Bringing health policy closer to citizens: challenges and future strategy

EU OPEN Forum

The EU Health Forum set up by DG SANCO brings together umbrella organisations representing stakeholders in the health sector to ensure that the EU’s health strategy is open, transparent and responds to the public concerns.

It seeks to cover four groups of organisations: Non-governmental organisations in the public health field and patients’ organisations; organisations representing health professionals and trade unions; health service providers and health insurance; and industry with a particular health interest.

The Forum is composed of two elements: a Health Policy Forum with a consistent set of member organizations - at present 46 (of which Eurocare is a member). An Open Forum, held each year, as a platform for general exchange of information and for a discussion with a broader range of groups and interested parties. Around 380 delegates attended the Open Forum in November 2005. At the Plenary session Mr Robert Madelin Director General of DG Sanco gave a general address outlining DG Sanco’ present concerns and this was followed by presentations from four groups of organisations. Eurocare this year had the privilege of representing the NGO section. We reprint the presentations of Robert Madelin and Derek Rutherford. Speakers were asked to address the following: ‘Does Europe matter?’ ‘How has the EU affected people’s health?’, ‘should the EU focus on health or is health determined by other factors beyond its influence, i.e. macroeconomic determinants?’, ‘Which one area in health should the EU prioritise if it had to focus on only one area?’ http://europa.eu.int/comm/health/ph_overview/health_forum/
open_2005/contributions_en.htm

Robert Madelin
Director General DG SANCO

Introduction

I am sure we all agree that Health policy has to respond to the needs and concerns of individual citizens of the European Union. That’s why we are here today.

The challenge, as viewed by a Brussels-based policy-maker, is how do we feed the concerns of individual European citizens into such a big thing as European Union health policy? How can the Commission and your organisations work together to develop policies that will meet citizens’ expectations? So today the objective is to identify the challenges facing citizens in their quest for health and what future policy we need. First, I would like to share some thoughts with you on EU health challenges and the need for more governance in health policy. I will then say a few words on citizens’ participation, on health systems and health products which are, together with health strategy, the themes of the parallel sessions we want to run in the course of today.

1. EU Health Challenges

Let me pick up a few of the health challenges as we see them.

First, and this is even clearer in a Union of 25 than it was before May last year, there is a huge health gap in population health and in access to healthcare services across the Union.

Citizens from some of the new Member States are expected to live 12 years fewer than a citizen from a Nordic Member State. The mortality rate for ischaemic heart diseases shows an eight fold variation across
the Union. Many regions lack highquality centres of reference with upto- date equipment and trained staff for some prominent health challenges in their regions.

This health gap goes hand in hand with an economic gap. Bad health impacts on productivity, on labour participation and on growth. This is why we in DG SANCO – and I think it is fair to say, the Barroso College – encourage Member States to position health as a long term investment. We try to do that by providing the data, the studies, and to help to channel more clearly the Structural Funds to health projects in eligible countries and regions.

The second major challenge is the increase in lifestyle related diseases. It is a real increase. It is not just that the infectious diseases’ burden has gone away and we suddenly notice lifestyle. Lifestyle related diseases are growing rapidly as a threat.

Overweight and obesity affects 14 million EU children and their number is rising by almost half a million a year. Unsurprisingly, therefore, type 2 diabetes is also increasing.

Addressing lifestyle problems – not just nutrition or the lack of exercise, but also smoking or alcohol abuse – will require action from a wide range of stakeholders. We launched an antitobacco campaign to help young people to resist or to quit smoking. We have also created this year a European platform on nutrition and physical activity to encourage concrete action by all our partners to promote healthy eating.

A third challenge is the health budget problem. Pressure on health budgets has increased steadily over the past few years, partly because the new technologies and high-quality healthcare that all national health systems need to provide cost more, but also because the message that “health equals wealth” has not got across to the Treasuries of Europe; has not got across to the macro-economists; has not got across to the Heads of State or Government.

Addressing these challenges requires us to contribute both on the demand and on the supply side to find more cost-efficient use of technology; to improve quality without always throwing more money at quality issues; to promote health more actively in order to reduce healthcare demand; and to co-operate between health systems so that we can share the load, for example by centres of reference cooperation. In these areas, I think that in the last couple of years, in the light of the reflection process launched under David Byrne’s leadership, we are beginning to see a willingness of Member States to work together not to have a European policy, but to create common approaches to dealing with these common problems.

The fourth challenge I would identify is ageing. I received an email from Washington overnight asking: “Who is in charge of ageing in the European Commission?” Well, quite a lot of people should be taking an interest. Again, because Treasury views seem to dominate, ageing is primarily seen as a pension issue or a workforce issue and therefore it is my colleagues in DG Employment and their partners around Europe who are perhaps the most best known discussants of the ageing issue. But ageing is a major challenge for health and feeds back again through the health aspect into the future prospects for the European economy and for European society.

We expect, as you know, that over the next quarter of a century, the number of people aged 65 and over will increase by 37% and the number of people over 80 will more than double.

We therefore need to have a much more active policy to address the health maintenance needs of this burgeoning section of society, so that people don’t just live longer, but have healthy life years. And that is another reason why it is not just life expectancy but “Healthy Life Years” that we have adopted with the European Council as a key performance indicator for the Lisbon process.

Those are the four major challenges we see for the future.

I think what we need to know is whether you agree; whether your major challenges and core business can be found under those four pillars or whether there is something that we would miss if we try to build the European movement for health, the European strategy for health, around those four key drivers.

2. The case for better governance and the new strategy

Let me talk a little about governance. I have already talked about governance by complaining that macro-economists and treasury officials failed to grasp the importance of health policy. Of course, that is not because those individuals are necessarily opposed to health; it is because somehow the way we run our society fails to give then the data and the incentives to realise the truth that probably all in this room realise.

According to a recent survey (which we run through the so-called Eurobarometer system of EU public opinion polls), half of our citizens think that the European Union could usefully play a greater role in health matters in the coming years. But, at the same time, citizens are worried that they do not get to participate in policy-making.

More than half of them believe that if a decision is taken at EU level, their voice does not count. You have the paradox that on the one hand people like Europe when it works, but on the other hand, they do not think it does work and so they vote against it in referenda.

Knowing that health is a primary concern for citizens, we feel that the public consultations we have carried out around our health strategy show two key things: firstly, they would expect Europe to integrate a strong role on health alongside the strong role on economics, but secondly, they want to be sure that they have a guaranteed say in decisions that affect their health.

Right now the Commission is encouraging a wide public debate on the future of the EU. I think that the debate is particularly important when it comes to health.

I hope therefore that when you go home after this conference, one of the things that you will take the time to say is firstly that you’ve been to Brussels to talk about health (because most people do not know that this sort of discussion takes place); and secondly that what we have been discussing today is an important part of the debate about re-launching Europe.

Too often, I think we as citizen leave the future of Europe to Foreign Ministers and Prime Ministers and similarly important people, and then we wonder why our concerns as citizens are not reflected in any vision for the future of Europe.

The one thing leads to the other. I would very much urge you to take away from this conference the fact that Europe can do things which will be good for health, but only if we in the health community go home and work for that to happen.

And that brings me to the point about participative policy which I made last night. You cannot make health in Brussels for half a billion citizens. You cannot make health in one town for 25 Member States and goodness knows how many regions.

We therefore need to think very carefully about how to bring all the citizens of Europe closer to a European debate about health, while at the same time recognising that whatever we can do within the Union is only a complement to national and regional health policies.

And within those national and regional health policies, each Member State has its own different ways of setting priorities, feeding citizens’ concerns into policy-making, and organising health services. So what do we intend to do?

We intend to try to work more closely with citizens’ elected representatives, not just in the European Parliament but with national Parliaments. We intend to use the so-called “Plan D”, Vice- President Wallström’s dialogue plan to respond to the failed referenda, and to use it as one of the platforms for a much broader, more grass roots debate on health as one theme. But in addition to working with central governments and national legislators, we need to find new ways of involving the regions and civil society.

Organisations such as the ones you represent therefore have a key role in voicing and advocating the concerns of citizens. We need your advice not just on what should the content of the strategy be – are our four pillars the right ones? – but also on how can we set about structuring the discussion, structuring the process in such a way that the individuals who are represented by your organisations will notice that people in Brussels are trying to listen to them. It is one thing for us to feel that we are trying to listen, but real democracy only happens when people around Europe notice that we are trying to listen to them. And that is really difficult.

We are not starting from scratch. Here we have the Health Policy Forum, we have the recommendations of that Forum on issues such as health and enlargement; and that Forum plays an important role not just working with DG SANCO but helping to integrate health in other policies such as research.

We also want to use the participation of NGOs in policymaking and that’s part of the Health and Consumer programme we proposed this spring. We need more money for that, so we continue to argue for the financial perspectives being discussed in the remainder of this year to double or more than double the modest funds available for health within the overall European budget.

I must say I am not optimistic. But I would also say that budget making is like any other aspect of democracy. So I hope that your organisations are writing to your national counterpart government representatives and to your MEPs to say that you think, as an organisation, that let us say “a euro per citizen by 2013 for health” would be a good idea. If we fail to get that, and you have not written, you will only have yourselves to blame.

Certainly we in DG SANCO continue to fight hard for it in season and out of season. I say to everybody I can contact here in Brussels that a euro per citizen for health is not too much to plan for by the end of the 7 year period for which the budget is now being set. So if you think that this is a reasonable request, please write to those who can take the decision.

The question is how do we use that money, or less money if that’s what we get, in order to support your advocacy work? I said last night and I said this morning that we want your organisations to be active not only in regions and the Member States but right across Europe. How can we support you effectively?

Is it a question of better information on health status and policies? If that is the case, then I would encourage you to look at the presentation stand outside the room about our new health portal, which is designed to provide user-friendly information on health in 20 languages.

Can we do anything else to foster the capacity of non-governmental organisations or to foster not just your capacity internally but your ability to network with each other? These are the questions that I think are crucial in terms of governance.

3. Health systems

Let me now come finally to health systems and health products. On health systems, the parallel session is going to look at the scope for fostering co-operation and exchange of best practice between health systems without harmonising national and regional approaches whether on policy or on clinical practice. I believe, as a newcomer to this field eighteen months ago, that the new appetite for this sort of “soft co-ordination” is relatively high amongst national Ministries.

What is lacking is the ability of those who indulge in such co-ordinationin national Ministries, who are often in international departments, to reach out to those who are actually running policy at national and regional level and to reach out beyond administrative structures to those in your organisations who also have an interest. I think there is a discussion which is beginning, but at the moment the participation in that discussion is too narrow.

Thinking about this from a citizens' perspective, I would say that in the health systems field there are questions that your organisations could be asking in the health systems co-operation debate, to see whether it has something in it for you. Maybe three questions:

Firstly, if you have a healthcare need which is not met in the hospital down the road, do you know where you would go?

Secondly, if you were to need healthcare abroad, would you find the same level of quality and safety? What would it take to give you a feeling of comfort equivalent to that you feel in the hospital next door (which I hope is a good hospital), if you went to a hospital 500 or a 1000 kilometres away across one or more national borders?

And finally, how do you feel about issues of redress? Are they important? Do you feel, when you go to a hospital or into the health system, “I am confident because I have redress and so if I go to a foreign country I might not have redress?” Or is that not such an important issue?

All these challenges – under the headings of patient rights, quality and safety, patient safety – are issues which are currently on the agenda among the Member States in the High level group that I chair. We are beginning to discuss them, there is an appetite to discuss them, and we are looking to get more input from your organisations to drive that part of our policy-making forward.

4. Health products

Then on health products, and this is my last point, it is clear that products, whether it is medicines or medical technology, are crucial; that they are a major field of innovation; and that Europe is a leading innovator, amongst others, in this field.

The question is for citizens and patients: Do you get the information that you need? Are you happy with the channels whereby European health culture provides you that information?

The parallel session we will be organising on health products will therefore be discussing a set of important relevant issues there: the need for medicines to be available; safety concerns related to new pharmaceuticals; and the costeffectiveness issue – how to get better European level health technology assessment.

I think the link to those issues is also the one about patient information: Have we got the balance between professionalisation of information flows and general background education right in Europe or not? That is a very old and long running debate in Europe, but it is not one that has gone away.

Conclusion

Let me conclude. The fact that there are so many questions demonstrates the need for this sort of Forum not just to be a day of intensive discussion, but to be the sort of focal point where at regular intervals this community comes together and takes away a series of questions to structure the work we are doing together over the years ahead.

We think that this is a particularly crucial moment. It is crucial for several reasons.

First, the budget is being set for the next seven years. If the UK Presidency is successful, it will be set by Christmas and there will be no further questions about how much money is available until 2013. That is important.

Second, because we are talking about budget we are also talking about strategy and we are doing it at a time when the failure of referenda in certain countries in Europe creates an opportunity – an opportunity to re-position health within the panoply of public policy issues. That opportunity is reinforced by the European Council’s decision this year to make Healthy Life Years a performance indicator in the Lisbon process. So far this is a little noticed innovation, it may not even have been noticed by all the Heads of State and Government, as they took the decision in the Spring. It is up to us to make it real.

For those reasons, I think this is the right time to have this meeting. Indeed I hope this is the right meeting. You will tell us at the end if it has met your objectives. I am certainly very pleased to have such good participation and I hope to be able to listen to some of the panel discussion.