Impressions from the Twelfth European Health Forum Gastein

Bad Hofgastein 06 October 2009The global economic crisis poses a massive threat to the stability of the public health care and social systems and to general access to health care services, warned leading experts speaking about this year's key theme of "Financial Crisis and Health Policy" at the European Health Forum Gastein (EHFG), that was held 30 September to 3 October 2009 as the leading health policy event in the European Union.

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Empty government coffers reduce the possibility and willingness for government support of the health care system; declining economic output and rising unemployment in turn lead to a decline in contributions to the health insurance schemes. The problem is also intensified by the fact that the economic crisis also encourages unhealthy behavioural patterns - poor nutritional habits, smoking, alcohol, less movement. As a whole, the consequences for socially weak groups are substantially more serious and the health differences between population groups are becoming considerably greater.

"The crisis is a serious threat to the health care system, but the negative consequences are not inevitable", stated Armin Fidler, the World Bank's chief advisor on health issues. "The problem could be efficiently countered with specific measures in the scope of the various national economic stimulus programmes." Experience from earlier crises shows that spending on general health care is considerably reduced during economic downturns and that afterward it takes a relatively long time before it reaches the former standard again. "Those who allow the crisis to reduce the standard of health care are getting into a long-term problem with potentially catastrophic consequences for the social situation", Armin Fidler stated.

Armin Fidler basically assesses as positive, that substantial parts of the numerous national economic stimulus programmes are devoted to the health care sector. For example, the area of health care accounts for approximately 7,5 percent of the United States economic stimulus package; in Germany it is ten percent of 50 billion euro. What is problematic, however, is that most of the spending will only have an impact in the long term and does not help to safeguard the current health care situation.

Thus, in the United States the development of a modern health information system certainly makes sense in the long term and is also an impulse for the IT industry, but it fails to improve the health care situation at this time. The same is true of the German economic stimulus package, whose health care component is largely allocated to the modernisation and building of hospitals. "This supports the labour market and may improve infrastructure in the long term, but it does nothing for the precarious health care situation during the crisis."

Thus Armin Fidler demanded that the portions of the economic stimulus programme devoted to health care focus primarily on safeguarding and improving the current state of health care with health benefits. In the process, the health sector can even finance a significant part of such programmes on its own. "The crisis should also be viewed as an opportunity to implement long overdue reforms and there is enough latitude in which cost cuts are possible without negative consequences for health care."

Even possible cuts in health-oriented areas in development aid and bilateral support could have negative repercussions on industrialised nations, Armin Fidler feared. Less funds for battling illnesses such as the new flu, bird flu, tuberculosis, AIDS or SARS also pose a potential danger to European countries.

"It is unavoidable that the financial crisis has negative effects on other areas of life and the latest studies being presented at the European Health Forum also show how dramatic these can be", stated EHFG President Günther Leiner. "But it is the task of policymakers to govern where losses can be accepted and where they cannot. In the truest sense of the word quality assurance and access to health services concerns the lives of people and for that reason there should be no question that this area is granted utmost priority. There can be cuts in the area of health care only as a result of rationalisation, but absolutely no cuts in services resulting as a result of rationing."

European Union Commissioner Vassiliou warns of budget cuts in health care

European Union Health Commissioner Androulla Vassiliou has directed a serious warning to her fellow policymakers in a greeting to the participants of the 12th European Health Forum Gastein: "There is now a risk that decision-makers are being tempted to think short term and to make cuts in the health budget."

It is expected that the crisis will lead to a decline in the health status of Europeans: "The crisis is causing increased psychosocial stress and in many cases an increase in hazardous behaviour such as alcohol abuse, smoking and unhealthy nutrition. For this reason the demand for health services will significantly rise as a result of the crisis."

This is all the more reason to do everything to increase the efficiency of public health care, something the Commission is also contributing to with a series of initiatives:

  • In the area of medical technology the Commission supports co-operations between the member states for the evaluation and approval of new technologies.
  • The Commission proposal on the issue of patient safety has made quality assurance a highly-regarded health care issue throughout the European Union.
  • The European Partnership against Cancer initiated by the Commission facilitates co-ordinated cross-border measures.
  • The further development of e-health solutions advanced by the Commission enables extensive increases in productivity.

"In the crisis we should be investing in health rather than cutting budgets", Androulla Vassiliou concluded. "But we also have to seek favourable cost solutions just as much and grant prevention and health promotion, in particular, a greater priority."

Economic crisis: saving banks or lives?

Economic downturns can lead to rises in suicides and homicides, unless governments respond with key investments in social and health protections. These are the main points of a series of studies presented at the European Health Forum Gastein.

Dr. David Stuckler, social epidemiologist at the University of Oxford and author of a highly regarded Lancet study on health impacts of the crisis, explained: "Crisis poses potential risks and benefits to public health; what ultimately happens will depend on how governments choose to respond. In Sweden, where spending on health and social care per capita is relatively high, economic crisis did not result in higher suicide rates. In contrast, in Spain, where the public health care system is less well-resourced, suicide rates have risen sharply as unemployment increased." However, Dr. Stuckler added: "Rising suicides are the 'tip of the iceberg'."

Dr. Stuckler warned against radical cuts in the health and social budgets: "Cutting public health services is not a price worth paying. Times of crisis are when people need help from their governments the most." He added that the arguments that health sacrifices have to be made in the short term in order to profit in the long term are wrong. Reducing primary care services only delays the expense. Furthermore, worse health and health care slows the long-term recovery of the economy due to rising sick leave and lower productivity. Dr. Stuckler noted: "There is strong evidence that investing in health promotes economic growth. Financial crisis creates an opportunity to align economic stimulus with improved public health."

To prevent additional deaths would require modest funds: "For less than one percent the money spent to rescue the financial system, we could prevent any additional deaths from the crisis." Preventive measures should move beyond 'health care' to promoting 'health'. "Against a threat like financial crisis, labour market protections offer much greater health benefits than traditional health care programmes", Dr. Stuckler stated.

Health strategies that are important in good economic times are even more necessary in bad economic times. "What is right in a boom is also right in crisis - it is just more urgent", Dr. Stuckler pointed out. Programmes to fight alcoholism, smoking and unhealthy nutrition are crucial. "If McDonalds, Kentucky Fried Chicken and British American Tobacco are reporting rising profits, it is a sign that people's lifestyles are becoming less healthy - with health impacts that will show up decades in the future."

More information is available at the University of Oxford website.

Biotech crisis puts brakes on pharma research

The biotech industry is being hit twice as hard by the economic crisis. In addition to the general economic downturn, the largely dried-up equity market, which has massively complicated the usual equity financing through the stock exchange or venture capital, is causing problems for companies. The problems in the biotech industry are now threatening to affect the classic pharmaceutical groups as well. At the European Health Forum Gastein, experts warned that the crisis in financing at biotech firms could lead to a substantial restriction or slowdown in research activities in the pharmaceutical industry.

"In the last five years the large pharmaceutical groups have increasingly turned to outsourcing their research activities to smaller biotech firms", explained Viola Bronsema, managing director of the industry association BIO Deutschland and member of EuropaBio's National Association Council. "If the generally small- and medium-sized biotech companies fail to survive the current economic crisis, this will lead to a dramatic decline in the power of innovation in the entire pharmaceutical industry and ensure that important innovations do not appear on the market or do so with an enormous delay. The rapid medical advances from which patients have benefited in the recent past could soon be history."

The extent of the financial crisis is, in fact, dramatic: in 2008 the capital raised through the IPOs of biotech firms in the European Union declined by 89 percent and there was 77 percent less inflow of funds from capital increases. Even with venture capital, a relatively stable form of financing, there was a significant decline of 15 percent. Despite a slightly improved situation in 2009, the current inflow of funds is still far below the level of 2007.

The biotech industry intends to counter the negative development with an entire series of initiatives. Companies are placing great hopes in a platform for small- and medium-sized biotech companies. The "EuropaBio SME Platform" is to provide support for the solution to current financing problems as well as to develop new financing opportunities. It therefore demands European institutions such as the European Investment Bank develop short-term investment vehicles for this crisis period and in so doing increase the amount of risk capital for capital ventures. At least until the crisis is over the restriction on the amount of the credit facility per company should be suspended, Viola Bronsema recommended.

Despite the current problems, however, Viola Bronsema is very confident in the short term: companies expect new ideas, particularly from the trend toward "personalised medicine". Commissioned research for large pharmaceutical companies will provide further potentials for growth. Viola Bronsema stated: "Those who survive the current dry stretch will find an extremely promising market environment later on."

New study on cancer underscores need for more innovative funding research and a rethink in regulation

Europe is facing the challenge of an expected dramatic increase in the prevalence of cancer that could reach 15 million Europeans by 2020. Health systems will require the promotion of innovative funding and a rethink in regulation, according to a new study released at the European Health Forum Gastein. Titled "The Role of Funding and Policies on Innovation in Cancer Drug Development", the study identifies avenues to address the disease challenge including an expanded role of research for governments through direct and indirect incentives, as well as a re-think about regulation and pricing and reimbursement systems. While applauding the progress that has been made, the report suggests that European Union and national policies to fight cancer must invest and act decisively to remove obstacles in order to meet this complex challenge. The study was funded by an unrestricted educational grant from Novartis.

"While Europe has considerably increased its funding since 2004, funding still appears fragmented, with duplication in some areas and insufficiencies in others", stated co-author Panos Kanavos, senior lecturer at London School of Economics. "Moreover, despite efforts at the national level to promote public-private partnerships in cancer research, we found that surprisingly little thought has been given to the nature of international public-private partnerships in cancer research, a method we believe could significantly improve research. There is a also a need for a holistic regulatory approach to foster innovation in the area of oncology."

"In addition, to create a more conducive environment for drug development we'll require the right mix of incentives for innovation, an enhanced role for government with regard to incentives as well as a rethink of how regulation works and how systems of pricing and reimbursement operate", stressed co-author Richard Sullivan, chair of the European Cancer Research Managers Foundation.

Participants also welcomed the recent launch of the European Partnership Action against Cancer and expressed their hope that it will contribute to the better co-ordination and facilitation of cancer research in the European Union as well as to exchange of information and best practices in the area of cancer prevention and treatment.

Andras Fehervary of Novartis Oncology acknowledged that significant progress in the fight against cancer had been achieved at European Union level, pointing out inter alia that "this study confirms the critical role of industry in bringing innovative medical technologies that improve the quality and extend the lives of Europeans". In addition, it highlights the complex interdependencies between academia, the public and private sectors in the research, discovery and commercialization processes. "This means we need to find ways to enhance and deepen our partnerships to advance the fight against cancer. What remains is to find ways at the member state level to ensure these commitments are translated into improved access to care for patients."

Oncologists call for co-ordinated policies to tackle cancer

Cancer is a major cause of ill health within the European Union, yet co-ordinated attempts to tackle it have been thin on the ground until now. At a dinner workshop at the European Health Forum Gastein, speakers from the European CanCer Organisation (ECCO), set out their plans to tackle this anomaly and to promote collaborative action between all players in the field of oncology - patients, scientists, doctors, and carers.

"It is essential that we all contribute to help strengthen European policy on cancer and ensure that it takes its rightful place in the European Union health and research policy agenda. Cancer is the second most common cause of death in the European Union, accounting for two out of every ten deaths in women and three out of every ten deaths in men, and 3,2 million European Union citizens diagnosed each year. As the population ages, these figures will increase if we do not take action now", stated Professor Alexander Eggermont, ECCO President.

Professor Julio Celis, from the Danish Cancer Society, introduced the newly formed European Academy of Cancer Sciences, an independent body set up in order to provide knowledgeable and unbiased advice on matters of oncology policy and priorities. "Europe does not have a unified research strategy or vision to effectively fight the disease. We have created a European Research Council to stimulate fundamental research, but we do not have a strategy for filling the gap between basic disciplines and clinical research in the health area", he stated.

As a first step, a 'Founding Group' of 114 Academy members has been created. 30 of these members were chosen on the basis of their experience and reputation, and in turn they voted for the other members. Among the distinguished experts co-opted in the first place are Nobel prizewinners Professor Harald zur Hausen and Sir Paul Nurse; leading epidemiologist Sir Richard Peto; and the eminent Italian cancer surgeon Professor Umberto Veronesi. Members of the ECCO Board and Policy Committee also belong to the Founding Group. Elected membership is a life-long distinction, and the Academy will introduce new blood by electing up to 50 new members per year.

The Academy hopes to collaborate with the European Commission's recently announced 'European Partnership on Action against Cancer' which plans to "invest in Europe's future health by taking long-term and sustainable actions to tackle cancer". "We are looking forward to working closely with the Commission in order to improve cancer detection, prevention, and health care approaches", stated Professor Celis.

Professor Gordon McVie, from the European Institute of Oncology, Milan, Italy, described the special 'European twist' of cancer. "We European scientists punch above our weight, compared to the rest of the world, but our cure rates for cancer are poorer. This is in part due to extraordinarily poor collaboration between scientists and doctors, and unacceptably inadequate communications among those cancer professionals and patients", he stated. The new Eurocancercoms consortium, set up under the 7th Research Framework Programme and bringing together all the major players in cancer at European level, will help to deal with this problem by conducting an inventory of all existing information tools currently in use, investigate their faults and flaws, and suggest requirements for the future.

"We need a one-stop shop, a Eurocancergoogle, perhaps, through whose portal anyone interested in getting accurate information about a cancer gene of a cancer trial will glide", he stated. "Only when we all start communicating with each other will we realise that Europe already has the tools within its grasp to defeat cancer."

In another presentation, Professor Ulrik Ringborg, from the Karolinska Institutet, Stockholm, Sweden, described the initial steps towards the creation of a European Platform for Translational Research. Translational studies build the bridge between basic research and human testing, and provide the data to support the opening of clinical trials, which move research results into practical applications as soon as possible. In 2008, the directors of 18 cancer centres came together to formulate the 'Stockholm Declaration', a manifesto that stated their intention to join forces in order to reach the critical mass and sustainability that is necessary to innovate and perform in all areas of cancer research. "The aim is to create a cutting-edge, virtual world-class infrastructure to improve diagnosis and care of cancer patients, a development that will require the sharing of patients, biological materials, infrastructures as well as competency", he stated.

The European Commission responded to the Declaration by announcing a call in the 7th Framework Programme with the title "Structuring translational cancer research between cancer research centres in Europe". "Through a Network of Excellence linking comprehensive cancer centres and preclinical cancer research centres it will be possible to establish a collaboration between centres which will guarantee a complete translational cancer research process and a critical mass for technologies, patients and competences, and a platform for discovery-driven translational cancer research for innovation in prevention, early detection and individualised treatment", stated Professor Ringborg.

"We are optimistic that these initiatives will have a positive effect on all those associated with cancer, be they patients, doctors, scientists or carers", stated Professor Eggermont.

Cutting costs with medical technology innovations

Medical technology innovation, often viewed as a cost-driver can also be the key to cost-cutting in health care while at the same time improve the health outcome for patients. This was the core message of an experts' panel organised by the European Health Technology Institute for Socio-Economic Research (EHTI) at the European Health Forum Gastein.

With increasing life-expectancy and demands from patients and citizens showing no signs of abating, policy makers face difficult and often conflicting challenges. The recent economic downturn has simply increased pressures to come up with health care reforms that ensure continued effective and efficient provision of health care to all at an affordable cost.

Zeger Vercouteren, Johnson & Johnson and member of EHTI's Research Council referred to the work of Professor Christensen of Harvard University: "With the convergence of many scientific and technology breakthroughs, the pace of medical invention is accelerating, inspiring hope for better clinical outcomes with less invasive procedures and shorter recovery times, all in lower cost settings. These are powerful forces at work that are driving rapid fundamental change in healthcare. Unfortunately, barriers from lack of funding and reimbursement of the technology and the medical procedure are still standing in the way of full patient access, preventing this potential from being fully embraced."

One especially promising area in terms of cost reduction is the use of telemonitoring in health care. A striking example of how medical technology can contribute to improving the way health care is delivered are remote implantable device checks which can reduce physician time up to 70 percent and costs up to 60 percent. Studies into the potential of improved patient disease management have shown about 20 percent decrease in hospital admissions and in all cause mortality in heart failure patients, who have been followed more closely through telemonitoring.

Professor Michael F. Drummond of York University and member of EHTI's Research Council discussed the fact that current methodologies used to assess the value of medical devices were designed with pharmaceuticals in mind and might not necessarily capture the full socio-economic contribution of innovations. He emphasized that "medical technology can play a strategic role in fostering the change of health care delivery towards better health outcomes and financially sustainable systems".

Rosanna Tarricone, Executive Director at the EHTI, talked of the importance of the Institute: "Academic research can effectively help to close the research gap thus providing evidence to better inform policy decisions and helping industry better understand the health care sector's dynamics. EHTI was founded three years ago to be the first institute in Europe to engage in such innovative and timely research; new health care models cannot be interpreted through old paradigms."

Medtec industry sees five key factors as a way to better health care

With respect to the sufficiently rapid utilisation of innovations, European health care systems are inadequately prepared for the pace of innovation that has now been reached, representatives of the European Co-ordination Committee of the Radiological, Electromedical and Healthcare IT Industry (COCIR) said at the European Health Forum Gastein. In the coming ten to 15 years the gap between supply and demand will become even greater. The reasons are the rising age of the population, the increasing frequency of chronic illness and people's demand for a greater and better range of health care options.

"If we continue to operate with the current model - fee-for-service - rather than result-based health models we will not reach the quality of care that we can and need in Europe", stated Paul H. Smit, chairman of the sustainable health care team at COCIR. In his lecture he introduced five key factors which are to improve European health care systems.

Focus on prevention

The priority of an efficient health care system should lie with illness prevention and early detection. This promotes accountability for one's own health, keeps patients from suffering and also provides economic advantages. Employers can play a crucial role: a study presented by PriceWaterhouse Cooper in 2007 showed that for every euro invested in prevention there were three euros return on investment which flowed back to the employer. More commitment on the part of employers not only makes financial sense, but also sends a strong signal to public health officials and can enhance the influence of companies with respect to decisions concerning finance in the public health sector.

Promote best-practice models for patient-centred processes

The lack of integrated information on every patient leads to considerable disadvantages. The fragmented health care system with "islands of information" must be replaced by a patient-centred process incorporating all treating locations. It is necessary to integrate technological innovations into treatment methods - for example in therapeutic strategies for stroke, coronary disease, diabetes or cancer, and to do this on all levels, from prevention to diagnosis, treatment to rehabilitation and aftercare.

E-Health: stimulating information technology

Data is only available in European health care systems today in fragmented form, despite the fact that medical data should always be available exactly where it is needed. It is necessary to establish an IT infrastructure in every European country in order to make patient data available for every health care provider and to make clinical decision-making processes comprehensible. Technology can support the work of health professionals in the therapy of the chronically ill - particularly when several employees of multi-disciplinary teams are caring for one patient: everyone authorised can comprehend the previous steps of his or her colleagues and knows what therapies were used and medications prescribed.

Faster approval of new medical solutions and technologies

Currently, approval of new technologies and IT-supported processes is too long: by the time one piece of equipment is authorised, a more innovative one that has not been approved is generally available. If more rapid implementation were to succeed in practice, all those involved would benefit: patients through faster diagnoses and better health conditions, physicians, nurses, therapists through increased patient flow and more certain bases of decision-making, and health care systems as a result of cost efficiency.

Performance-based pay for health care service providers

Physicians, practitioners and hospital managers have to be encouraged to keep people healthy. This is not possible with the current payment system, as fees are based on individual services. As a result, there tends to be excessive rather than optimal use of services. In order to change this, new incentives are needed based on quality and transparency. Future payment systems should be oriented toward treatment results or the implementation of treatment methods.

Integrated care works if incentive systems exist

"Integrated health care" has become one of the key concepts for European health officials in the search for efficient solutions for their countries' health care systems. The quality of medical services and cost efficiency is to be increased through the improved linking of health service providers, or resident practical physicians and specialists, hospitals, nurses, physiotherapists, etc.

"The enormous hopes placed in the integration of all service providers can be deceptive", experts have now warned at the European Health Forum Gastein. "Networking alone does little", stated Hans-Dieter Nolting, managing director of the IGES research institute in Berlin.

Hans-Dieter Nolting mentioned a series of conditions necessary for integration to go from a fashionable slogan to a sustainable improvement of performance and efficiency: "For integrated care to generate gains in efficiency, conventional service providers must be transformed into genuine 'integration providers' who themselves are interested in the highest cost efficiency of the overall system. Medical experts must also be integrated into decision-making processes (clinical governance), physicians must assume budgetary responsibility (fundholding), and high quality and transparency in pricing must reinforce positive competition between providers."

In Europe the first advances have been made in the direction of effective integrated care. "I'm not pessimistic about it", Hans-Dieter Nolting stated. More transparency, better efficiency and quality will also succeed in Europe. With its integration of insurers, hospitals and mobile physician groups, the Kaiser Permanente health plan in California is exemplary with respect to the increase of quality and efficiency through integration. It focuses on treatment and the most effective stage of care, information technology, competition and options. The key elements of this system can be implemented in Europe immediately as well.

Integrated care providers

It is not enough simply to improve the co-operation and coordination between those involved, who ultimately are in pursuit of their own particular interests. A new type of care provider must be developed who is genuinely interested in the realisation of the most cost-effective treatment methods. Fundholding plays a crucial role in this.

Fundholding

The quality and efficiency of medical care depend on the latitude of the integrated care provider. The greater the latitude, the more effective the integrated care. Lump sum remuneration in the sense of a fundholding expands the latitude, but also bears the risk of physicians selecting their patients. This can be avoided by distributing risk: the risk of morbidity (risk of disease, "bad risk") lies with the insurer, the performance risk with the caregiver.

Clinical Governance

In the scope of clinical governance, physicians not only stipulate the methods of treatment patient diagnosis and care are to follow, but they also influence the structures themselves: what departments and diagnostic facilities do we need in the hospital, which ones will we keep elsewhere?

Competition

What functions in a hospital - more transparency in medical outcomes - must also be created in the outpatient and integrated area as fast as possible. Medical indicators such as the Pay4Performance models in German and Great Britain are helpful. Here physicians earn a portion of their income based on performance and medical outcome. Physicians play an important role in the issues of transparency and quality: they become motors of quality and efficiency with their professional and business interests.

Association of key vaccines with judicious antibiotic use turns out to be an efficient strategy against antibiotic resistance

Based on recent programmes to control pneumococcal diseases, experts show that targeted action can assist in preventing ill health and in controlling antibiotic resistance at the same time, when associating the judicious use of antibiotics with prevention in the form of key vaccines. This was the message delivered by leading health experts at a workshop addressing anti-microbial resistance at the European Health Forum Gastein.

Evidence shows this strategy has worked in at least one risk group - young children - in preventing pneumococcal diseases like pneumococcal meningitis, pneumonia or middle ear infection. (Cohen R. - The need for prudent use of antibiotics and routine use of vaccines. Clin. Microbiol. Infect. 2009 Apr;15 Suppl 3:21-3.) Samuel Coenen, post-doctoral fellow at Antwerp University, Belgium, pointed to statistics showing the range of antibiotic uptake across the European Union. He further provided examples of successful programmes in Belgium and France that focus on the rational use of antibiotics. In Belgium for example, the prevalence of antibiotic-resistant pathogens, in particular, penicillin-non-susceptible S. pneumoniae, has decreased since the start of the national public campaigns.

Hanna Nohynek of the University of Tampere, Finland explained that there can be a synergy between national programmes to control unnecessary antibiotic use and immunization programmes with an effective pneumococcal conjugate vaccine. "In fact, this strategy brings at least a 2-fold decrease in antimicrobial resistance even to bacteria commonly responsible for widespread infections in children and adults", she explained. She continued by outlining how infant vaccination can limit the spread of disease causing pneumococci within a community - particularly for the antibiotic-resistant pneumococci - by reducing the likelihood of S. pneumoniae transmission between vaccinated children and other unvaccinated members of the community, such as elderly adults.

Paolo Bonanni of the University of Florence, Italy added: "Given the effectiveness of key pneumococcal conjugate vaccines, there is a need to enhance access to preventive medicine like these vaccines for all European citizens." Philippe Beutels of the University of Antwerp, Belgium, concluded the session by highlighting a report stating that "the cost-effectiveness of PCV7 vaccination can be viewed as attractive in most developed countries". (Beutels P., Thiry N., Van Damme P. - Convincing or confusing? Economic evaluations of childhood pneumococcal conjugate vaccination - a review (2002-2006) Vaccine 25 (2007) 1355-1367.)

"At a time when countries are looking to shrink their budgets, these experts' findings come as good news", stated David McIntosh, Medical Director, Wyeth Pharmaceuticals. "Invasive pneumococcal disease is serious at any age and the high prevalence of resistance to antibiotics in some countries means we need new solutions. Whilst effective pneumococcal conjugate vaccines are not the only solution, when used in association with the judicious use of antibiotics, we have seen positive results. They offer real life health care solutions against pneumococcal disease that can save money and more importantly alleviate concerns of families across Europe."

Gender-specific differences in health are larger in the new European Union countries

The health-related differences between men and women are considerably larger in the new European Union countries than in the old ones. While on average women are healthier and live longer than men in every country, the extent of the difference in this regard varies remarkably. In the coming years the study titled "European Health Life Expectancy Information System" (EHLEIS) discussed in the scope of the European Health Forum Gastein, is to investigate in more detail possible reasons for these significant differences. The study is to be concluded by the end of June 2010.

"Life expectancy" as an indicator is less relevant as our population ages. Interest is now moving to a more complex measure of "healthy life years" (HLY). Why the differences between men and women in the new European Union countries are particularly large cannot be conclusively answered at this time, said Carol Jagger, professor of epidemiology and director of the Leicester Nuffield Research Unit at the University of Leicester. One possible reason may be the more hazardous lifestyle of men: heavier consumption of alcohol and nicotine, more accidents compared to women.

The poorer health in the new European Union countries in general and the male population specifically is being addressed through a number of measures by the European Union. One initiative for this is the "Task Force on Health Expectancies", which was initiated by the European Union Directorate General for Health and Consumer Protection in 2005. Its aim is to improve the comparability of the data within the European Union as well as internationally.

The Hospital of the Future: counting for beds was yesterday

Classic orientation around the number of beds in hospital planning will soon be obsolete in modern health care systems. Capacity planning must be oriented around the demand for health services and not the patients' length of stay, the authors of a new study on the necessary reforms in hospital planning demanded at the European Health Forum Gastein.

In the sensational study titled "Investing in Hospitals of the Future" new fundamentals in planning are specifically urged. "Hospital beds largely function as a waiting area until the hospital institution can carry out its actual function, namely the treatment", stated one of the study's authors, Steve Wright, management board member of the European Centre for Health Assets and Architecture. "Those oriented around this are actually unable to operate efficiently."

Procedures must therefore be the focus of planning for the hospital of the future: how many operations are to be carried out, how many doctor/patient contacts are necessary, etc. "Orientation around these figures is undoubtedly more complicated, but leads to greater efficiency, particularly in the current operations of the hospital. Overall, the current costs of operating a hospital must be granted greater priority in planning. The building costs for a new hospital are only two to three times the annual costs, with the tendency declining. Thus higher start-up investments which enable simpler, more affordable processes will pay off very quickly", according to Steve Wright.

The study's authors have summarised additional requirements in the "Ten commandments for the hospital of the future":

  1. Ensure future flexibility: Demographic and epidemiological transitions, advances in medical technologies and pharmaceuticals, and rising public expectations mean that the future of health care provision is very difficult to predict. It is therefore essential to build sufficient flexibility into new health care facilities, such as through buildings that are easily adaptable and have scope for outward expansion.
  2. Embrace sustainability: In the context of climate change, the environmental sustainability of health facilities assumes an ever greater importance. Sustainably built hospitals can help to meet the environmental challenge and improve the lives of patients, staff and local communities. Health care is a major source of carbon emissions, partly due to the journeys generated, and hospitals in particular should be places designed to improve, not worsen health.
  3. Take a life-cycle perspective: The initial investment costs for hospitals are very small in comparison with the recurrent costs (facilities management and medical) over their life-cycles (roughly equivalent to 2-3 years of recurrent costs). Taking a life-cycle perspective helps to ensure that the long-term costs of buildings are taken into proper consideration when deciding on design features.
  4. Ensure quality-at-entry: All too often, hospital projects are driven by short-term tactical considerations, such as the political desire to build a new hospital, rather than an analysis of long-term strategic performance and need. It is essential to improve the quality of hospital projects in the earliest stages of their development.
  5. Place the patients at the heart of new hospitals: Health facilities need to be designed around the needs of patients, and staff; active engagement of both groups in new hospital projects can help to achieve this aim, including through the provision of healing environments that offer nature, daylight, fresh air and quiet.
  6. Embrace a whole systems perspective: There is increasing recognition that hospital treatments are often only part of much longer care pathways. The development of integrated care pathways across different settings of care, and the social sector, has great potential of improving the delivery of health care, such as through avoiding unnecessary hospitalizations.
  7. Enable the flow of patients and services: The hospital is a complex functional network, where the effective capacity of the system is set by constraints, many of which may be hidden. It is crucial that the often complex pathways through the system are organised in ways that ensure a smooth flow for both patients and services and eliminate waiting, mistakes and inappropriate procedures.
  8. Maximize the economic and community impact of capital investment: Hospitals are major features of the urban environment. Investment in health facilities can play a vital role in regenerating deprived areas, empowering local communities and creating employment opportunities.
  9. Use appropriate financing models: The financing and provision of hospitals can encourage the flexible provision of services when they are not locked into inappropriate long-term contracts, such as in some public-private partnership schemes, but are much more adaptable to the changing services required.
  10. Expand the evidence base: In many areas of capital investment, the evidence base on what works best is still sparse. It will be essential to evaluate hospital projects rigorously, and to identify and share best practices.

Approximately 30 million European Union citizens suffer from a "rare disease"

Rare diseases are surprisingly frequent in occurrence. Altogether, more than 25 million people suffer from one of the 6000 to 8000 known "rare diseases" in the countries of the European Union. Viewed as a whole, they affect between five and eight percent of the population and thereby reach the level of a widespread disease. In the scope of the European Health Forum Gastein, experts demanded that the fight against rare diseases be granted higher priority.

The programme "e-rare" initiated and financed by the European Union Commission occupies a key position in this regard. Its aim is the intensive integration of still strongly fragmented research activities: the advantages of international co-operation in rare diseases are greater than in every other medical area. "In practice, the low number of cases often makes high-quality research in individual countries impossible, explained Sophie Koutouzov, secretary general of the French Institute of Rare Diseases Research (GIS) and co-ordinator of the project. "e-Rare enables an intensive exchange of knowledge and cross-border co-operation on a common theme and ensures the availability of sufficient amounts of clinical and genetic material and the development of relevant databases for the purposes of research", Sophie Koutouzov explained. "With it we are creating the conditions for greater efficiency and better research results."

Research institutions from eight countries - Germany, France, Italy, Spain, The Netherlands, Belgium, Turkey and Israel - are currently participating in e-rare. In 2010 when the extension of the programme by another four years is on the agenda - the extension is applied for in the scope of a new project application, but approval only occurs after a decision-making process by experts and policymakers and is not yet guaranteed - at least three additional countries will join - Greece, Austria, Portugal.

Smaller countries with naturally even smaller numbers of patients, like the three probable new e-rare member countries, can especially benefit from cross-border co-operation. Recently an initiative was launched by the Austrian Ministry of Health for co-operation between several countries in Central Europe. "We hope we can also promote and accelerate the desired European co-operation", explained Professor Robert Schlögel, section head in the Austrian Ministry of Health. The regional initiative and Europe-wide programme do not compete with one another, but complement each other instead.

Key stakeholders should share the responsibility of balancing the benefits and risks from new medicines, as the EBE workshop debated during the European Health Forum Gastein

The European Biopharmaceutical Enterprises (EBE) hosted a lunch workshop co-sponsored by EBE, Novartis and Roche during the European Health Forum Gastein on "Biopharmaceuticals: Balancing Benefits and Risks - Sharing Responsibility". The event highlighted the need to share responsibility amongst key stakeholders during the development process of a medicinal product, from its research and conception until its release on the market. Sharing responsibility would help ensure a balanced approach that reflects the interests of all parties concerned.

Speaking at the event, Christoph Thalheim, Secretary General of the European Multiple Sclerosis Platform, emphasised the importance for patients to play an active role in the health care debate. "Patients are ready to accept a much higher risk than medical experts think IF the benefit is clearly described and likely to happen and if the risk information provides an educated guess on worst-case scenario and likeliness for this to happen", stated Christoph Thalheim. He also underlined that patients are involved in several Working Parties at the European Medicines Agency and positive lessons can be drawn from such active participation.

The industry panellist, Dr. Trevor Mundel, Global Head of Development at Novartis Pharma, explained that there is a new paradigm shift from Efficacy-Safety to Risk-Benefit. This is introducing a profound change for the pharmaceutical industry and it has specific implications such as extensive phase III clinical data requirements, increased time and development costs for new products and significant post-marketing authorisation commitments for innovative medicines. From the biopharmaceutical industry's standpoint, an earlier collaboration with regulators and payers would be essential for a balanced benefit-risk development, on top of the important dialogue with patients.

"Our EBE workshop in Gastein has contributed to establishing a new multi-stakeholder platform on benefit-risk balance. Such a forum helps foster better understanding of the roles and responsibilities of each stakeholder in the identification, assessment and management of risks during the development process of a medicinal product. It is important to highlight the need for a balanced and shared responsibility and to have benefits equally taken into consideration", concluded Emmanuel Chantelot, EBE Executive Director and panel moderator.

EBE initiated discussions on benefit-risk balance in 2008 around the "shared responsibility" concept, engaging with different stakeholders involved in the management of a disease and the introduction as well as use of new medicines - industry, researchers, health care professionals, ethics committees, patients and regulators. In December 2008, EBE published a brochure on "Balancing Benefits and Risks: Sharing Responsibility" that can be accessed at the European Biopharmaceutical Enterprises website.

Innovation in existing biotech medicines to benefit patients

Biotechnology medicines have a high potential for application across additional therapeutic indications, offering the promise to address currently unmet medical needs. This potential stems from the targeted mode of action of biotechnology medicines, which involve molecules or pathways that are common in many seemingly different diseases.

The workshop on "Investing in Medical Progress" at the European Health Forum Gastein, sponsored by Amgen, brought together key stakeholders to advance a public discourse on the value of innovation in the biotech industry, and the association between innovation and the development of additional therapeutic indications from existing biotechnology medicines. Such additional therapeutic indications offer the prospect to address unmet medical needs and improve access to medicines for patients in Europe.

The workshop was set against the backdrop of the European Year of Creativity and Innovation 2009, which seeks to promote policy debate and raise awareness of the role of innovation in economic, social and personal development. "The existing structures in Europe support the development of new biotechnology medicines; however there is a need to better support continued research into existing biotechnology medicines which can offer new medical benefits in different therapeutic indications", commented Ulrik Schulze, Partner and Managing Director, The Boston Consulting Group. (Continued Development of Approved Biological Drugs - A Quantitative Study of Additional Indications Approved Postlaunch in the United States, White Paper, The Boston Consulting Group, December 2007.)

The investment required by industry into the research and development of new indications from existing biotechnology medicines is significant. Additional non-clinical and clinical data are required to support the development and approval of a new indication, with costs reaching in excess of 140 million euro on average per indication.

"Amgen's discovery of a new biotechnology medicine for the treatment of the serious auto-immune blood disorder ITP is a recent example of a biotechnology breakthrough innovation by Amgen scientists", stated Tamas Suto, MD PhD, Executive Medical Director, International Clinical Development, Amgen. "This novel medicine may offer real benefits in several other indications with unmet medical need, underlining the importance of advocating constant innovation in exploring the full therapeutic potential of each novel biotechnology medicine."

Speaking on the situation in Europe, Morten Frank Pedersen, Associate Vice President, Novo Nordisk (Brussels office), stated: "In other countries such as the United States and Japan, support and incentives are provided to encourage research and development into new indications from existing biotechnology medicines. This drive to protect biotechnology innovation needs to be reflected in Europe."

EuropaBio, the European Association for Bioindustries, supports this call for a debate on how to stimulate innovation and the identification of ways to deliver the full potential of new biotechnology medicines.

EHFG 2009: health policy between ethics and finances

The economic crisis has considerably intensified the relationship between what is ethically desirable and financially possible. This is clearly demonstrated by the numerous events devoted to the subject of "Financial Crisis and Health Policy" in the scope of the 12th European Health Forum Gastein. Around 600 participants in the areas of politics, health administration, medicine, science and NGOs took part in the four-day congress this year.

"Decision-makers in health policy and administration as well as experts in the medical and academic sphere recognised the need for health care to adapt to the changed economic circumstances", EHFG President Günther Leiner explained at the closing press conference of the EHFG. "But it is also very clear that the decisions in health policy must continue to be oriented primarily around medical and ethical standards. Budgets provide frameworks, but money cannot be the predominating standard in questions of health care."

Günther Leiner does not view the crisis primarily as a threat to the standards achieved in health care, but as an opportunity to put through overdue reforms: "The health care system is similar to a reasonable diet, which does not weaken the patient, but makes him stronger: here an effective diet is overdue. It is not enough to know what has to be done; reforms must also be carried out, and if under the pressure of empty coffers we finally get rid of the excess fat in the health care system, then people will benefit from it in the long term."

Günther Leiner considers the measures for improving the efficiency of the health care system as an obligation for all decision-makers in the health sector: "If we don't want the necessary cost-cutting measures to be taken at the expense of people, then it is not the patients who have to make the sacrifice, but we who have to work more efficiently - even if several sacred cows have to be slaughtered for this. This is certainly the more difficult path, but the only right and justifiable one."


Source: European Health Forum Gastein

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