Ninth European Health Forum Gastein 2006 covers diverse range of aspects in European health care policy
Bad Hofgastein 06 October 2006The 9th European Health Forum Gastein (EHFG), which took place from 4 to 7 October 2006 in Bad Hofgastein, was a complete success. With nearly 600 participants from 41 countries, it was the best attended forum so far. The range of topics was also impressive, with 20 plenary sessions, fora and workshops held. The focal points of this year's forum were of particular interest for patients. Several events addressed different aspects of quality assurance in the health care industry. The topic of cross-border co-operation was especially current as a result of the release just a few days ago of a memorandum by the European Union (EU) Commission on the planned EU Health Directive. The directive is crucial for the extent to which patients will be able to claim benefits for services in other countries within the EU. At the EHFG longer-term perspectives for migration in health care professions were also discussed, focusing on the somewhat less observed migration of highly-qualified personnel, doctors in particular. Here follows an overview of the hottest themes addressed.
At the opening EHFG President Günther Leiner stated that the "European Health Forum offers an ideal, well-established platform which is necessary as a think tank for health policy and above all for health care administration in Europe." Mr. Leiner is only partially satisfied with the development of European health care policy, however. "What functions very well at an expert level is in no way true at the level of policy. Experts have to develop solutions, but politicians also have to adequately communicate this to the public. Sometimes I have the impression that at least certain EU Commission members have no great interest in this. As long as leading EU Commission representatives are ambivalent about the work of their own experts and with regard to adequate information for the populace, then no one should be surprised that in many countries, and not just in Austria, the EU fails to enjoy the credit it actually deserves."
Health care infrastructure is an important way to accelerate the cohesion between old and new Europe. However, investment in health care is sometimes put behind other infrastructure measures like transport and energy. "It is a fundamental misunderstanding if policymakers think that they have to decide between investing in health or in wealth", stated Karl-Jürgen Schmitt, Chairman of the Structural Funds Taskforce in COCIR, the European trade association for the radiological, electromedical and health care IT industry.
At the EHFG, COCIR sponsored a session on "Improving Health care Infrastructure". Experts urged new EU Member States to pay greater attention to the role of health care infrastructure. Health and wealth are interdependent as healthy people contribute to economic growth, they concluded. Health care creates jobs and in the EU approximately 10 percent of jobs are in this sector, the COCIR experts stressed.
"The window of opportunity for Member States to apply for Structural Funds is closing soon. The time to act is now", stated Frank Anton, COCIR Chairman. Member States have until February 2007 to submit their applications for Structural Funds.
"Health care infrastructure plays a comparable role to other forms of infrastructure. It contributes to society in many different positive ways", stated Karl-Jürgen Schmitt. "Structural Funds can boost the quality of health care, create jobs and improve the standard of living for citizens in the respective countries."
"It becomes more and more evident that health care and its infrastructure play a dynamic role in meeting the goals of the Lisbon agenda. In addition, health care infrastructure is very important to European citizens and has a long-term perspective in improving the future of the European Union", stated Peter Ungar, DG Regio, European Commission.
The most important health policy event in the EU, Andrzej Rys, director of public health on the EU Commission, emphasized is the importance of the EU Health Services Directive currently being developed. With the consultation process launched a few days ago, the crucial phase has begun. "The German EU Council Presidency starting in a few months will be the most important period for the EU's future health care strategy." Andrzej Rys also emphasized the importance of the European Health Forum: "Gastein is a set point on the agenda for the commission's work and is the best opportunity to present the work of previous years and plans for next year to experts."
The opportunities for co-operation go far beyond those in the area of clinical research. The exchange of experience in the organisation of the health care industry can make enormous advances possible for European countries.
Experts agreed that public trust in the quality of available health information must be strengthened in order to help empower patients and citizens to make more informed decisions about their own health care needs. New mechanisms that use independent review and appraisal may have potential to enhance public confidence in information.
In a recent global survey of 192 patient organisations conducted by PatientView, 60 percent of these groups said the most important goal of publicly available health care information is to enable patients to make informed decisions about their health care and treatment. Yet many patients also felt currently available information to be largely unreliable. Information could be improved by ensuring that it is easy to understand, transparent with regard to data sources and vested interests, and based on scientific evidence.
Independent review and accreditation of health information might also present a way to increase confidence in publicly-available information. In England, the Department of Health has initiated discussions on the development of a National Information Accreditation Scheme (IAS), which is due to be implemented next year. It is hoped that the IAS will help patients recognize good quality information and make more informed decisions about their health, and support health professionals to deliver good care.
Accreditation mechanisms may also serve to widen the scope of available information. In Switzerland, the non-profit Swiss Pharma Quality Association (SPQA) has designed a multi-stakeholder mechanism with an independent audit board to guarantee the reliability of information found on pharmaceutical company web sites. Such accreditation mechanisms may be a practical compliment to existing government regulation of publicly available information. In the PatientView survey, over 60 percent of patient groups said pharmaceutical companies should be allowed to supply information directly to the public under specific circumstances, and particularly if the patient requests it.
However, accreditation alone is not sufficient to address the issue of public mistrust. There is little empirical evidence to show the impact of accreditation and quality marks on health improvement, and past efforts have run up against challenges with uptake, and cost of participation. Some feel accreditation is a paternalistic approach which limits access to information.
In discussions, participants called for more co-operation between stakeholders, especially patient and consumer groups who have traditionally had different views on how to improve access to patient information. Progress requires action and dialogue at both the national and European level.
Two thirds of all patients in Western Europe seek therapy-relevant information on the internet and more than half of consumers expect to find new medical information on the web. This poses new challenges to pharmaceutical companies, but also opens up new opportunities.
The figures show that health information taken from the internet is of growing importance for patients as well as experts - provided the content is safe and of high quality. An internationally exemplary project has been initiated in Switzerland and presented at the EHFG. After completion of a quality audit, five pilot companies - Menarini, Lundbeck, Novartis Pharma Schweiz, Merck Sharp & Dohme-Chibret, Novartis Pharma Schweiz and Takeda - have received the first so far only European quality label for "reliable, confidential and safe internet information" in the pharmaceutical industry.
The Swiss Pharma Quality Association (SPQA) was established for the quality label. The president of the non-profit organisation, Hans Seiler, emphasized the comprehensive basis for granting the label: "We take into consideration the fulfilment of legal conditions, norms and standards, the content of the information, how it is presented as well as regulations from the area of information and communication technology." The quality label is granted by an independent institution for two years. In addition to this, random checks as to whether the quality standards are fulfilled on a steady basis are carried out continually.
The SPQA label guarantees internet users that the information presented on the web is correct, balanced and current and that it fulfils all regulations of Swiss Data Protection Law and voluntary obligations in the industry within the scope of the Swiss Pharma Code. For pharmaceutical companies which feature this quality label on their web sites, the certification also has a series of important advantages. The quality label is now recognized as proof of honest communication with patients and contributes to the fact that patients are more likely to make use of the original information than information from a third party.
Health systems over the globe face ever increasing competition for resources at the same time as technological innovation accelerates and citizens live longer. Citizen participation in decision-making cannot ignore the necessity to prioritise scarce resources across competing priorities. Knowledge transfer across borders and disciplines intensify and require integrated approaches that allow decision-makers at different levels to successfully deal with the complex pressures they face.
Health Technology Assessment (HTA) was developed as an effective tool to assist in informing health care planning and decision-making on complex issues based on research. HTA is an interdisciplinary process that brings together the clinical expertise of professions and systematic and rigorous assessment of the research base with organisational and health economic analysis, and assessment of wider consequences for the individual and society. It takes in evidence multi-disciplinarity, pragmatism, and policy orientation - and recognises that results of research are necessary yet not sufficient to inform decisions.
The aim to inform decision-making necessitates the early involvement of various stakeholders' perspectives from the very start and throughout the HTA process. The European network for Health Technology Assessment, EUnetHTA, will seek HTA stakeholders' involvement to increase responsiveness of the HTA process to their needs.
General recommendations and conclusions include:
- HTA is a tool to inform the formulation of safe, effective health policies that are patient focused, seek to achieve best value, and promote patient access to innovative and effective health technologies.
- Focal point for sharing knowledge and supporting co-ordinated HTA from the Members States respecting national and regional differences should be established on a permanent basis.
- The stakeholder groups contributing to production or use of HTA reports should actively interact with those entities establishing the European HTA network and provide their views and constructive comments fostering responsiveness and transparency of HTA processes in Member States.
- The European network for HTA (EUnetHTA) should contribute to the development of the high quality of HTA methodology and practical tools with increased general applicability across European borders, including New Member States.
- EU and Member States should invest in the development of a permanent European HTA collaboration mechanism beyond the 3-year project period (2006-2008).
Health policy planning operating under budgetary constraints requires structured, transparent and research based input generated by several disciplines. The European Health Technology Assessment Forum that gathered a wide spectrum of stakeholders confirmed the potential of health technology assessment to deal with complex issues faced by decision makers in health care.
Introduction of technologies simultaneously in several countries and knowledge transfer across borders highlight the need for European solutions. Maturity of HTA methods at a European level has reached the point that it is possible to answer needs expressed by Member States and EU Commission to transform existing cross-border collaboration into a sustainable network. Stakeholders agreed that to ensure responsiveness and effectiveness of the European HTA process, EU and Member States should support a permanent and sustainable European HTA collaboration mechanism.
Perceptible growth in the migration of highly-qualified medical personnel was shown by a study performed by the Organisation for Economic Co-operation and Development (OECD) presented at the EHFG. EU enlargement and the associated simpler emigration and immigration to European states have fostered the development in the last few years. By long-term comparison the development is dramatic: in the last 30 years the number of doctors who do not work in the country in which they were educated has risen 240 percent and therefore has far more than tripled.
By far the biggest "winner" of this migration is the USA. More than 200.000 doctors who were born abroad work there. This is equal to 25 percent of all doctors employed in the USA. The highest share of foreign doctors is represented by New Zealand, however, at 34 percent and in Europe by Great Britain at 33 percent. Health care systems in numerous countries are already dependent on the migration of doctors and "if no adequate measures are taken, this number could still substantially increase", stated the author of the study, Jean-Christophe Dumont.
Globally there are several migration patterns which can be ascertained: the migration of doctors from developing countries in the South to industrialized nations is already traditional. Migration from the western countries of continental Europe to Great Britain, the USA and Canada has considerably increased. At the same time, a large number of Central and Eastern European doctors are "on their mark": unlike with nurses and allied health professionals, the wave of migration for them has yet to begin. There is great interest in employment in the West, which ultimately can be mitigated only by a substantial increase in the level of income in the countries of the East.
Former Lithuanian Minister of Health Zilvinas Padaiga formulated the concerns of Eastern European countries at the EHFG: "So far three percent of Lithuanian doctors have requested documentation for recognition of their diplomas abroad, but surveys show that more than half of all Lithuanian doctors have at least considered migrating abroad."
The continuing threat of the H5N1 strain of influenza in wild and domestic poultry in Southeast Asia, and more recently in Europe, the Middle East and Africa, represents the most serious risk of a human influenza pandemic in decades. Over the last year, there have been a number of avian influenza outbreaks in wild birds and domestic poultry in European countries. In addition, there have been several cases of human infection in Turkey. Although there is no absolute certainty that an influenza pandemic will be caused by avian flu, these factors nonetheless contribute to increasing concerns that there may be a pandemic outbreak in Europe in the near future.
Speaking at an expert panel on the threat of modern pandemics at the European Health Forum Gastein, David Reddy, Influenza Pandemic Taskforce Leader, F. Hoffman-La Roche, outlined the role antivirals can play in containing or controlling pandemic influenza and the importance of stockpiling drugs in advance of any such pandemic outbreak. Dr. Reddy emphasized the following points:
- There is a huge range in the level of preparedness among European countries and very little collaboration on planning for an influenza pandemic
- Significant work still needs to be done on co-ordinating an international pandemic response
- Antivirals play a very important role in the early phase of such a pandemic, as vaccines are not immediately available
- The initial challenge for supply has been met, but industry is now facing a challenge in demand to maintain capacity
- Once stockpiles are in place, countries must also develop the ability to provide rapid access to citizens
Although experts stress it is not possible to predict which specific virus will cause the next pandemic threat, they regard the stockpiling of antivirals as an important contribution to pandemic preparedness. This corresponds to the opinion of the World Health Organization (WHO), which has advised that "stockpiling drugs in advance is presently the only way to ensure that sufficient supplies are available at the time of a pandemic."
In terms of medical intervention, the stockpiling of antivirals is an extremely important factor. For instance, production of the antiviral medication Tamiflu has recently been increased to the capacity for producing up to 400 million courses of treatment annually.
Statistics highlighting the impact of long-term disease on European health services were presented at the EHFG. The figures clearly indicate the inadequacy in how the problem of chronic disease is handled.
"The increasing burden from long-term medical conditions threatens to overwhelm European health services unless innovative management systems are put into place", stated MEP Miroslav Mikolasik. "Member States and the EU Commission need to take this particularly seriously. There are huge variations in hospital admission rates for long-term conditions." Austrians are admitted to hospitals with osteoarthritis seven times more often than the Portuguese (e.g. Osteoarthritis: Portugal 73/100.000 compared to Austria 544/100.000). Laszlo Gulácsi of Hungary commented, saying: "I refuse to believe this difference could be put down to genetics alone."
Hospitalization due to osteoarthritis per 100.000 hospitalizations according to OECD Health Data in 2004:
- Portugal: 73
- Spain: 118
- Italy: 146
- Ireland: 147
- UK: 156
- Denmark: 198
- Sweden: 210
- Belgium: 242
- France: 256
- Finland: 448
- Austria: 544
The use of health services across Europe is not uniform and there are large variations depending on the socio-economic group, ethnicity, and gender. "Men can be considered a hard-to-reach group concerning health literacy", commented Prof. Banks, president of the European Men's Health Forum. "Men's poor use of primary care services is a significant factor in hospital admission rates and mortality. Men will be admitted as a hospital emergency almost twice as often as women over the age of 50", he added.
At a workshop, organised by the European League against Rheumatism (EULAR), health professionals, patients and researchers shed light on the medical, social and economic consequences of rheumatic diseases and concluded that the place of rheumatic diseases in national and European health policy does not correspond to the enormous overall impact of rheumatic diseases. Over 100 million Europeans, including many young people, are affected by some form of rheumatic disease in their lives. Over the next years, ageing European population and changing lifestyles are expected to boost dramatically the number of the people affected.
Rheumatic disorders are the most common causes of severe long-term pain, sick leave and physical disability. They have a major impact on quality of life of the patients and their relatives. Direct and indirect costs related to muscoskeletal diseases in Europe are estimated at more than two percent of GNP each year. "Despite existing figures on prevalence and estimated disease burden, rheumatic diseases have often not been among the health priorities at national and European level, because they usually do not have fatal consequences for the patients", stated Tore K. Kvien, Professor of Rheumatology at the University of Oslo and President of EULAR.
Enhanced research efforts are needed to improve knowledge about the causes of most of the diseases, to find cures and develop better treatments. "Improving pan-European collaborative research is one of the main challenges for rheumatology research", Josef Smolen, Professor of Internal Medicine and Chairman of the Department of Rheumatology of Vienna General Hospital pointed out. "The major burden of rheumatic diseases should be mirrored in higher European Union support for pan-European collaboration in this field."
"There is a lot of work to be done to correct existing myths about rheumatic diseases. The majority of the population still thinks that rheumatic diseases only affect the elderly", stated Sandra Canadelo, Chair of the EULAR Social Leagues who developed arthritis at the age of 24. "This misperception is reflected in the field of paediatric rheumatology which faces significant problems in ensuring the financial support for clinical and laboratory studies, best treatment and disease management."
The financial burden of asthma in the EU amounts to nearly 17,7 billion euro. Every week, one in four Europeans with asthma suffers from attacks so severe they cannot even call out for help. In light of this common challenge, it is vital for EU Member States to work together to improve this dire situation. To this end, an expert panel on asthma at the EHFG discussed the way forward. The panelists emphasised the following three points:
- A patient-centred approach is needed, enabling guided self-management in asthma
- Better training and awareness of treating health care professionals (e.g. GP, nurse, specialist) is required
- Member States need to learn from best practices in asthma care
The panel discussed the remarkable success of the innovative Finnish public health programme on asthma. Erkka Valovirta, from the Finnish Steering Committee, outlined how this programme dramatically improved patient outcomes whilst also significantly reducing health care costs of asthma.
"We need concerted efforts to emulate some of the success achieved in Finland across the whole of Europe", stated Prof. David Price, Chair of Research at the International Primary Care Respiratory Group (IPCRG). Susanna Palkonen from the European Federation of Allergy and Airways Diseases Patients' Associations (EFA) added: "The Finnish example has demonstrated what can be achieved at national level. The EU can make a difference by ensuring that other Member States adapt best practice solutions to their own health care systems."
An international panel of experts assessed the new EU Regulation on Paediatric Medicines extremely positively. However, the panel also stressed that much more needs to be done to achieve the overall goal of making standards of safety and effectiveness equivalent to those for adult medications.
To summarize, Peter Stephens of IMS Health, a provider of business intelligence and strategic support for the pharmaceutical and health care industries, said that "the regulation is a significant development in children's medicines but it is simply a starting point. We need to ensure that the incentives to manufacturers actually work in practice, we need to develop effective tools for paediatric drug safety and it is essential that there is collaboration between all parties if medicines are to be prescribed, dispensed and administered without error."
According to the experts at the EHFG, the main challenges for improvement of paediatric medicines are:
- The areas of competency of the Paediatric Use Marketing Authorisation (PUMA) need to be clarified if the financial opportunities are to outweigh the financial risks;
- Further work on the co-ordination of research is essential if the potential of cross country studies is to be realised;
- Longitudinal studies are particularly essential to the safe use of drugs and this in turn means greater use of computerisation in health care systems;
- Consistency in interpretation of the Data Protection Directive across member states is essential if sufficient information is to be gathered on adverse drug reactions;
- A practical approach needs to be found to ensure that there is a common understanding between patients, researchers, policy makers and health care professionals concerning the vital need for research and the appropriate management of disease;
- This information needs to be tailored in particular to the needs of the patient and should harness the power of the media to develop trust and thus effective treatment and clinical trial recruitment;
- Health care professionals should work together collaboratively in multi-disciplinary clinical teams and this in turn requires a more structured approach to training and practice.
The number of this year's EHFG participants will be considerably exceeded again next year. Mr. Leiner has planned quite a lot for the ten-year anniversary. For the first time a European health prize will be awarded to municipalities or regions which have implemented model initiatives for the promotion of public health. "This will provide added momentum to the EHFG and its degree of recognition among the general public and I am sure it will bring the 10th European Health Forum Gastein another giant step forward", Mr. Leiner concluded.
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