Health system performance: does the EU care and dare? (F6)

15397259016_776cb9f5b3_mThe answer to this question given by Martin Seychell, Deputy Director-General of DG Health and Consumers of the European Commission, speaking at the European Health Forum Gastein 2014 was a clear “yes”: “Yes the EU cares about health system performance!” And: “Yes, the EU can and will support member states in creating more performing health system”. (For the record: Martin Seychell first said that the answer to the second part of the question was more difficult than the answer to the first part.)

I was pleasantly surprised by the clear answers given during this session!

Health system performance has been a buzz word amongst policy-makers and researchers for quite some time – certainly since the publication of the World Health Report 2000 on “Health Systems: Improving Performance”.

Improving health system performance is currently on the political agenda in almost all EU countries. However, it often remains unclear what people mean when talking about health system performance or about “improving performance”. Are people concerned about efficiency? About health outcomes? About patient experiences? About financial sustainability?

Peter Smith, the author and editor of two books published by the European Observatory on Health Systems and Policies about Health System Performance Comparison and about Performance Measurement for Health System Improvement was present during this session to also give clear answers: “Poor performance means that resources somewhere are wasted – and health suffers because these resources are lacking somewhere else”. More efficient health systems (maximising outputs at a given set of inputs) are certainly better performing than those health systems that waste resources.
However, when actually aiming to measure health system performance, things get much more complicated. There is no consensus about how health systems function or should function, and there is no consensus about what health systems should achieve. Consequently, because performance can only be measured in relation to health systems’ objectives, people inevitably talk about different things when talking about health system performance.

15405635706_c7ebd56874_mThere are different frameworks for conceptualising and measuring health system performance. The OECD framework for health system performance assessment, presented during the session by Francesca Colombo, head of the OECD health division, is one of the more influential frameworks for international comparisons. It is used by OECD in its annual Health at a Glance publication, providing comparative information on the performance of health systems in OECD countries.

National policy makers may have particular needs that might be different from those addressed by international comparisons. For example, in Finland, as pointed out by Liisa-Maria Voipio-Pulkki from the Finnish Ministry of Social Affairs and Health, there is particular interest in having measures of the combined effects of health and social care interventions.

It is clear that national health systems pursue different (but always multiple) objectives and may place different weights on their multiple objectives. Therefore, measuring performance across countries remains challenging, and can not usefully result in simple rankings of countries.

Yet, international comparisons of different aspects of health system performance are very useful: they can help to identify weaknesses of national health systems, and they can provide strong impetus for reform.

The expert group on health system performance assessment that is soon to be set up by the EU Commission may help in developing a European system for health system performance comparison. Ultimately sharing of information on differences in performance and on best practices for performance improvement can certainly contribute to better health systems and better population health.

by Young Gasteiner Wilm Quentin




The importance of person-centred care when developing future health strategies (L4)

DNVGLOn Thursday 2nd October at the EHFG 2014, DNV-GL hosted a lunch workshop on the topic of ‘Person-centred care. Towards a safer and smarter future’ in collaboration with the Young Forum Gastein network. Eva Turk, senior researcher, and Stephen Leyshon, Deputy Programme Director, represented DNV GL Norway. Hedinn Svarfdal Björnsson, Project Leader, Determinants of Health, Iceland, represented the Young Forum Gastein and Nick Fahy, Director of Nick Fahy Consulting Ltd, UK, moderated the event. The workshop started off with a discussion on a vision for healthcare, linking in with the conference theme of ‘The Europe We Want’. Workshop participants were asked to consider their own interactions with healthcare in the past year and to describe the kind of care they want.  Answers included ‘accessible’, ‘sustainable’, and ‘person-centred’. The challenges of ensuring sustainable healthcare were then outlined, and included lack of safety, changing needs, rising costs, fragmented care pathways and unequal access. These themes had been echoed in other fora and workshops during the conference.

Discussion of the challenges painted a worrying picture. However, the speakers emphasised that one of the key points currently in our favour is that we are increasingly gaining a better understanding of why people become sick. Rather than taking the traditional linear approach of connecting a single cause with an outcome (e.g. poor diet and bad health), taking into account more of the full lifespan of a person will help us to understand how to best improve their health (e.g. what factors are impacting the person’s ability to eat well and how can they be improved?). In conclusion, we need to consider the full picture and engage with it to improve health. Person-centred care was described as the basic philosophy and process where healthcare becomes more responsive to the psychology, social abilities, needs, and preferences of patients in addition to physical aspects of their health. In order to make this a reality, system change is needed.

How do we engage with patients to improve healthcare systems?

Stephen Leyshon discussed current and potential future approaches to engaging patients in healthcare design, or ‘co-creating healthcare’. It would seem that the same system failures continue to recur in healthcare as a direct result of not engaging patients in care design. If we are to learn from previous mistakes, and thereby improve patient safety, we should adopt approaches from other industries where service users are invited as co-designers and co-creators. This workshop invited participants to share in the opportunity to create a strategy for person-centred healthcare.

Participants watched videos of six patients/carers with different health conditions describing their experiences of the health system. Each table of participants then discussed a particular patient/carer and considered the current journey of the patient and how their care might look under a person-centred care system.  Participants considered how we can involve patients as co-designers and how we could use emerging technology and real-time feedback to improve safety and quality in healthcare. Finally each table fed back their discussions.

Current variations in person-centredness across different health systems

As participants came from many different countries, many variations in current levels of ‘person-centredness’ were found. Some participants described existing cases of ‘expert patients’ who have learned to care for their own illness and can serve as trainers to empower other patients. Also, in some healthcare systems there are staff members employed specifically to listen to patients. These can include former patients who act in ‘patient support’ roles or staff members with the title of ‘Chief Listening Officer’.  However, in many countries feedback is not actively encouraged and patients are often unaware of the best ways to give feedback on their care. Where feedback is taken, often the feedback loop is not closed and patients are not shown the effects of their feedback in changing healthcare. The importance of feedback from patients as an aid to improving safety was agreed by all.

Concrete steps to enhance person-centred care

Practical steps to improve person-centredness which were discussed included the use of new technologies such as apps, which may be used to collect health data or opinions submitted by patients. The human supports of social networking and coaching were raised as ways to help patients navigate health systems in the context of fragmentation of care. Also it was felt that more could be done to inform and empower patients about their potential as co-creators.  There was some discussion of the limitations of person-centredness. For example, while it may be important to a patient to access services locally, the best quality care may not be logistically achievable at a local level. When discussing this kind of problem, it was concluded that we must ensure that patients are equipped to make their own decision on what services they avail of, rather than dictating what care the patient must receive. This means clearly highlighting the risks and benefits of treatments and ensuring patient autonomy.

Having shared perspectives from different health systems, each participant was invited to declare their pledge towards person-centred care. Further sessions at the EHFG conference, e.g. personalised medicine, reflected some of the themes which emerged during the person-centred care lunch workshop. It was clear from this year’s EHFG that the Europe we want has the patient at the centre of healthcare.

Written by Young Gasteiner Susan Spillane

Susan photo for applications etc.


Moving your body for health and well-being – creating ‘win-win-wins’ for everyone involved (F8)

F8During last week’s Gastein Forum, I participated in a forum on ‘Moving your body for health and wellbeing’, organised by DG Research and Innovation.

To health professionals it seems almost common wisdom that non-communicable diseases account for an incredibly high percentage of total mortality in Europe. Some estimates state that up to 86% of total mortality can be attributed to non-communicable diseases – many of which could be prevented through changes in lifestyle. Interestingly, the increase in sedentary lifestyles seems to be an issue in virtually every EU-member state, making this a relevant topic for collective action and policy. It therefore makes sense to look beyond national borders and to approach these developments from a European perspective.

The session kicked off with an overview of some recent EU-activities which promote physically active lifestyles. This included quite some noteworthy developments such as the EU Work Plan for Sport 2014-2017, the EU Council Recommendation on promoting health-enhancing physical activity across sectors, and the introduction of the annual European Week of Sport (the next one is taking place in September 2015). To me as an observer it felt as if the Commission was stepping up its game in pursuing its physical-activity agenda.

During the session, some very interesting EU-funded projects were presented. Each of these projects offered some interesting ‘out of the box’ thinking on the promotion of physical activity. One project called “Credits for Health” (C4H) stood out for me, because it took a particularly noteworthy approach to promoting healthy behaviour in the population. The main objective of C4H foresees that citizens define personal goals in the areas of nutrition, physical activity and participation in social life. If participants then adhere to these goals, they can earn credits which they can spend. In other words: imagine buying your groceries from money that you made through exercise and through creating healthy habits. The project is still ongoing but I am very eager to hear about its final results and whether this will be rolled out to all European citizens in the near future.

Another equally interesting project focused on helping men lose weight and become active through something that men value more than anything else in this world: professional football! The so called Eurofit project focuses on involving men to become members of a weight loss team which is affiliated and working with their favourite football club. The project therefore engages men through their emotional connection with their favourite clubs in order to make sustainable improvements to their diet, activity, and physical fitness. Their website is definitely worth checking out (unfortunately my favourite club is not yet on the list of participating clubs). The third innovative project I was able to learn about was called PAPA (Promoting Adolescent Physical Activity). It is a European-based project committed to enhancing young peoples’ health and well-being through ensuring positive experiences in youth sport. The project aims to develop, deliver and evaluate a theoretically-grounded and evidence-based coach education programme that can help coaches make youth sport more engaging, empowering, and enjoyable. I think that this is certainly a project with some direct and positive impact in the years to come.
What I liked most about all projects was that they took a practical and positive approach to the promotion of more physical activity and health – and it surely will be interesting to follow-up on their final outcomes in the future.

During the second part of the forum, three break-out sessions allowed for an active discussion on barriers and facilitators in enhancing physical activity. Through some lively round-table style conversations, stakeholders who worked in this field were able to engage directly with EC-staff to share their experiences in enhancing physical activity. It quickly became clear that for any health promotion related activity, contexts and environments play an important role. I think that especially across European member states, this seems to be a crucial point. Another important aspect during these discussions was that any programme and partnership should explicitly show the added value to each party, including the citizen. Creating those ‘win-win-win’ situations for all stakeholders involved was considered paramount for the effective development and implementation of programmes and partnerships.

Written by Christoph Aluttis
Department of International Health, Maastricht University

C Aluttis


Undocumented migrants: access to health care vs. imprisonment (W11)

Imagine what it would be like to fear arrest when seeking health care. This is the reality for undocumented migrants (UDM), one of the absolute weakest groups in the EU. This was the focus of one of the final workshops of EHFG 2014.

DSC_0012The workshop was moderated by Lilana Keith, Programme Officer for the Platform for International Cooperation on Undocumented Migrants (PICUM). She started out by bringing us all closer, turning the workshop into an intimal interaction between the audience and the panel, consisting of Lilana, Frank Vanbiervliet from Doctors of the World and Carina Spak representing the Austrian initiative AmberMed. The introduction movie made by PICUM in 2011 gave us a view into the world of UDM in need of health care, and the altruistic people working in NGOs trying to provide this. Even though regulation and access varies between countries in the EU, it seems that all the UDM in Europe (between 2 and 4 million) face similar situations of disparity and risk of prosecution when seeking heath care. The WHO Constitution enshrines the highest attainable standard of health as a fundamental right for every human being. Therefore the current state of handling UDM seeking health care in most EU nations is in violation of human rights legislation.

Since the beginning of the economic crisis in 2008, the situation for UDM seeking healthcare has actually improved; but due to increasing unemployment and impoverishment the number of migrants losing their resident permits has increased, according to Lilana. She also pointed out that even though upgrading to a good system of health care can attract UDM, a situation many nations fear, research shows that these immigrants lack the knowledge to travel to the countries with the best legislation.

DSC_2894Carina Spak described the situation in AmberMed, a Vienna-based organisation working to support UDM with health care. Because of the fear of arrest, UDM often postpone seeking health care until the situation is very serious. Treating 2000 patients a year, the altruistic health professionals at AmberMed see the same kind of disease among the UDM as in the general population, but in a much more progressed state. Stories of children losing sensation in their ears from sleeping on concrete floors describe the human suffering we need to consider when discussing this topic.

Health tourism is a myth, according to US data discussed by Frank Vanbiervliet. His examples showed that immigrants are healthier than the local population. However UDM are more prone to become ill because of the circumstances in which they are forced to live. A major concern is mental health, where there is currently no good data to describe the situation, but the high number of UDM suffering from psychosomatic disease is a sign of the magnitude of this problem.

Earlier in EHFG 2014, Professor Sir Harry Burns pointed out that inequality is the major contributor to premature death in Scotland; and health illiteracy is a problem of major concern according to Ilona Kickbusch. I feel certain that UDM represent the poorest and most illiterate group in Europe today; their situation needs to be urgently addressed.

by Bendik Brinchmann 



All for health and health for all: providing public health leadership for the next five years (Closing Plenary)

It’s the end of a sunny three days in the Gastein Valley, with a lot to reflect on after thought provoking discussions and insightful presentations.  A room full of politicians, government members, decision makers, experts, civil society representatives, industry and Young Gasteiners have debated the European social model and its core values, the EU health mandate and health systems in the next 20 years. What the closing plenary will try to do is bring the take home messages from the four pillars of the European Health Forum Gastein and initiate a dynamic multistakeholder discussion.

15243476210_12b58625deThe high-level debate aimed to answer the questions of how the European social model and core European values will develop and whether the role of the EU in health will or should change in the future. To kickstart the debate and increase the energy in the room, Tamsin Rose, Director of Progress Works, presented the EHFG 2014 conference film that gave an overview of the conference and concluded that health is like a game of chess – you have to know how to move. This is important for all the participants because like a game of chess, health actors will have to make strategic moves to promote the health agenda in the future college of Commissioners and the new Parliament.

Vytenis Andriukaitis, Commissioner-designate for Health and Food Safety, joined the conference in a personal capacity and gave an idea of his priorities for the next five years if he is confirmed by the European Parliament. Dr Andriukaitis said we need health for all and all for health and that in times of austerity spending in health is not only expenditure but an investment in human capital. His passionate speech also stressed the need to reduce health divides across Member States.

Karin Kadenbach MEP reminded participants that health is a key priority for EU citizens and 3rd after employment and the environment. But the EU needs to re-engage with citizens to foster trust. Ms Kadenbach also called for medicinal products and health technologies to remain with the health portfolio referring to a proposed move by President-elect Juncker. Ms Kadenbach closed with a call to action to challenge MEPs and make them your partners in all policy areas.

Nicola Bedlington, Executive Director, European Patients’ Forum explained that patients are not a problem to be solved but co-designers of public health policies and sustainable health systems. Ms Bedlington advocated for a paradigm shift away from “repair” medicine – health literacy gives individuals power to steer their own destiny. The future of healthcare will be the full continuum of care that emphasises both prevention and chronic care management.

Boris Azais, Director, Europe and Canada, MSD explained that industry is also willing to engage and interested in a multi-disciplinary approach to policy making. He explained that industry works with the public sector to drive innovation. In the future of health care, we need to see the cross-silo value of ‘disruptive’ high cost but cost-effective medicines. This would require a deeper debate about the value of innovation rather than just on the costs.

Bonnie Wolf-Boenisch, Science Europe, spoke about the role of EU programmes and policies outside the health sector that could be used to advance the health agenda. The EU has the largest research programme in the world, and health research is one of the priorities. The Europe 2020 strategy also has a digital agenda and this will be key to advancing eHealth.

15430206555_139b98e9cdPeter O’Donnell, Associate Editor, European Voice, gave more of a critical overview of what had been discussed. Despite the “warm-glow” between panelists and participants, he questioned whether ‘sincere’ co-operation was possible when it is put into question by different parts of the health community? He also reflected on the new structure of the Commission: there are only two Commissioners not connected to a team: competition and health. It is too early to say if this will give more weight to the health portfolio or be a barrier for health in all policies at EU level.

Mr Andriukaitis closed the conference by stressing that his priorities would be the 3 P’s: prevention, promotion, protection for the next 5 years. He proposed that health actors work together to promote the health agenda and gave an open invitation to engage with him as Commissioner, stressing he would listen.

This year’s European Health Award and its 10,000 euro cash prize went to the EpiSouth Plus Project. The EpiSouth Plus Project was a three-year project co-ordinated by the Italian National Institute of Health (ISS), National Centre for Epidemiology, Surveillance and Health promotion. The project, financed by the European Union, aims to share the burden of disease control with a focus on environmental and epidemiological commonalities. The project both demonstrates the links between EU health policy and foreign policy, and the importance of cross-border collaboration on infectious disease.

This year the European Health Forum Gastein decided to close the ceremony with a reading of poetry to give the ‘Europe we want’ a more creative edge. This new style was warmly welcomed by participants tweeting.

Social Media responses

Roz Way @iddy_elle_pea_If increase in digital health but lack of data/digital literacy does equitable health become a bigger challenge? #EHFG2014

Susan Spillane @Susan_Spillane Single european pricing regime? Discussion in closing plenary #ehfg2014

Paul Giepmans @pgiepmans Whatever agenda is,Commission has the ambition to lead & actively coordinate.Will Member States/Council accept change in attitude? #EHFG2014

by Leonardo Palumbo