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)
Date: 2004-10-28
Institutions: European Economic and Social Committee
Subjects: ESC opinion, EU Member State, European social policy, elderly person, equal treatment, health care, health care system, health policy, social security, therapeutics

20.5.2005

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 Economic and Social
Committee and the Committee of the Regions — Modernising social protection for the develop-
ment of high-quality, accessible and sustainable health care and long-term care: support for the
national strategies using the open method of coordination’

the European Parliament,

(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 communi-
cation.

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

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 circum-
stances and competences of each state (4).

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 coor-
dination’.

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

In order to meet

1.4
these challenges, social protection
systems must be reformed in an integrated and coordinated
manner. Health and long-term care is one sector where the

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

final.

(2) COM(2001) 723 final.

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 strate-
gies 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
the preparation of an initial comparison table of
different national situations and permitting the assessment
of progress vis-à-vis the stated objectives.

(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

C 120/136

EN

Official Journal of the European Union

20.5.2005

2. General comments

be carefully analysed for every restructuring scheme in the
health-care system.

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 devel-
opment 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
quality care that is accessible to all.

sustainability of high

The EESC agrees that these objectives are all
important and
mutually dependent and that their development and stream-
lining 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-initia-
tive 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 (1).

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.

The EESC considers that addressing one aspect of a
2.1.5
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 interdepen-
dence, 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-effec-
tiveness 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.

People's needs and expectations regarding their own
2.1.7
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
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.

to guarantee that all

Similar competition for financial resources and inter-
2.1.4
active 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

(1) EESC opinion on Health care – OJ C 234 of 30.09.2003 – rappor-

teur: Mr Bedossa.

The EESC believes that health care is a right and a
2.1.8
priority in Community policy. However,
it maintains that in
order to safeguard this right in the long term, we need to iden-
tify effective tools to ensure a fair level of care that is accessible
to all and compatible with available resources. As a conse-
quence, 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
thereby
making the system financially sustainable.

the health system,

20.5.2005

EN

Official Journal of the European Union

C 120/137

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 there-
fore a top priority to identify new ways of re-allocating and
building up specific resources for services provided to the
dependent population (1)
elderly),
without withdrawing resources from other social services.

(predominantly,

the

— 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 technolo-
gical 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, them-
selves, 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 expec-
tancy. 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 (2).

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

(2) The most recent statistics show that Europe has a dependent popu-
lation 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)

— 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 defini-
tion (3). 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
in organisations, employment sectors, and cultural
inherent
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 antici-
pating 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, conti-
nuity 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.

rate,

reduces

2.2.4
The second aspect of demographic change cited in the
Communication, i.e. changes in family life and a higher female
the family's ability to provide
employment
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 there-
fore 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.

(3) International Classification of Functioning, Disability and Health

2001 (ICF)

C 120/138

EN

Official Journal of the European Union

20.5.2005

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 organisa-
tions and associations providing social services to people. In
general, it has been observed that it is not sufficiently devel-
oped 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 initia-
tives 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. (1)

2.2.7
Solutions of this type promise to be more economical
for the service provider and more satisfying for elderly benefici-
aries 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

The health care and long-term care sector employs a
2.3.1
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. Never-
theless, 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 condi-
tions but should also take into account the multifaceted

(1) 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

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
i.e. at different levels of the care
long-

in which they operate,
system (intensive care, hospital care, primary care,
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.

The EESC considers that,

2.3.3
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; assess-

ment of results to improve resource allocation.

The EESC is in favour of using the European Social
2.3.4
Fund for training programmes in order to raise skill levels in
the health care and long-term care sectors, prevent the prema-
ture loss of workers from the sector and enhance quality, flex-
ibility 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.

20.5.2005

EN

Official Journal of the European Union

C 120/139

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, objec-
tives 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 prio-
rities 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.

Budgetary constraints, which partly arise from the
2.4.1.1
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 assis-
tance 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.

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 develop-
ment 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 (heal-
thier 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 facili-
tates 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 exigen-
cies. 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, aware-
ness-raising of health-care costs amongst health workers etc.).

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.

The structure and operational procedures of

2.4.3.1
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.

2.4.1.3
The use of the open method of coordination advo-
cated 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 undoubt-
edly important and necessary, they are, unfortunately, often

The new Member States are working intensively to
2.4.3.2
modernise their health-care systems and the EESC strongly
recommends the use of Structural Funds, and in particular, the
ERDF and the Cohesion Fund,
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.

to support

C 120/140

EN

Official Journal of the European Union

20.5.2005

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 moder-
nisation 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 chal-
lenges.

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 infor-

mation, 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, opera-
regulations and practice, patient
tional guidelines, medical
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 indi-
cators make it possible to monitor and assess trends relating
specifically to the elderly and the care they receive, a short-
coming 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 (Euro-
pean 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.

20.5.2005

EN

Official Journal of the European Union

C 120/141

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

systems. Furthermore,

The EESC therefore hopes that the Commission will take

3.4
swift action to:

— provide a precise definition for terms such as social protec-
tion, health care, socio-health care, care at home and other
in the Communication and
expressions which appear
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 insti-
tutions 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;

Brussels, 28 October 2004.

— develop a European socio-health impact-assessment model
based on indicators for investment/funding (input), struc-
tured 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 (1);

— 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
the
A particularly important and pressing need is
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 infor-
mation 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.

The President

of the European Economic and Social Committee

Anne-Marie SIGMUND

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

Mr Jahier