EN Official Journal of the European Union C 120/135

Opinion of the European Economic and Social Committee on the ‘Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions — Modernising social protection for the development of high-quality, accessible and sustainable health care and long-term care: support for the national strategies using the open method of coordination’

(COM(2004) 304 final)

(2005/C 120/25)

On 20 April 2004, the Commission decided to consult the European Economic and Social Committee, under Article 262 of the Treaty establishing the European Community, on the abovementioned communication.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 22 September 2004. The rapporteur was Mr Braghin.

At its 412th plenary session of 28 October 2004, the European Economic and Social Committee adopted the following opinion with 104 votes in favour and three abstentions.

1. Gist of the Communication

1.1 The aim of this Communication, as announced in the Spring Report 2004 (1), is to define a common framework to support Member States in the reform and development of health care and long-term care using the ‘open method of coordination’.

1.2 The Commission identified three principles (2), approved by the Barcelona European Council in March 2002, that could serve as a basis for reform: accessibility of care for all based on fairness and solidarity; high-quality care; long-term financial sustainability of this care, aiming to make the system as efficient as possible.

1.3 The definition of health care as a service, within the meaning of the Treaty, persistent inequalities and problems of access, sometimes inadequate service quality and financial imbalances have highlighted the need to intensify the coordination of national policies so as to ensure the modernisation and development of the sector, whilst taking account of the impact on social cohesion and employment of the complex consequences of demographic ageing.

1.4 In order to meet these challenges, social protection systems must be reformed in an integrated and coordinated manner. Health and long-term care is one sector where the coordination of social protection must be streamlined (3). The open method of coordination is ideally suited to this context because it is a flexible tool that respects the specific circumstances and competences of each state (4).

1.5 The Communication identifies the following steps: — Reaching an agreement on joint objectives in 2004. Member States should present preliminary reports on the challenges facing their respective national systems at the next Spring Summit. — Drafting an initial series of development and reform strategies in health care and long-term care for the period 2006-2009 which will be presented by the Commission in the joint report on social protection and social inclusion in 2007. — Setting up a high-level group on health services and medical care to create a work programme in coordination with other high-level groups in related fields. — Identifying indicators for these objectives. The interim reports due in spring 2005 will contribute by facilitating the preparation of an initial comparison table of the different national situations and permitting the assessment of progress vis-à-vis the stated objectives.

2. General comments

2.1 Socio-economic and demographic factors

2.1.1 The EESC reiterates its full support, already expressed in previous opinions, for the common objectives for the development of health-care systems. In particular: — Ensuring access to high quality health care based on the principles of universal access, fairness and solidarity; and providing a safety net against poverty or social exclusion associated with ill-health, accident, disability or old age, for both the beneficiaries of care and their families. — Promoting high quality health care in order to improve people's state of health and quality of life. — Ensuring the long-term financial sustainability of high quality care that is accessible to all. The EESC agrees that these objectives are all important and mutually dependent and that their development and streamlining require effective governance, based on involving and giving responsibility to the players concerned, as the social partners and civil society as a whole must contribute to the reform effort.

2.1.2 Furthermore, the EESC argued, in a recent own-initiative opinion, that the ability of national health-care systems to fulfil these objectives depends on a number of socio-economic and demographic factors that require deeper analysis if we are to achieve a better understanding of the complexity of the problem, and anticipate potentially disruptive trends (5).

2.1.3 Such factors influence present and future needs and available resources. Achieving efficiency in the health-care system is also vital because health care interacts with other components of the welfare system. Its funding requirements therefore compete with the requirements of other areas of social protection, whilst its problems impact upon them, and vice versa.

2.1.4 Similar competition for financial resources and interactive mechanisms operate within the health-care sector itself. For instance, when allocating funds, streamlining one sector may produce the opposite of the desired effect in another sector. Moving staff from one sector to another could result in an unforeseen deterioration in quality. Such measures should be carefully analysed for every restructuring scheme in the health-care system.

2.1.5 The EESC considers that addressing one aspect of a problem without considering the repercussions for other sectors, or failing to monitor inter-connected trends within different sectors, could create distortions or prevent the desired objectives from being fulfilled. For this reason it is essential to share a global vision of the problems and their interdependence, and to find viable solutions through common strategies.

2.1.6 There is an important social and psychological aspect to health care. When facing illness, suffering, or death, people expect the best care and do not stop to think about cost-effectiveness and sustainability. This poses a delicate political problem. Public sector decision-makers have to prioritise and provide cost-effective sustainable health services. However, such choices often come up against sectoral interests and the subjective perceptions that sometimes make it difficult to apply the necessary restructuring measures to the demand and supply of services.

2.1.7 People's needs and expectations regarding their own health — this implies not only a desire for quality of life but also for a life worth living — should be taken into proper consideration when assessing cost-benefit ratios and financial sustainability in order to guarantee that all restructuring measures in the health sector lead to better streamlining and are viable in the long-term. This should also facilitate public sector decision-making that takes into account the real needs of the population as a whole, as well as the needs of patients and people with specific health needs.

2.1.8 The EESC believes that health care is a right and a priority in Community policy. However, it maintains that in order to safeguard this right in the long term, we need to identify effective tools to ensure a fair level of care that is accessible to all and compatible with available resources. As a consequence, it is essential to carry out in-depth research to find out which of the population's health-care needs and expectations are justified. It is also necessary to identify tools to promote responsibility that will encourage the appropriate use of resources and the efficiency of the health system, thereby making the system financially sustainable.

2.2 Demographic ageing and new epidemiology

2.2.1 Demographic ageing means more than a mere rise in the percentage of the population over 65, and an even sharper rise in the number of over-eighties, often, but not necessarily, accompanied by an increase in the number of patients with multiple illnesses, a phenomenon which may in turn result not so much in a proliferation of medical treatment as in a more holistic approach to treatment. Demographic ageing results in certain problems that are sometimes neglected but should be faced: — Changes in the demographic pyramid without adjustments to the retirement age will lead to a more unfavourable ratio between contributors (the population of working age) and beneficiaries (the elderly population, in particular), not only in the health system but also in other services. It is therefore a top priority to identify new ways of re-allocating and building up specific resources for services provided to the dependent population (6) (predominantly, the elderly), without withdrawing resources from other social services. — Demographic ageing alters not only the incidence but also the type of disease occurring. Age-related illnesses are often incurable but may be controlled in the medium to long term through palliative medical or surgical treatment that will, however, never restore the patient to his previous state of health. This implies a different approach to medical care that can integrate treatment and care, and that affects research, pharmaceuticals, diagnostic tools, and technological interventions. This further requires a shift in emphasis from the ‘acute’ to the ‘chronic’ (i.e. the successful long-term management of medical problems that cannot, themselves, be resolved). — In epidemiological terms, there has been a steady increase in the incidence of chronic or long-term disease, which is partly due to the success of medical treatments that, whilst falling short of a total cure, substantially prolong life expectancy. As a result, there has been a rise in the incidence of physical and mental disability, particularly in the field of trauma and neuro-degenerative disease, that can only be dealt with through a higher level of integration of medical and social services, and requires a substantial commitment from family carers (7). — The concept of ‘health’ should not be restricted to its physical aspects but should also include its psychological and social aspects, as is apparent from the WHO definition (8). This definition presupposes the need to assess an elderly person's social context so as to meet other needs such as safety, social circumstances and relationships, self-esteem and self-realisation etc.

2.2.2 The social net, which came into being under different demographic circumstances and needs, must be rethought in order to counter the inflexibility and resistance to change inherent in organisations, employment sectors, and cultural mind-sets. The EESC believes that this can be accomplished by assessing the population's state of health and needs, which vary considerably within and amongst Member States, and by anticipating demographic changes. These changes have already begun and are likely to intensify, though in a fairly predictable manner.

2.2.3 Moreover, solutions should be found to improve the management of supply and demand for services, improving access to care, meeting demand, helping the more vulnerable to benefit fully from the services provided, ensuring integrated assessment of needs and personalised care programmes, continuity of care and the systematic assessment of results. The open method of coordination should also include these aspects and, therefore, promote more homogeneous approaches and strengthened social cohesion mechanisms.

2.2.4 The second aspect of demographic change cited in the Communication, i.e. changes in family life and a higher female employment rate, reduces the family's ability to provide informal care. This fact, in turn, implies that home care needs to be rethought since it cannot be left entirely to professional carers, due to the cost and difficulty of recruiting staff, the risk of losing 24-hour care, and in many cases, the need to take into consideration the patient's other human needs. It is therefore necessary to consider new social support policies for family care, including the possibility of providing some form of remuneration for the family carer, ensuring appropriate living conditions, transport facilities, and similar support services.

2.2.5 At present, domiciliary health care is provided in many different forms by national and local authorities, national health services and insurance schemes, and non-profit organisations and associations providing social services to people. In general, it has been observed that it is not sufficiently developed in some countries. It needs to be improved in order to take into account the changing needs that result from the higher epidemiological incidence of dementia, neurovascular disease, and more generally, polypathology resulting in loss of independence, which affects over 30 % of the population over 75.

2.2.6 The EESC recommends that ongoing support initiatives for informal carers in Member States be compared and analysed in depth. These might include tax advantages, pension and social insurance for care givers, the right to leave from employment to care for a relative, provision of substitute carers during rest periods, and provision of day-care centres, etc. (9)

2.2.7 Solutions of this type promise to be more economical for the service provider and more satisfying for elderly beneficiaries in so far as they combine professional resources and informal resources, offering solidarity with the elderly whilst substantially reducing the cost of care. In other words, a win-win situation is created since costs would be considerably higher if the equivalent level of care were provided exclusively in residential homes, and informal care, which is in any case provided, is safeguarded.

2.3 Employment

2.3.1 The health care and long-term care sector employs a significant percentage of the work force in the European Union. It is the second largest creator of employment. Between 1997 and 2002, 1,7 million jobs were created in EU-15. Nevertheless, it is feared that the ageing of the health-care workforce and difficulties in ensuring quality services could lead to a serious crisis in the sector.

2.3.2 Vocational and lifelong training must be restructured in order to meet emerging needs, maintain quality services, and ensure that employees remain professionally active: — The training received by medical staff should not be restricted to the treatment of symptoms and acute conditions but should also take into account the multifaceted aspects of health in the elderly. Training in geriatric care should be adapted to reflect these needs. — Nursing staff should be able to adapt to the specific fields in which they operate, i.e. at different levels of the care system (intensive care, hospital care, primary care, long-term care, home care etc.). — The training of care workers should be extended to include socio-health services for reasonably self-sufficient elderly people, whose needs and dignity should nevertheless be respected. — Social cohesion means that the borders between health care and social assistance will become more blurred. Similarly, professional roles will have to accommodate a demographic structure and composition that will be very different from today's.

2.3.3 The EESC considers that, in addition to improving training for different categories of care workers, as described above, the following new capacities should be developed: — gathering, providing and exchanging information through networks and making the best use of new technologies; — working in groups, interpersonal communication skills, dialogue with other vocations and institutions; — work practices aimed at preventive care and promoting new approaches to emerging needs; — working on projects that target specific segments of the population, transcending the narrow confines of traditional disciplines; — awareness of the economics of services provided; assessment of results to improve resource allocation.

2.3.4 The EESC is in favour of using the European Social Fund for training programmes in order to raise skill levels in the health care and long-term care sectors, prevent the premature loss of workers from the sector and enhance quality, flexibility and, consequently, the efficiency of the care system. This approach is particularly important for the new Member States, where the modernisation process is faster and more intense, and where the need for vocational training is correspondingly greater.

2.3.5 In order to achieve good results, cooperation between the public and private sector must be rethought in positive terms. Cooperation must be actively sought not only to avoid competition between service providers in a world where the active section of the population is forecast to decline steadily in percentage terms (with consequent staffing bottlenecks and rising labour costs), but also to fully integrate in to health-care systems the qualities of efficiency and attention to needs, objectives which, at present, would appear to be the prerogatives of one or the other sector, rather than both.

2.4 Financial sustainability

2.4.1 Continuing to provide accessible quality health care without withdrawing funds from other sectors or political priorities is a major challenge for both old and new Member States. This requires a strategy that pays close attention to long-term trends, and to supply as well as demand. Action that has failed to take both these factors into account has not been successful in containing costs in the medium term.

2.4.1.1 Budgetary constraints, which partly arise from the Stability Pact, generally make it impossible to increase spending on welfare in proportion to growing demand for social services. Nevertheless, it is possible to make substantial improvements by restructuring existing services and concentrating on services that have proved effective, while eliminating unjustified use of the health service. Furthermore, an effective health policy means that interactions between health care and social assistance must be rethought in order to identify structures and types of treatment and professional services that are better suited to present and future contexts and the population's needs.

2.4.1.2 Various approaches have been tried in the effort to control the rise in costs, including the transfer of part of the costs to the user (this not only shifts the financial burden onto the individual but also curbs demand); containing supply and demand in price and volume terms; and reforms encouraging the efficient use of resources and the transfer of resources from hospital and social care to domiciliary care.

2.4.1.3 The use of the open method of coordination advocated in this analysis will result in a better understanding of the disparate underlying conditions and the likely impact on other social service sectors and so make it possible to assess which measures have been most effective and what combination of measures is likely to be most successful.

2.4.2 Although preventive health care policies are undoubtedly important and necessary, they are, unfortunately, often neglected. A concrete plan for preventive measures (preferably far-reaching and universally applicable measures) should play a major role in the proposed strategy for the sustainable development and reform of health care. Various preventive measures, and in particular those already tried at national level, should be thoroughly tested through the open method of coordination to ensure that specific action is taken. The EESC realises that implementing preventive measures is difficult, as it requires policy coordination, which is still far from being achieved, and educational programmes to promote healthier life styles (healthier diets, and more intensive physical and mental activity). These programmes should pay particular attention to the segments of the population that are more exposed to health risks and are more socio-economically disadvantaged, and should also strive towards healthier working conditions. Such measures take a lot of time and effort to set up but do not offer any guarantee of success.

2.4.3 Differentiating expenditure according to care services, referral procedures and treatment is a laudable approach to containing costs. Therefore, any investment that will improve the health system's ability to respond to needs, or that facilitates modernisation, must be considered as a means of making health care more sustainable in the long term. However, this type of investment is sometimes sacrificed to economic exigencies. The EESC believes that investment in the streamlining of the health-care system should be combined with measures to influence demand (criteria for referral to specialists, ceiling above which costs are borne by the individual, charges, etc.) as well as supply (health-care infrastructures, cost of innovative technologies and pharmaceuticals, where the cost/benefit ratio is not always clear, payment criteria and procedures, awareness-raising of health-care costs amongst health workers etc.).

2.4.3.1 The structure and operational procedures of the health-care system, as well as transferral from one service to another, should be carefully analysed to ensure efficient and effective operation and coordination. This should be a priority of the open method of coordination.

2.4.3.2 The new Member States are working intensively to modernise their health-care systems and the EESC strongly recommends the use of Structural Funds, and in particular, the ERDF and the Cohesion Fund, to support infrastructural improvements to health-care systems. Furthermore, the EESC considers that the assessment of experience through the open method of coordination could be particularly valuable to the new Member States since it could prevent them from adopting systems which are likely to become obsolete rapidly.

2.4.4 Strengthened cooperation between care providers currently working in isolation (intensive care, primary health care, social services), as recommended in the Communication, is certainly appropriate, as people with high dependency needs generally require a variety of services, not all of them medical. Positive cooperation between families, care workers and medical personnel produces better results at lower cost. The EESC hopes that the recently established high-level group on health services and medical care will be given a clear mandate that includes the task of recommending concrete operational arrangements for cooperation.

2.4.5 Technological progress and greater awareness on the part of patients undoubtedly has the potential to curb spending since it lowers the cost of treating specific conditions and reduces their incidence. However, it also creates new needs and the right to have these needs met. As a result, well-established, cost-effective and generally adequate diagnostic and therapeutic procedures are abandoned. Unless innovative procedures are specifically targeted towards more effective health-care for the elderly, they are likely to have a negative rather than a positive impact on health care expenditure in the long term. Pressure from the better educated and more health-conscious sector of the population could lead to a further decline in services to the more disadvantaged groups, whose access to health care is already restricted.

3. Specific comments

3.1 Given that European legislation on long-term health care is impossible, the EESC considers that the open method of coordination is of primary importance for the effective modernisation and development of accessible, sustainable, long-term quality health care, and to ensure public health protection in different contexts and in the face of growing pressure and challenges.

3.1.1 Analysis and exchange of experience should focus on: — the structure and coordination of health-care systems and institutions (from primary health care, to long-term care, and including domiciliary care); — the procedures and waiting periods for access or transfer from one service to another; — internal procedures and output (monitoring and assessing the quality of health services); — the volume and type of services provided and, in particular, the efficient use of new technologies; — the methods used to make more efficient use of resources and the most effective mechanisms for cost containment; — the involvement of medical and health-care personnel in the management of resources; — respect for patient rights, and their access to relevant information, therapeutic options and patient records; — transparency of services provided.

3.2 The application of the open method of coordination entails the identification of indicators that can address existing knowledge deficits whilst taking into consideration prevailing situations and the long-term social dynamics that impact upon the health-care system. The set of indicators must include all structural considerations (network of services, availability of equipment and staff, levels of training and experience etc). It must also include the intrinsic qualities of health care (methods for providing services and carrying out interventions, operational guidelines, medical regulations and practice, patient rights' protection etc.). Finally, it must cover the quality of specific health-care outcomes, according to type and social expectations.

3.2.1 A special effort must be made to ensure that the indicators make it possible to monitor and assess trends relating specifically to the elderly and the care they receive, a shortcoming of the indicators currently identified or in use. Work on developing indicators will need to go hand in hand with work on clarifying the common objectives. In the meantime, it would be useful to take stock of data already available from a range of sources, including WHO, the OECD and ECHI (European Common Health Indicators). The arrival of the data under the new EU SILC later in 2004 should also be taken into account.

3.3 The ‘next steps’ proposed in the Communication touch on extremely important aspects of the problem and extend the debate to pertinent spheres of interest. However, the proposals are general in nature and therefore run the risk of failing to take the open method of coordination significantly forward.

3.3.1 The EESC hopes that more precise ‘common objectives’ will be identified, provided that they are not overprescriptive and do not have a negative impact on the organisation of national systems. Furthermore, the proposed preliminary reports should serve as useful tools that do not result in additional administrative costs and burdens that overstretch the limited resources of new Member States.

3.4 The EESC therefore hopes that the Commission will take swift action to: — provide a precise definition for terms such as social protection, health care, socio-health care, care at home and other expressions which appear in the Communication and which are often used differently in the various Member States — for historical reasons and due to the operational specificities of different welfare systems; — provide a clear guide for the preparation of the ‘preliminary reports’ so as to ensure that they cover the same topics and make comparison possible. They should not refer to the entire range of partial objectives but should focus on the measures best suited to identify and illustrate national policy guidelines and challenges; — appoint a group of experts (with input from national institutions and specialised bodies with expertise in the field) to draw up specific indicators for long-term care, so as to ensure an effective assessment of macrosocial and macro-economic factors that affect health care and long-term care. Such experts should be qualified to assess all aspects of a global perspective and, in particular, to assess the indicators' value as forecasting tools; — develop a European socio-health impact-assessment model based on indicators for investment/funding (input), structured response (output) and the effectiveness of action taken (outcome). This would make it possible to use reliable indicators to assess the welfare standards achieved in different countries (10); — address gender-specific issues by, for instance, taking into account the fact that on average women live five years longer than men, and have biological and physiological characteristics that make a considerable difference to their health-care needs; — facilitate the joint preparation of health-care guidelines that are not restricted to pharmacological treatment but also include social and organisational factors. Such guidelines would serve as a reference point for operators in different health-care systems.

3.5 A particularly important and pressing need is the promotion of activities to improve the skills of operators and professionals by developing appropriate training schemes that cover the common professional ground between health care and health-related social work. This goes beyond technical aspects and requires the acquisition of new skills, such as information management, in particular using computer networks, and broad-based financial administration. Such new training schemes should be supported and promoted by the Community in order to exploit the experience exchanged using the open method of coordination.

Brussels, 28 October 2004. The President of the European Economic and Social Committee Anne-Marie SIGMUND

(1) Delivering Lisbon - Reforms for the enlarged Union, COM(2004) 29 final.

(2) COM(2001) 723 final.

(3) The EESC issued an opinion in favour of streamlining in OJ C 32 of 5.2.2004 – rapporteur: Mr Beirnaert.

(4) Communication from the Commission - Strengthening the social dimension of the Lisbon strategy: Streamlining open coordination in the field of social protection COM(2003) 261 final

(5) EESC opinion on Health care – OJ C 234 of 30.09.2003 – rapporteur: Mr Bedossa.

(6) WHO terminology would define a dependent person as a person who is partially or totally unable to perform functions independently at an organic, cognitive, behavioural or interpersonal level, or to interact with the environment (see International Classification of Functioning, Disability and Health, 2001 (ICF).

(7) The most recent statistics show that Europe has a dependent population of some 60 million, which is expected to have risen to 75 million in 2003 (information source: EUROSTAT, The social situation in the European Union 2003, European Commission, DG Employment and Social Affairs, 2003)

(8) International Classification of Functioning, Disability and Health 2001 (ICF)

(9) See the Joint Report entitled Health care and care for the elderly: Supporting national strategies for ensuring a high level of social protection, COM(2002) 774 final of 3 January 2003, p. 9

(10) cf. EESC opinion: OJ C 80 of 30.3.2004, point 4.5.2 – rapporteur: Mr Jahier