Opinion of the European Committee of the Regions — Integration, cooperation and performance of health systems
Date: 2017-03-22
Institutions: Commission for Natural Resources, European Committee of the Regions
Subjects: chronic illness, disease prevention, health care, health care system, health statistics, innovation, nursing staff, public health, quality of life, right to health








C_2017272EN.01001901.xml










17.8.2017   


EN


Official Journal of the European Union


C 272/19





Opinion of the European Committee of the Regions — Integration, cooperation and performance of health systems
(2017/C 272/05)












Rapporteur:


Birgitta Sacrédeus (SE/EPP), Member of Dalarna County Council









POLICY RECOMMENDATIONS

THE EUROPEAN COMMITTEE OF THE REGIONS (CoR)

Health in Europe









1.


observes that good health among the general population is important for prosperity and well-being in society. Good health is valuable in itself, while a healthy population contributes to economic development, and vice versa;












2.


notes that EU citizens are living longer, healthier lives than before. There are however significant health disparities in the EU, both between and within Member States. Life expectancy in the EU has increased over time, but there are still major variations between and within different countries, regions and municipalities. For example, there is a difference of nearly 9 years between the EU countries with the highest and lowest average life expectancies (83,3 and 74,5 years in 2014 (1)). The increase in average life expectancy is linked, amongst other things, to changes in lifestyle, better education and better access to good quality healthcare;












3.


observes that healthcare and social care represent a large and important sector of society that employs large numbers of people and helps to give many people better, healthier and longer lives. However, the EU’s 28 Member States have a variety of different health systems, and access to resources varies between them;












4.


notes that health and health promotion play an important role in the UN’s global sustainable development goals for 2030, adopted in 2015. Most of the 17 goals have a clear health dimension, but one of them (goal 3) seeks specifically to ensure healthy lives and promote well-being for all at all ages. Likewise, health promotion is seen as the cornerstone for achieving the sustainable development goals. This goal is also in line with the objectives of the Health 2020 cross-sector health policy framework adopted by the WHO European Region in 2012;





EU competences in the field of health









5.


observes that the goal for the EU’s work in the health sphere is according to Article 168 of the Treaty on the Functioning of the EU to improve public health, prevent disease and eliminate health risks. This is achieved for example via the EU health programme, the structural and investment funds and the research and innovation framework programme and the protection of fundamental rights. Indeed, Article 35 of the EU Charter of Fundamental Rights stipulates that ‘everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities’;












6.


recalls that the EU has some legislative powers in fields that impact public health or relate for example to cross-border healthcare, and also makes recommendations in areas in which its competence is limited. In the context of the European Semester, the European Commission issues country-specific recommendations which in some cases involve the health sector;












7.


stresses, however, that it is fundamentally for Member States themselves to decide how healthcare and social services should be organised, funded and designed. Many Member States have opted to give local and regional authorities primary responsibility for health, care and public health. Even in countries with national health systems, responsibility for social services and social care often lies at local level;





The State of Health in the EU









8.


welcomes the Commission’s The State of Health in the EU initiative of June 2016. Its aim is to bring together international expertise to improve country-specific and EU-wide knowledge on health and to support Member States in their decision-making (2);












9.


notes that in November 2016 the OECD and Commission published the Health at a Glance: Europe 2016 report. In addition to statistics showing significant differences in health, health determinants, health spending, access to care and its effectiveness and quality, the report contains analysis of the impact of ill health on the labour market and the need to improve primary care systems;












10.


highlights how important it is for the Commission to involve regional and local authorities in its ongoing work and gather their opinions on the future development of health systems, not least because best practice can often be found at local or regional level;





Several major challenges









11.


notes that the health systems of the EU are facing several major challenges — some of which are more pronounced in some Member States than others:






a.


inequalities in health and access to healthcare — differences which often have socio-economic and geographical causes;










b.


a new disease profile in which chronic diseases represent a very large proportion of healthcare costs. According to the WHO, 86 % of deaths in the European Region are caused by the five most common types of chronic non-communicable disease (diabetes, cardiovascular disease, cancer, chronic respiratory disease, mental illness) which are often the result of an unhealthy lifestyle — smoking, excessive alcohol consumption, poor eating habits and a lack of physical activity. These factors are also behind the growing problem of overweight and obesity, especially amongst children and young people;










c.


an ageing population, with many older people suffering from one or more chronic diseases (multimorbidity);










d.


communicable diseases and ongoing fears of global pandemics. Our increasingly globalised world means there is a higher risk that various types of health threat may spread;










e.


a significant number of patients are harmed as a consequence of inadequate patient safety, including through healthcare-associated infections;










f.


antibiotic resistance is a growing public health issue — one which causes increased morbidity and mortality, but also entails significant healthcare costs;










g.


a lack of health and care workers — in many parts of Europe there are problems training/recruiting/retaining sufficient numbers of qualified staff;










h.


increased public expectations and requirements in terms of patient-centred care;










i.


pressure on health systems to reduce costs and become more cost effective, since health spending is high and is expected to rise;










j.


new welfare technology can contribute to improving the health of many people — innovations reduce the cost of certain health problems, but these increased possibilities for treating certain illnesses and conditions can also lead to increased costs;










k.


an increase in migration, especially of in many cases traumatised refugees, which requires an increase in the availability of appropriate psychiatric, psychotherapeutic and psychosomatic treatments, amongst other things;










l.


changes to our environment and climate that have a negative impact on our health and well-being;










m.


mental and physical ill-health as a result of the demands of professional life and a poor work-life balance.









Measures to respond to these challenges









12.


considers that in order to achieve health equality it is essential that everyone has access to healthcare. Adequate and sustainable funding of care is of vital importance in guaranteeing good coverage, access and quality. Informal payments and other forms of corruption within healthcare must be combated, since they harm the accessibility and efficiency of care;












13.


observes that chronic diseases dominate the burden of disease and generate the majority of costs for healthcare and other welfare systems. In order to remain sustainable over the long term, healthcare systems therefore need to be adapted to be better able to deal with chronic disease, and any unsustainable spiralling of costs must be prevented. Many chronic diseases can be prevented through lifestyle changes, and with the right approach the deterioration typical of these conditions can be held in check;












14.


wishes to draw particular attention to mental health problems. Mental health must be given the same priority as physical health. Mental illness is often best treated with outpatient care. Good mental health is generally based on good relationships with family, friends and others, a good home and work environment and a sense of belonging and purpose in life;












15.


considers that greater emphasis should be placed on preventive action and health promotion, and that care should become more knowledge and evidence based. Cooperation between healthcare and social care needs to be improved, especially to improve the lives of elderly people and those with disabilities. Health and social care service integration with a focus on individual assessment and continuity of care is proving beneficial in this regard. Since habits are formed at an early age, family life and school have an important role to play in prevention;












16.


shares the view expressed in Health at a Glance: Europe 2016 that EU Member States need to strengthen their primary care systems to meet the needs of ageing populations, create better chains of care and reduce the unnecessary use of hospital care. Investment should be made in primary care, outpatient care and home care, and highly specialised hospital treatment should be centralised in order to ensure quality. To relieve the pressure on hospitals, primary care must be available even outside normal working hours. A multidisciplinary approach must be developed urgently. Primary care staff should be specialists in preventive action and health promotion, and in caring for those with chronic diseases;












17.


notes that social care systems vary greatly between Member States. There are major differences in the extent to which public funding is provided and social care is offered in ordinary or special accommodation. In order to achieve health equality, it is essential that everyone has access to high-quality social care if they need it. It is important that informal carers are given support. Voluntary organisations can play an important supporting role;












18.


calls on the national authorities to pay attention to the important role of local and regional authorities in the transition away from hospital-centred to community care, providing an opportunity to develop creative, preventative activities, early intervention services and long term care options rather than focusing on reactive care;












19.


shares the view expressed in Health at a Glance: Europe 2016 that greater efforts are needed to prevent chronic diseases among the working-age population. Chronic diseases lead to lower employment, lower productivity, earlier retirement, lower income and premature death. A physically and psychologically healthy work environment is crucial in managing occupational diseases and injuries and reducing sick leave and health-related unemployment. Greater synergy is therefore needed between health and labour market policies, and the social partners need to be involved in the process. It is important to view health-related initiatives as investments rather than costs;












20.


stresses that efforts must be made to enable people with disabilities to work in a way which suits their own personal attributes. Effective rehabilitation plays an important role in enabling sick and injured people to make a swift return to work;












21.


considers that greater emphasis should be placed on issues relating to patient empowerment and person-centred care (3). Patients today are generally better informed and many people would like to choose their healthcare providers and request information about accessibility and quality. Health systems should therefore support people looking after their own health — by living healthily, making informed choices regarding treatment and healthcare providers, practising self-care and avoiding medical complications;












22.


also points out that it is crucial for jointly funded care to be provided in accordance with needs, and not on the basis of individual patients’ own requests, which would risk leading to overuse of care and treatment;












23.


considers that there should also be a greater focus on quality of care and clinical results. The collection of big data, transparency and open comparisons based on common indicators can be used to stimulate improvements and map the effects of health investments;












24.


finds that, in order to guarantee access to well-trained healthcare and social care professionals, planning and coordination between health sectors are needed, as well as an education system offering good opportunities to develop skills. There are currently shortages in several occupational groups, uneven geographic distribution and imbalances between different occupations. One of the issues is the need to train more primary care doctors (4) and the need to retain skills. In order to recruit and retain staff, employers should offer a good work environment and good conditions. To improve their operations, employers should develop multi-professional teams and use task shifting in order to strengthen the roles of nurses and other occupational groups. The Committee of the Regions hopes that the Commission’s efforts to establish a European Solidarity Corps can help get more young people interested in working in the health sector;












25.


welcomes developments in medical technology and the production of new medicines. Research and innovation are key to the evolution of healthcare. Use of assistive devices and development of new technology can also allow those receiving care to become more independent;












26.


considers that the most important tool for making healthcare more effective is new digital technology, which offers new opportunities for prevention, detection, diagnosis, treatment, provision of information and communication. Innovation is moving quickly in this field. Although there are often justified reasons to consider data protection and privacy, the healthcare sector has nevertheless been all too slow in taking advantage of the latest advances in information technology. Data protection law must be drafted such that it does not hinder effective health care, monitoring and research, while at the same time respecting people’s privacy;












27.


believes that digitalisation also means that the approach to and organisation of care will undergo profound change. The power relationship between different groups of staff will be affected, as will the balance of power between patients and staff. eHealth and mHealth systems can give people more influence over — and opportunities to take greater responsibility for — their own health and care. Greater recourse to self-care will enable patients to cut back on the number of visits to healthcare providers, often increasing patient satisfaction whilst also reducing costs for the health authorities. Greater digitalisation can also help to improve services in peripheral and sparsely populated areas;












28.


points out that new medicinal products play a major role in the development of healthcare. New and improved diagnostic methods make it possible to use personalised treatments and medicines with fewer adverse effects and better clinical results. In order to make healthcare more cost-effective, it is however important to address high pharmaceutical prices and over-prescribing of medicinal products. The Committee of the Regions therefore supports the initiatives taken for voluntary cooperation between Member States on procurement, pricing and access to medicines;












29.


encourages more efforts to capture possible economic and qualitative advantages of cooperating in the field of cost-intensive and/or highly specialised medical equipment;












30.


considers that the determined efforts being made in many quarters to improve patient safety must continue. Action must also be taken to address antibiotic resistance, for example by limiting the use of antibiotics, developing new antibiotics and taking a holistic approach covering both animal and human health, as well as specific measures aimed at fighting healthcare-associated infections. To maintain effective protection against infection it is essential to ensure that everyone living in Europe has equivalent, optimal protection against vaccine-preventable diseases;












31.


believes it is important that healthcare and social services in Member States are mindful of the vulnerability of many newly arrived migrants and take steps to provide for their care needs, for example support for mental health issues;












32.


stresses that local and regional authorities play a decisive role in protection from environmental risk factors and related health promotion. Local authorities often have primary responsibility for environmental protection, air quality, refuse collection, town planning, public transport, water and sanitation, green spaces for recreation, food safety and so on. Healthcare and social care can also contribute, for example by using safe, environmentally friendly products, ensuring efficient waste management and reducing energy and water consumption;





EU level responses









33.


welcomes European cooperation on healthcare in the context of the Member States’ right to decide for themselves how healthcare should be designed, organised and funded. The challenges may be the same, but the solutions often vary. The EU should support the Member States and their local and regional authorities in their efforts to improve public health and develop healthcare. The EU must act in accordance with the subsidiarity principle and respect the diversity of Member States’ health systems;












34.


finds that, at the same time, it is in the EU’s interest to improve health and reduce health disparities, as this is a necessary condition for reducing economic and social disparities in Europe. The EU needs to be more consistent in applying the principle of ‘health in all policies’;












35.


highlights the need to continue EU cohesion policy funding after 2020 in areas such as healthcare infrastructure, e-health, and health promotion programmes in order to foster regional development and to reduce social and economic disparities. The effectiveness of projects financed with EU funds should be examined from the perspective of public health and economic development of regions concerned (5);












36.


considers that cross-border cooperation can help to develop European health systems. It is appropriate for the EU to have some legislative powers in areas pertaining to cross-border health threats and healthcare, but in other respects the EU’s action should focus mainly on supporting the Member States’ actions and promoting quality development. The EU can achieve this for example by making recommendations, initiating and funding development projects, fostering cooperation in border regions, promoting exchange of knowledge and experience, sharing success stories and best practice, taking an even more active role in the work on open comparisons, and assessing the effectiveness of health systems, including in cooperation with the WHO and OECD. As part of these activities, it is important to highlight the effects of various healthcare services on individual patients and public health;












37.


in this context, proposes that the European Commission establish an Erasmus like programme for healthcare professionals;












38.


regards the priority areas chosen by the Expert Group on Health Systems Performance Assessment (HSPA) (integrated care; access to health care and equity; primary care; health outcomes/effectiveness; chronic diseases and quality of care) as equally valid for subnational level and expresses its readiness to collaborate with the group in view of bringing local and regional expertise to the fore;












39.


in that context, requests an observer seat within the Expert Group on HSPA, established in September 2014 by the Commission and the Member States, upon the invitation from the Council;












40.


believes that the EU should notably support efforts to prevent chronic diseases, support innovation in and use of the latest information and communication technology, foster enhanced European cooperation on the assessment of medical techniques and continue to engage in the global effort to tackle antibiotic resistance. The Committee of the Regions therefore welcomes, for example, the new antibiotic resistance action plan which the Commission intends to publish in 2017;












41.


in that context, reminds the Member States of their commitment to have in place before mid-2017 national action plans against antimicrobial resistance ‘based on the One Health approach and in line with the objectives of the WHO Global Action Plan’ and calls on the health ministries to involve local and regional authorities in the development and implementation of these plans;












42.


observes that, through judgments of the EU Court of Justice and the 2011 Patient Mobility Directive, EU citizens have been given greater opportunities to seek care in another Member State. This is advantageous, for instance for patients who have a rare diagnosis or need specialist treatment which is not available in their home country. The Committee of the Regions therefore welcomes the Commission’s work on introducing European reference networks (ERNs) for care providers and centres of expertise in the Member States in the aim of supporting highly specialised medical care.












43.


calls on the EU, in its work on the State of Health in the EU, to showcase good examples of effective, high-quality healthcare, identify forms of health service organisation that make a particular contribution to effective, high-quality healthcare, and demonstrate how high-quality healthcare can reduce the need for social services. In this context, the Committee of the Regions would underline the importance of identifying local and regional organisational models that have proved to work effectively.





Brussels, 22 March 2017.


The President of the European Committee of the Regions

Markku MARKKULA




(1)  Health at a Glance: Europe 2016.

(2)  This 2-year initiative will be undertaken in cooperation with the OECD, the European Observatory on Health Systems and Policies and the Member States, and comprises four elements:






—


publication of the Health at a Glance: Europe 2016 report (November 2016);










—


country-specific ‘health profiles’ highlighting the particular characteristics and challenges of each Member State (November 2017);










—


analysis building on the two previous elements, providing a succinct overview and linking the results to the broader EU agenda, with an emphasis on cross-cutting policy implications and opportunities to learn from each other (November 2017);










—


opportunity for voluntary exchanges of best practice, which the Member States can request in order to discuss specific aspects of the situation in their own countries (from November 2017).





(3)  An approach in which the patient and their family members take an active role and participate in planning and implementing care, and the patient is seen as more than just their condition.

(4)  Health at a Glance: Europe 2016.

(5)  CDR 260/2010.