving the performance of primary care in the EU requires working on several fronts. First, the increase in demand of health services due to epidemiological changes requires investing in specialist primary care health professionals, making them more person-centred rather than a disease-specialist oriented.32 Multidisciplinary team practice and enhancing the role of nurses appears to respond to the need for new models of primary care delivery. Nursing continues to be under-utilized despite the evidence that greater reliance on advanced nurse practitioners could improve accessibility of primary care services while also saving on costs.34 Second, many EU MSs need to tackle healthcare workforce shortages through a regular system of workforce-capacity planning. Raising the general attractiveness of the profession, particularly by showcasing the monetary gains, can also be successful in attracting much needed practitioners.35 Investing in specialist primary care health workers is an important step in guaranteeing continuous and comprehensive care.32,36 Third, the impact of new technologies has thus far been most dominant in tertiary care, but increasing evidence shows their potential in primary care as well. There is also the need to improve and modernize processes by using ICT such as electronic medical records to support primary care systems. Better ICT services can increase continuity of care if medical information is made available to all professionals, especially when care is coordinated through different levels of the healthcare system.36 Fourth, primary care could potentially play a role if services are better integrated and providers adopt a more preventive attitude. At present, however, the focus is still strongly on curative care and integration among primary care, prevention and social services and schools in the community which are still poorly developed in many EU MSs.31 Fifth, accessibility and equity, crucial features of the primary care system, are not guaranteed in many EU MSs as a result of various conditions.37 Much of this is due to high workload for GPs and nurses, and their shortages as mentioned above. In addition, most EU health systems struggle to guarantee comprehensive provision of out-of-hours primary care services.38 Out-of-hours care prevents unnecessary and expensive secondary care or emergency department use.39 An associated trend is the increasing demand for care for those who are home-bound, while GPs mostly are not willing to make home visits. Finally, although there are generally few financial obstacles for visiting a GP, in many EU MSs, patients must pay for prescribed medicines.31 The governance in health Governance concerns the comprehensive set of actions and actors involved in steering systems towards national or regional goals. The WHO define governance as ‘a wide range of steering and rule-making related functions carried out by governments/decisions makers as they seek to achieve national health policy objectives that are conducive to universal health coverage’.40 Several attributes of organizations determine whether governance can be considered effective. According to Greer et al.,18 governance has five main features: Transparency of decision making coupled with clear mechanisms and lines of Accountability, Participation of key stakeholders, Integrity (management and anticorruption measures) and policymaking Capacity (TAPIC framework). This framework could allow comparison between different EU health systems’ governance in Europe.18,41 In addition, it can help to avoid duplication of tasks and excessive administrative structures which result in additional costs to the sector.11 According to Transparency International, transparency is ‘a principle that allows those affected by administrative decisions, business transactions or charitable work to know not only the basic facts and figures but also the mechanisms and processes. It is the duty of civil servants, managers and trustees to act visibly, predictably and understandably’.42 Transparency is therefore a code of conduct or set of rules which guide actions in health organizations. Transparency makes it possible to understand an institution, identify possible incompetence, and adapt plans to its behaviour. Transparency for health services should mean that data and decisions are available to experts, citizens and other organizations who can challenge a decision and the decision-making process.18 Good governance is not feasible without accountability. Accountability can be defined as a relationship occurring when one social actor informs another actor, and can be disciplined for the failure to provide adequate information. A clear line of responsibility and accountability for the efficient delivery of healthcare is required at all levels.18 Participation means that affected subjects have comprehensive access to the decision-making process, so that they acquire a meaningful interest in the work of the institution or service.43,44 Effective participation of affected populations can be a route to legitimacy and ownership: the participation of key implementers is usually necessary to avoid poor implementation or even sabotage. In addition, participation improves the effectiveness of policy, because consulting affected parties can produce useful information for decision makers.45 Integrity means the clear specification of the processes of representation, decision making and enforcement. Individuals should have a clear allocation of roles and responsibilities, and be able to understand the processes by which an institution takes and applies decisions.18 Finally, policy capacity is the part of government that transforms ideas into feasible, designed policies. It refers to the ability to turn a political idea into a thought-out proposal.18,46 During the parliamentary debate, the governance of the Veneto Region in northern Italy was presented as an example of good governance. In order to improve transparency and accountability of the health system governance, the Regional Council approved a reform of the health system in 2016. It proposed two fundamental areas of innovation. The first one, aiming at increasing policy capacity, was the establishment of a new central body (the so called ‘zero enterprise’), which is ideally allocated between the Regional Council (responsible for the programme’s direction) and the healthcare authorities (responsible for the provisions of services). The zero enterprise has two functions, namely, to undertake management tasks of a technical and specialist nature, and to coordinate the work of service providers. The second one, aiming at gaining integrity, was the merging of local healthcare units from 21 to 9.47 Routine data reuse: a pathway towards smarter health systems Health systems in Europe are undergoing a shift towards complex integrated care models as a response to an epidemiological transition. At the same time, Europe is witnessing a revolution on health information. Almost inadvertently, Europe is shifting from a fragmented quasistatic hard-paper data environment towards a continuous stream of digital data that is growing exponentially. Making sense of the massive wealth of existing data seems to be a smart way to underpin health systems transition and inform on its outcomes. Regrettably, a report by the OECD revealed that a substantial number of OECD MSs were unsure or did not find likely, in a near future, that they would use electronic health records for national healthcare quality monitoring.22 Moreover, making this happen is not always obvious; partly because new thinking, capacities and tools are required to deal with such a density of information;48 partly because, although the wise reuse of data is necessary, it is not sufficient to transform a health system.49,50 Nonetheless, there is a growing number of system-wide inspirational experiences that show how a health system may learn out of the systematic use of data;51 for example, see the case of the Spanish, Dutch, English Atlases of Variations in Medical Practice where the continuous monitoring of healthcare performance, using routine data, informs policy decisions on the health system.52–54 Besides these countrywide experiences, there are some international efforts worth learning from; for example, the Bridge-Health network (currently, Joint Action InfAct), project funded by the European Commission (EC), that gathered a number of EU projects whose common denominator was the use of health data to inform policies on population health or health systems performance.55 The lessons of one of those projects, the European Collaboration for Health Optimization (ECHO) were discussed during the parliamentarian debate. ECHO was deemed a proof of the EU potential of turning routine data into meaningful information on health systems’ performance19 and showed the way to build data-driven learning health systems as well as demonstrating the complexity of such an endeavour. With regard to the complexity, the development of data-driven learning health systems entails enormous challenges on data linkage, curation, management and motion, and requires high analytical capacities and appropriate infrastructures. Although its progress is uneven, the EU is on its way to achieving the reuse of routine data for policy-making purposes. Most EU MSs have made substantial investments in ICT development, the EC has led the development of a common interoperability framework for the reuse of publicly owned data, and the academic community, using EU public funds, is developing joint capacities both in the management of massive data and in new analytics. Last but not least, EU health systems will also have to prepare to digest the wealth of real-life data (e-Health and m-Health) that will flood public decisions in a few years, although this data is not yet routinely collected. Upcoming initiatives by the EC, such as the 2015 eHealth interoperability framework or the Joint Action on eHealth, are first steps in that direction.56 Conclusions The STOA parliamentary debate on the EU health systems allowed participants to openly debate on the health-policy agenda for Europe in upcoming years. Speakers and policy makers discussed the concept that, in the near future, health systems’ effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems. Policy strategies are subject to broad social, political and economic forces, such as the new EU fiscal governance regime.57 Therefore, public health advocacy should give more consideration to a full range of strategies that implement policies and maintain them over time.27 This being said, it is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges. Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue.55 The course of action is driven by political leaders with visionary ideas about the proper direction of public policy, able to invest in the future of public health, even though the results will stretch beyond their policy cycle. Acknowledgements The authors would like to thank all speakers and contributors to the STOA workshop entitled ‘Health systems for the future’ held at the European Parliament in June 2017. We are grateful to Carys Lawrie, Scientific Foresight Unit (STOA), European Parliament, for her comments and suggestions in the revision of the article. Disclaimer The views expressed in this publication are the sole responsibility of the authors and do not necessarily reflect the views of the affiliated organizations. Funding None. References 1 European Commission . 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Journal of Public Health – Oxford University Press
Published: Mar 26, 2018
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