EN Official Journal of the European Union C 242/48

Opinion of the European Economic and Social Committee on the ‘Communication from the Commission on effective, accessible and resilient health systems’

(COM(2014) 215 final)

(2015/C 242/09)

Rapporteur: Mr José Isaías RODRÍGUEZ GARCÍA CARO

On 4 April 2014, the Commission decided to consult the European Economic and Social Committee, under Article 304 of the Treaty on the Functioning of the European Union, on the

Communication from the Commission on effective, accessible and resilient health systems

COM(2014) 215 final.

The Section for Employment, Social Affairs and Citizenship, which was responsible for the Committee’s work on the subject, adopted its opinion on 18 December 2014.

At its 504th plenary session, held on 21 and 22 January 2015 (meeting of 21 January), the European Economic and Social Committee adopted the following opinion by 206 votes with 10 abstentions.

1. Conclusions and recommendations

1.1. The EESC welcomes the communication, setting out its comments in this opinion, and calls on the Commission and the Member States to work together as fast as possible on the strategic guidelines the communication proposes, coordinating their efforts.

1.2. We consider that, in the interests of the greatest well-being of the EU citizens, the Member State health systems must remain firmly rooted in principles and values such as universality, accessibility, equity and solidarity. Without these fundamental principles we cannot create a social dimension for Europe, and they must therefore be safeguarded and protected in all EU policies connected with citizens’ health.

1.3. We firmly believe that the economic crisis affecting the European Union in general and certain Member States in particular cannot be resolved with measures that ultimately reduce the European citizens’ rights to health protection. Despite healthcare costs and prices, health is not a commodity, and it must not, therefore, depend on people’s purchasing power.

1.4. Increasing the effectiveness of health systems means ensuring the value of resources, using them as efficiently and effectively as possible, linking the concept of scientific and technical quality with that of efficiency and sustainability as the basic vision of health organisation and professional practice, while still fully respecting the patient.

1.5. The EESC considers it unacceptable that, in the early 21st century, we still have to admit that we lack comparable data. Without accurate, relevant data, progress cannot be made and uniform indicators to support decision-making and scientific analysis cannot be obtained. We call on the Commission and the Member States to press ahead with the adoption of a set of reliable indicators that will enable measures to be studied and adopted at EU level.

1.6. The EESC considers the fight against health inequalities to be a priority. The differences between social, economic and political environments are decisive factors in the distribution of illnesses. Member States must therefore commit to ensuring that healthcare is delivered in an equitable way, irrespective of geographical location, gender, disability, income, age, race or any other factor; and that health services are publicly funded (taxation, health insurance) as one component of a fair redistribution of resources. We believe it is necessary to continue to offer as wide a range of services as possible at reasonable costs and ensuring that co-payment does not pose a barrier to access among the most disadvantaged sectors of the population.

1.7. The EESC considers that health professionals are a key part of health systems. High-quality technical and scientific training is indispensable if we are to have highly-trained professionals who can successfully meet the healthcare needs of the EU public. Furthermore, we believe that the ethical component of their training must also be safeguarded and promoted in the Member States.

1.8. We believe that promoting primary care as a fundamental component of the healthcare provided by health systems can help improve the health results of these systems and reduce costs, thus making them more financially sustainable. The Commission should play a coordinating role in the sharing of national expertise among the Member States.

1.9. The EESC considers that efforts to contain pharmaceutical costs and the costs of high technologies are needed, as these are elements which have a decisive impact on the sustainability of health systems. National and EU agencies must play a key role in assessing the effectiveness and safety of medicinal and technological products placed on the market with regard to health.

1.10. Information and communication technologies must continue to play an increasingly important part in Member States’ health systems, without forgetting that the human dimension must be at the heart of eHealth.

1.11. In order to promote good governance of healthcare systems across the EU and to ensure that patients’ views are duly taken into account, data collection, monitoring and evaluation with regard to the accessibility, performance and resilience of health systems should make full use of patient feedback and involve full, active participation of patients’ associations, civil society organisations and social partners.

2. Introduction

2.1. Under Article 168 of the Treaty on the Functioning of the European Union, Union action shall respect the responsibilities of the Member States for the definition of their health policy and for the organisation and delivery of health services and medical care. Furthermore, paragraph 7 of this article states that these responsibilities include the management of health services and medical care and the allocation of the resources assigned to them.

2.2. The EU’s room for manoeuvre in respect of Member State health systems is therefore limited to action on the public health issues set out on the abovementioned Treaty article. In spite of this, the Commission’s role in providing support, as well as funding and coordinating initiatives, means that it can bring significant added value to other aspects of healthcare, allowing Member States to focus on consolidating and improving their national health systems. These systems are based on a common set of European values, including universality, access to good quality healthcare, equity and solidarity, as listed by the Council in June 2006 (1). In their Declaration, the health ministers of the Member States concluded that health systems formed a vital part of Europe’s social infrastructure.

2.3. In its communication, the Commission identifies a series of challenges that European health systems have had to tackle, compounded by the economic crisis. The challenges include increasing cost of healthcare, gradually ageing population resulting in an increase in chronic diseases, growing demand for healthcare, uneven distribution of healthcare professionals, with shortages in some Member States, and lack of equitable access to healthcare.

2.4. With this in mind, and in line with the conclusions of the Councils of the European Union of June 2011 (2) and December 2013 (3), the Commission has drafted the present communication on which it is requesting the Committee’s opinion. The communication met with a positive reception by the Council of the European Union of June 2014 in its conclusions on the economic crisis and healthcare (4).

2.5. The communication proposes a European Union agenda for efficient, accessible and resilient health systems based on respect for Member State competences with contributions from the European Union in the form of guidelines and monitoring and assessment tools. The plan contains the following elements:

2.5.1. Strengthening the effectiveness of health systems. This comprises three aspects: evaluation of health system performance; quality of care and patient safety; integrated healthcare delivery. Increasing the accessibility of health systems. To be achieved by: action in terms of the health workforce; cost-effective use of medicines; optimal implementation of Directive 2011/24/EU. Improving the resilience of health systems. By means of: assessment of health technologies; health information systems; and online health.

3. Comments on the background to the communication

3.1. Rising health costs, an ageing population and an increase in certain chronic diseases mainly affecting the elderly are not challenges that have arisen in the course of the last 10 years: these are problems that have built up over many decades and have been aggravated by the current crisis, which has led to funding cuts in these policy areas. What is therefore called for is a strategic approach focusing on how to tackle in an efficient and effective way the growing demand for resources that health systems will be encountering in the coming years in order to cater for an ageing population with growing healthcare needs because of increasing life expectancy.

3.1.1. Promotion of health and prevention of illness, as fundamental health protection measures, must play a major part in our national health systems. Healthcare costs can be reduced significantly by investing in health education, encouraging more active and healthy lifestyles to reduce obesity, smoking and alcohol consumption. Regular cancer screening and health checks can enable more older people to enjoy a long and healthy retirement.

3.2. The Committee agrees that the Member State health systems must remain firmly rooted in principles and values such as universality, accessibility for all, equity and solidarity. These are principles that guarantee all EU citizens the right to health protection and healthcare; that guarantee adequate and timely healthcare intervention to achieve the best health outcomes; that deliver healthcare in an equitable way, irrespective of geographical location, gender, disability, income, age, race or any other factor; and that ensure that health services are publicly funded (taxation and/or health insurance) as one component of a fair redistribution of resources.

3.3. We are convinced that the economic crisis afflicting the European Union in general, and certain Member States in particular, must not serve as a pretext for creating a rift between first and second class citizens: we all have the same right to health protection. In this regard, the Committee must also ensure that the varying capacity and quality of healthcare in the different Member States includes EU citizens who are working not in their country of origin but temporarily abroad. We must not lose sight of the users of health systems in our pursuit of efficiency and effectiveness. Despite healthcare costs and prices, health is not a commodity, and on no account must it therefore depend on people’s purchasing power.

3.4. In its opinion (5) on the Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions — Solidarity in health: reducing health inequalities in the EU (6), the European Economic and Social Committee explicitly stated that ‘the Commission should make best use of the tools available (e.g. OMC, impact assessments, research programmes, indicators, cooperation with international organisations) and should consider with the Member States new methods to ensure that EU policies and actions address the factors which create or contribute to health inequalities across the EU’. We reiterate our support for the content of that opinion and for all the recommendations issued by the Committee aimed at reducing health inequalities.

3.5. In its opinion (7) on the Proposal for a Regulation of the European Parliament and of the Council on establishing a Health for Growth Programme, the third multiannual programme of EU action in the field of health for the period 2014-20 (8), the Committee took the opportunity of expressing its views on a number of aspects of the communication. In this respect, we again reaffirm the comments made regarding the assessment of health technologies, training of health professionals, use of evidence-based medicine and exchange of good practices.

3.6. The Committee views the inclusion of the health sector in the European Semester as very important. The sector’s share in the Member States’ Gross Domestic Product, the size of its workforce and its capacity for innovation are sufficient reasons for including it. Nevertheless, the recommendations that emerge from the assessments of the European Semester must be based on the premise that they will in no way dilute the principles and values underpinning the health systems of the EU Member States.

3.7. Strengthening health systems purely from the perspective of obtaining good results would be to overlook other aspects that, at a time of limited resources and budgetary constraint, should be taken into consideration. An efficient and good value health system therefore maximises quality of care and outcomes obtained with available resources. In other words, we cannot envisage strengthening a health system’s effectiveness without taking account of its efficiency. Ensuring the value of resources means using them as efficiently and effectively as possible, linking the concept of scientific and technical quality with that of efficiency and sustainability as the basic vision of health organisation and professional practice.

3.8. We support the work of the Commission and the Member States in implementing EU-level indicators to measure the effectiveness of health action. To this end, all Member States must set up and make use of validated, transparent and objective data collection systems so that overall analyses can be undertaken. This will facilitate cooperation measures to reduce the health inequalities between and within the Member States. It is unacceptable that, in the early 21st century, we still have to admit that we lack comparable data. Without accurate, relevant and timely data, progress cannot be made and uniform indicators to support decision-making and scientific analysis cannot be obtained.

3.9. The usefulness of health indicators lies in their reliability, with quality a prerequisite for drawing comparisons. The Commission acknowledges in its communication that there is a lack of reliability, making it difficult to compare outcomes. For this reason, the Committee supports the European Core Health Indicators (ECHI) as they provide comparable data on health and health-related behaviour, as well as disease and health systems, allowing some Member States to improve their information systems and use indicators that they otherwise would not have, and thus facilitating exchange of good practices in general. In the same way, we welcome the Joint Assessment Framework in the area of health, drawn up by the Indicators’ Sub-Group of the Social Protection Committee.

3.10. The Committee fears that effective recognition of the universality of healthcare could be undermined by problems of health system accessibility. Where there are problems of access, it is always those population groups with the fewest resources of their own who are the most affected. If we want to reduce health inequalities, the first step must be to tackle accessibility. Effective primary healthcare in rural areas, local emergency services, adequate transport and communications infrastructure, access to specialist treatment and restraint when introducing co-payment arrangements (means-tested) are among the vital facets for ensuring that people have access to health services, and they need to be put in place in the Member States.

3.11. The EESC shares the Commission’s fears and recognises that by signing the UN Convention on the Rights of Persons with Disabilities we also need to take all appropriate measures to ensure access for persons with disabilities to health services — including ensuring that the facilities are accessible for those who are limited by a disability.

3.12. The Committee agrees with the Commission that stable financing mechanisms must be maintained for health services. In this sense, mixed funding comprising a combination of contributions and taxes could offer a stable financing framework for health services. We believe that the resilience or robustness of these systems is also linked to highly professional management based on efficient information systems, making it possible to provide accurate calculations of healthcare costs. The above, combined with highly qualified and motivated health professionals, could provide a firm and stable basis for sustainable health systems.

3.13. The EESC shares the Commission’s opinion that one of the main difficulties facing some Member States’ healthcare systems is a shortage of health professionals. This shortage is exacerbated by a high level of migration of these workers to other EU Member States and outside the EU. Given that the reasons for this are many and complex, we believe that the Commission’s action plan should include measures that help make the health professions more attractive to young people, so that not only do an increasing number of people apply to train in these professions but practising them becomes attractive from both a professional and an employment perspective.

4. Comments regarding the EU agenda for efficient, accessible and resilient health systems

4.1. In today’s advanced societies, assessment of health system performance serves, amongst other things, as a way of making health service providers accountable to users and as a planning tool for the future. In order to build on the commitments made in the Tallinn Charter, the Committee supports the idea of providing Member States with tools and methodologies aiming at bringing health systems closer together and reducing inequalities within and between them.

4.2. Patient safety involves minimising the risk of unnecessary patient harm, meaning an absence of accidental injuries arising from healthcare provision or medical error. Promoting patient safety calls for risk management, reporting, investigation and follow-up of accidents and a solution-oriented approach to minimise the risk of recurrences. The Committee endorses the recommendations it made in its opinion (9) on the Proposal for a Council Recommendation on patient safety, including the prevention and control of healthcare associated infections (10), and would extend them to all risks that are not related to infectious diseases, emphasising in particular the need to report adverse effects and take measures to remedy them. Appropriate action to this end should be outlined.

4.3. We feel that patient care calls for coordination among the various levels of healthcare delivery, so that primary care plays a more prominent role in diagnosing and treating health problems. A sound primary health network, staffed by highly qualified professionals, makes for greater proximity to health problems, avoids unnecessary specialist interventions and lowers costs by making systems less dependent on hospitalisation. The Commission should play a coordinating role here in the sharing of national expertise among the Member States.

4.4. The number of people employed in the health sector as a proportion of the total workforce in the Member States is of such a scale to be considered a health problem in the event of a shortage of such professionals. To avoid situations of this type, health training planning, although the responsibility of the Member States, should be subject to monitoring and evaluation by the European Union as a means of cooperating with Member States in maintaining a critical mass of professionals to meet the growing healthcare needs on the part of the public. The Committee believes that, in order to develop the necessary education and university capacity, financial support also needs to be provided.

4.5. The EESC believes that high-quality technical and scientific training is indispensable if we are to have highly-qualified health professionals who can successfully meet the healthcare needs of the EU public. Furthermore, we believe that the ethical component of their training must also be safeguarded and promoted in the Member States.

4.6. Spending on pharmaceutical products represents a major part of health service costs and affects their sustainability. Prescribing drugs according to active ingredient (WHO International Common Denomination) is one option that could reduce spending on pharmaceuticals, as it would mean prescribing on the basis of the active ingredient rather than using a trade name. Examples of this kind of prescription can already be found in some healthcare organisations in the EU, and the experience could be applied in other Member States. However, any measure adopted must factor in the need for research into new medicinal products and funding for these activities.

4.7. The Committee endorses the Commission’s statement in the present communication regarding the optimal implementation of Directive 2011/24/EU (11), but considers that this is not the main obstacle to accessibility of national health services by citizens; nor will the optimal implementation of the directive increase access to national systems. It is our understanding, within the context of this communication, that greater accessibility means primarily increasing population coverage to provide universal access, offering as wide a range of services as possible at reasonable costs and ensuring that co-payment does not pose a barrier to access among the most disadvantaged sectors of the population. Guaranteeing safe and good quality cross-border healthcare is not a guarantee that the individual citizen will receive basic healthcare in his or her country of origin.

4.8. Medical research and innovation is leading to the appearance of new health technologies in response to diagnostic and therapeutic challenges in the medical field. The high cost of these technologies and their supposed efficiency call for a robust system of evaluation. The Committee finds it of great interest that the European network for Health Technology Assessment (EUnetHTA) brings added value to Member States’ national and regional agencies, facilitating synergies and the dissemination of its assessments.

4.9. The progress made in using information technologies in patients’ clinical records should be applied in other settings, not just health centres. A patient’s computerised health record, available to any treating health professional, would seem to be an objective worth striving for, however far-off the results may seem at the present. The EU should back health and health information systems enabling a person’s clinical records to accompany them no matter where they are. Computerised health records are an extremely useful tool for patients, but at the same time a challenge for the authorities when it comes to coordinating applications compatible with their health systems, allowing any health professional to become acquainted with a person’s health problems, irrespective of where they happen to be. The challenge is huge but, if it can be met, we believe that it will lead to an improvement in the health of the people of Europe.

4.10. The EESC considers it vitally important for the public to have access to digital health information systems, to find information on matters such as medical devices for human use approved by the regulatory authorities. This information must be comprehensible, accurate and up-to-date and secure, so that the person accessing it can supplement the information they have received from the healthcare professional assisting them.

4.11. In its opinion (12) on the Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions: eHealth Action Plan 2012-20 — Innovative healthcare for the 21st century (13), the EESC took the opportunity to express its views on eHealth. The opinion reiterates the following: ‘eHealth must foster mutual trust between patients and professionals by avoiding the risk of “being impersonal” and failing to pay attention to psychological factors. The human dimension must be at the heart of eHealth’. We therefore conclude by stating that the citizen is the central focus of health systems.

Brussels, 21 January 2015. The President of the European Economic and Social Committee Henri MALOSSE

(1) OJ C 146, 22.6.2006, p. 1.

(2) OJ C 202, 8.7.2011, p. 10.

(3) OJ C 376, 21.12.2013, p. 3.

(4) OJ C 217, 10.7.2014, p. 2.

(5) OJ C 18, 19.1.2011, p. 74.

(6) COM(2009) 567 final.

(7) OJ C 143, 22.5.2012, p. 102.

(8) COM(2011) 709 final.

(9) OJ C 228, 22.9.2009, p. 113.

(10) COM(2008) 837 final.

(11) OJ C 175, 28.7.2009, p. 116.

(12) OJ C 271, 19.9.2013, p. 122.

(13) COM(2012) 736 final.