Belgian Presidency of the Council of the European Union

Average health expenditure in the EU Member States is forecast to nearly double to 16% of GDP by 2020 due, in large part, to the costs of dealing with the impact of chronic conditions. Despite being largely preventable, chronic conditions are the cause of 86% of premature deaths in the WHO European Region and have significant economic implications.

The risk factors, including tobacco use, obesity, hypertension, alcohol abuse and lack of exercise, are well known to policy-makers, healthcare professionals and – to a certain extent - the public but, despite the abundance of evidence , success in addressing the highly complex social and economic challenges of chronic conditions has been patchy at national and EU level. Their sheer range (from cardiovascular and respiratory to physical disability and mental health), the multiplicity of determining factors (health, socio-economic, genetic, environmental and behavioural) and the long-term nature of care and treatment have all served to confound traditional, top-down, government-led responses.

Chronic conditions are not just a health issue – they impact on the workplace, the home environment, social support services and family networks – yet governments for the most part have been slow to integrate policies, inter-departmental budgets and service provision to suit the needs of patients and providers and facilitate the input of community and private expertise.

As Dr Ala Alwan, WHO Assistant Director-General, Noncommunicable Diseases and Mental Health, commented in the WHO’s 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, “Considerably more gains can be achieved by influencing policies of non-health sectors than by health policies alone. All stakeholders will need to intensify and harmonise their efforts to avert these preventable conditions and to save millions from suffering needlessly and dying prematurely.”

EPPOSI’s first workshop in 2008 identified the clear need for a Europe-wide strategy to ensure open, equal access to care and treatment for patients with chronic conditions, which is patient-centred and must recognise the often ignored role of carers. Now the challenge is how to turn that into reality.

The Workshop

Objectives

Even without the ongoing effects of the financial crisis an inexorable rise in expenditure is unsustainable, so how can policy-makers, patients, healthcare providers and insurers, the healthcare industry, social services and employers better work together to reduce the risks of chronic conditions, improve quality of life and confront the economic implications?

Complex challenges call for innovative responses: EPPOSI invites all stakeholders to its Second Workshop on Chronic Conditions to help formulate the principal elements of a holistic new model which can actively reduce the debilitating personal and economic burden of chronic conditions. The model will be developed by a Task Force, to be set up after the workshop and based on its outcomes, which can be adapted and implemented in all Member States.

Context

i Innovation

This follow-up meeting, supported by the Belgian Presidency and complementing its health ministerial on innovative approaches to chronic conditions, will also link in to the EU 2020 – Innovation Union strategy for smart, sustainable and inclusive growth. In the health sphere, this includes innovations not only in products and treatment, electronic health records and IT services, but also in processes, funding and care management.

Among the issues to be discussed, the workshop will encourage stakeholders to look at how can innovation can be applied to:

• mapping: in order for the EU and national governments to best target policies, human and financial resources, it is crucial to establish an EU-wide map of the prevalence of chronic conditions to help determine the underlying factors (socio-economic, cultural, climatic etc) causing them. National maps exist in some cases but information is patchy and a co-ordinated approach is now needed
• social exclusion (discrimination due to mental or physical disability, lack of access to employment or social services) and its economic as well as social implications
• moving from a ‘disease treatment’ approach to chronic diseases to a ‘prevention and lifelong wellbeing support’ approach
• empowering patients and fostering enhanced communication between them, care providers, funders and treatment suppliers
• process improvements: streamlining administration, care payment mechanisms, care management, health systems
• improving skills, education and information-sharing among all stakeholders

ii Integration

To achieve significant reductions in the burden of chronic diseases, all stakeholders must be prepared to rethink their working practices, processes, policies and relationships. To help stimulate the debate, we list below a few current and past examples of successful integrated approaches.

• National Service Framework in England (heart, lung , mental diseases…): strategies set clear quality requirements for care. These are based on the best available evidence of what treatments and services work most effectively for patients.

One of the main strengths of each strategy is that it is inclusive, having been developed in partnership with health professionals, patients, carers, health service managers, voluntary agencies and other experts. (www.nhs.uk)

• Disease Management Programmes in Germany (Diabetes, asthma/COPD, heart disease...) help co-ordinate and guide care for the chronically ill. "German-style" Disease Management Programmes were implemented in a nationwide roll-out in 2002. The explicit goal of the programmes is "to enhance co-ordination of care and to improve quality of care for the chronically ill. To ensure this, a number of quality assurance measures are in place including evidence-based treatment recommendations and continuing medical education. (Patient Empowerment – A New Paradigm in Disease Management?, European Life Science event at the European Parliament, 2 March 2010).
• In the 1970s, Finland had the world’s highest death rate from cardiovascular disease, largely as a result of widespread and heavy tobacco use, a high-fat diet and low vegetable intake. In response to local concerns, a large-scale community-based intervention was organised, involving consumers, schools, and social and health services. It included legislation banning tobacco advertising, the introduction of low-fat dairy and vegetable oil products, changes in farmers’ payment schemes (linking payment for milk to protein rather than fat content), and incentives for communities achieving the greatest cholesterol reduction. Death rates from heart disease in men have been reduced by at least 65% leading to greater life expectancy – approximately seven years for men and six years for women. (Preventing Chronic Disease – A Vital Investment, WHO, 2005)

What are the key questions facing each of the stakeholders and the questions they will have to address in order to create and deliver a successful new model? In the run-up to the workshop, we set out below a summary of some of the key issues.

1. Patients and Carers

Patients and carers must be at the centre of all policy decisions and education relating to the daily management and treatment of chronic conditions. Their buy-in and feedback is crucial if behaviours and other determining factors underpinning their conditions are to be addressed to achieve the best possible quality of life.

• How can healthcare professionals, employers, health systems, insurers and pharmaceutical providers best support patients and carers?
• How can patients’ daily experience and knowledge of their conditions feed into better education, policy and care management?
• How can patients and carers’ daily experience of service delivery be fed into national and EU policy-making to ensure better practical outcomes?
• How can the latest information and clinical findings be better shared with patients and carers?
• How can the latest e-health and telemedicine tools be better targeted to enable improved knowledge-sharing, quicker and better care management?

2. Healthcare Service Providers (public and private)

Healthcare policy and service provision is still largely government-led and controlled in most Member States. Resource allocation for treatment and services is too often seen as a ‘health-only’ budget issue without sufficient reference to other departments whose policies also impact on those living with chronic conditions: employment, social services, environment etc. The average four- to five-year lifespan of an average government also mitigates against the long-term planning necessary to ensure continuity of service provision for those living with chronic conditions.

• How can government departments better co-ordinate and integrate policies to obtain enhanced and more cost-effective outcomes for the management of chronic conditions?
• How can the relevant agencies, industries and civil society groups improve the co-ordination of services and delivery to support patients?
• How can private health insurance be made more responsive to the changing needs of long-term treatment and management of chronic conditions?
• How can public and private agencies work better together to provide integrated care services over the longer-term?

3. Healthcare Professionals

The role of healthcare professionals is undergoing radical change in many Member States to encompass patient training and education and well as new methods of service provision (e-health tools, telemedicine etc). In the UK and Scandinavia, GPs have already developed training programmes in order to help them guide their patients through the health system for specific diseases, such as diabetes and asthma. In the UK and the Netherlands, a new profession “Nurse Practitioners” has been established to allow university-trained nurses to take over tasks that traditionally fell within a doctor’s remit, such as the prescription of some medicines and administration of certain treatments. In Germany, “Community Nurses” have the same role and are supported by e-health tools.

• How can the needs and expectations of healthcare professionals be better met to help them support patients and carers?
• How can their real-time experience of service delivery be fed into policy-making to ensure better practical outcomes?
• How can their clinical knowledge be better used in public-awareness and educational programmes?
• How can innovative tools and processes be used optimally to ensure better patient care and support?

4. Public Education

Despite widespread public education campaigns throughout the EU on the dangers of tobacco and alcohol misuse, the importance of health eating and exercise, chronic conditions linked to these factors stubbornly continue to rise in many countries. It is well known that human behaviour and choices are one of the most significant causes of chronic conditions but are among the most difficult areas to change.

• How can the public be better engaged/persuaded to make meaningful lifestyle changes?
• What role can innovation and technology play?
• Single-issue public awareness campaigns (eg breast cancer screening) have produced significant improvements in outcomes in many Member States. Can any lessons be applied to chronic conditions where a range of factors come into play?

5. Legal Frameworks and Regulation

Improvements in the health outcomes of people with chronic diseases have largely come about by coercion not persuasion: for example, banning smoking in public places, banning tobacco advertising and raising the tax on cigarettes saw widespread reductions in the numbers of people smoking and a consequent fall in cardiovascular, respiratory diseases and cancers linked to smoking. There is now a greater public appetite and acceptance of controls on some dangerous products and behaviours, although this remains controversial in many countries where there is opposition to extending this coercive approach to other products, such as alcohol and unhealthy foods or food ingredients, particularly where there is not such a clear evidentially-direct link as with smoking.

• How far can and should policy-makers go to extend legal controls and regulation to curb harmful human behaviours (eg increasing taxes, banning ingredients) and how could they better engage the support and acceptance of the public?

6. Employers

Suffering from a chronic disease is not a synonym for being “unemployable”. However, many patients with chronic conditions feel discriminated against simply because their employers will not agree to flexible working to accommodate time for treatment or because the workplace is not adapted to the employee’s needs. With such a high prevalence of chronic conditions in Europe, national economies and employers cannot afford to discount a large part of the workforce and must look at how to accommodate those who are able to work with a bit of support. This has been reinforced by a European directive adopted in 2010 which states that all kinds of discrimination in employment, including disability, must be prohibited in the 27 EU Member states.

• How can employers help support their employees with chronic conditions?
• How much of the cost burden should fall on employers to adapt their working conditions to the needs of employees with chronic conditions?
• How can other agencies (government etc) help employers integrate employees with chronic conditions into their workforces?