eurohealth, vol 13 no 4 - world health organization · choice and competition † migration of...

EurohealthVolume 13 Number 4, 2007RESEARCH • DEBATE • POLICY • NEWS

Restructuring municipal health services in Finland • Kaiser Permanente revisited – what can Europe learn? Choice and competition • Migration of Polish doctors in the EU • Assessing the performance of health services

Health care needs of UK pensioners in Spain

Genomics as a priority for publichealth

Pay-for-Performancein the US: what lessons for Europe?

Meeting the health careneeds of tourists

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Published by LSE Health and the European Observatoryon Health Systems and Policies, with the financial supportof Merck & Co and the European Observatory on HealthSystems and Policies.

Eurohealth is a quarterly publication that provides a forumfor researchers, experts and policymakers to express theirviews on health policy issues and so contribute to a constructive debate on health policy in Europe.

The views expressed in Eurohealth are those of the authorsalone and not necessarily those of LSE Health, Merck & Coor the European Observatory on Health Systems and Policies.

The European Observatory on Health Systems and Policiesis a partnership between the World Health OrganizationRegional Office for Europe, the Governments of Belgium,Finland, Greece, Norway, Slovenia, Spain and Sweden, theVeneto Region of Italy, the European Investment Bank, theOpen Society Institute, the World Bank, the London Schoolof Economics and Political Science, and the London Schoolof Hygiene & Tropical Medicine.

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Health on the move

At this time of year many of us start planning oursummer holidays. But it was not that long ago that thenotion of a foreign holiday was a luxury reserved onlyfor the very rich. Only in the post war period did theconcept of the low cost package holiday become a reality for many Europeans. Change continues apace.In addition to the annual holiday, we now have thephenomenon of multiple short-breaks planned andarranged independently. Health care systems are notimmune from these evolving patterns of tourism andtravel. In this issue of Eurohealth Simona Bellomettiand Luigi Bertinato provide an overview of measuresused in the Veneto region of Italy to cope with masstourism.

Another consequence of the greater exposure of Europeans to international travel, coupled with an increase in disposable income, has been the upturn inthe number of individuals choosing to spend their retirement outside of their home countries. Again, thisphenomenon can have impacts on both health and social care systems, but as Helena Legido-Quigley andDaniel La Parra illustrate, many UK migrants to Spaindo not avail of local health care services and insteadrely on private services because of language and cultural difficulties.

This experience is by no means unique. The lack oflocal social support networks can make older migrantsvery vulnerable after the onset of debilitating conditions. To adapt, local health care systems requirebetter information on their EU migrant populations;many still do not register with local health care services. Outreach services to make ex-patriots awareof their rights and responsibilities may well be merited.

Elsewhere in this issue, Walter Ricciardi and StefaniaBoccia look at the implications of rapid advances ingenetic technologies for public health, while a new occasional series of articles looking at what may begleaned from experience in the United States kicks offwith reflections on Kaiser Permanente and the use ofperformance related payment mechanisms.

David McDaid EditorPhilipa Mladovsky Deputy Editor

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Contents EurohealthVolume 13 Number 4

Simona Bellometti is a medical consultant in thearea of thermal medicine and spa therapy,Padova, Italy.

Luigi Bertinato is Director, International Healthand Social Affairs Office, Department of Healthand Social Services of the Veneto Region, Italy.

Stefania Boccia is Head of the Genetic Epidemiology Unit, Department of Public Health,Catholic University of the Sacred Heart, Rome.

Zachary Cooper is reading for a PhD at theDepartment of Social Policy and LSE Health,London School of Economics and PoliticalScience.

Anne Frølich is Clinical Associate Professor at theDepartment of Health Services Research, Instituteof Public Health, University of Copenhagen,Denmark.

Marin Gemmill is Research Officer, LSE Health,London School of Economics and PoliticalScience.

Walter Holland is Emeritus Professor of PublicHealth, LSE Health, London School of Economicsand Political Science.

Daniel La Parra is Senior Lecturer in Sociology,University of Alicante, Spain.

Julian Le Grand is Richard Titmus Professor ofSocial Policy, Department of Social Policy andLSE Health, London School of Economics andPolitical Science.

Helena Legido-Quigley is Research Fellow,London School of Hygiene and Tropical Medicine,UK.

Joanna Lesniowska recently completed a PhD atthe Institute of Foreign Trade Policy and EuropeanStudies, Warsaw School of Economics, Poland.

Walter Ricciardi is Director, Department of PublicHealth, Catholic University of the Sacred Heart,Rome.

Michaela L Schiøtz is a PhD Fellow at theDepartment of Health Services Research, Instituteof Public Health, University of Copenhagen,Denmark.

Martin Strandberg-Larsen is a PhD Fellow at theDepartment of Health Services Research, Instituteof Public Health, University of Copenhagen,Denmark.

Lauri Vuorenkoski is Senior Researcher, NationalResearch and Development Centre for Welfareand Health (STAKES), Helsinki, Finland.

Public Health Perspectives1 Tackling assessment of the performance of health services

Walter Holland

4 Assessment of genomics as a priority for public health Walter Ricciardi and Stefania Boccia

European Snapshots7 Migration patterns of Polish doctors within the EU

Joanna Lesniowska

8 Restructuring municipalities and municipal health services inFinlandLauri Vuorenkoski

Health Policy Developments11 Health care services for tourists in the Veneto Region

Simona Bellometti and Luigi Bertinato

14 The health care needs of UK pensioners living in Spain: an agenda for researchHelena Legido-Quigley and Daniel La Parra

18 Choice, competition and the political leftZachary Cooper and Julian Le Grand

Perspectives from the US21 Pay-for-Performance in the US: what lessons for Europe?

Marin Gemmill

24 Kaiser Permanente revisited – can European health caresystems learn? Martin Strandberg-Larsen, Michaela L Schiøtz, Anne Frølich

Evidence-informed Decision Making 27 “Mythbusters” The risks of immunising children often

outweigh the benefits

29 “Bandolier” Mobile phones and cancer

Monitor

30 Publications

31 Web Watch

32 News from around Europe

Life was simpler in the past. Doctors werejudged by their manners and bedsidebehaviour, their willingness to dispensemedicines, sign an off-work note and helpin certifying that their patients neededbetter housing. Hospitals were judged bytheir cleanliness, their willingness to treat,the ability to provide employment, and thecomfort of the chairs in the outpatientdepartment.

Before 1948 and the introduction of theNHS, about half the UK hospitals weresupported by charity, the rest were either‘Poor Law’ or Local Authority MunicipalHospitals with a very small number ofprivate institutions. Doctors were paid bythe patient, the National Insurance Fund,or a sick fund associated with work. Manyof the services they provided were given asan act of charity. This environment meantthat most health (medical) services wereconsidered as charitable and most patientswere grateful for what they received.

Hospitals and doctors were judged by“word of mouth” or reputation. The mostsuccessful practitioners were those with a“smooth line” and good communicationskills – some surgeons were shunned asbeing “killers”, but no one really ques-tioned the treatment they received.Florence Nightingale was considered a

revolutionary in reporting the deplorableconditions in Army hospitals in theCrimean War in the 19th Century, and shewas one of the first to advocate the need tomeasure the performance of health servicesand their employees. However, realconcern about health service performanceonly surfaced in the UK with the intro-duction of the NHS in 1948.

The founders of the NHS believed that itsintroduction would lead to less demand,following an initial surge due to an accu-mulation of untreated illness. But initialassumptions about future demand weregrossly incorrect. Although it was recog-nised that the demand for and costs of carewere rising, the open-ended system offunding and allocating resources meantthat the problem was not confronted.Doctors were only concerned withproviding what they considered was thebest treatment for individual patients,secure in the belief that with advances inmedical knowledge and methods oftreatment things could only get better. Thepublic assumed that their needs would bemet – and the necessary resources found.In the early years of the NHS patientscontinued to be deferential and grateful forany treatment they received. As a result ofthe Second World War they acceptedrationing and were willing to accept longwaiting times before receiving treatment.

These conditions could not last. With thestate responsible for funding all healthservices from tax revenues it became

obvious that some measures would need tobe introduced to control expenditure. Thepressures on health services wereincreasing because of the ageing of thepopulation and the increasing availabilityof effective remedies. In addition, theinequalities in the provision of services indifferent geographic areas becamenoticeable. Between 1938 and 1966 no newhospital was built (except the HarvardHospital on Salisbury Plain, built by theUS Army to accommodate its personnelduring the war.) With the renewal ofhospital building it was rapidly noticeablethat most, if not all, new building was inthe southern half of England. As healthresources were distributed on a historicalbasis, and before the introduction of theNHS health services were more prolific inthe south than north, it was not surprisingthat this difference existed and had becomeworse.

These were the main reasons why in 1974,with the reorganisation of the NHS,Health Authorities were enjoined todevelop methods of monitoring andassessment of the activities of the NHS. Inrecent years, with the growth of a‘consumer society’, and the perception thatmany of the component parts of the NHSwere not performing adequately, if notpoorly, indexes of performance began tobe developed. Furthermore with a greateremphasis on ‘business practice’ it wasconsidered that incentives to ‘performbetter’ both by individuals and institutionsshould be introduced.

Eurohealth Vol 13 No 41

PUBLIC HEALTH PERSPECTIVES

Tackling assessment of theperformance of health services

Walter Holland

Summary: The development of health care services in the UK in the past150 years is described with reference to assessment of the service. Possiblemeasures of performance such as acceptability, process and outcome arediscussed with their advantages and disadvantages. Greater clarity in thedevelopment of objectives for services are advocated.

Key words: Performance measures, Acceptability, Process, Outcome,Avoidable mortality.

Walter Holland is Emeritus Professor ofPublic Health, LSE Health, LondonSchool of Economics and Political Science.Email: [email protected]


Monitoring and assessment frameworksDonabedian,1–3 from Ann Arbor, Michi-gan, is undoubtedly the progenitor of aframework by which the delivery of healthservices can be assessed and monitored. Heidentified three components – structure (ororganisation), process and outcome. Doll4

recognised three major components forany evaluation – economic efficiency,social acceptability and medical efficacy.Each of these components, on their own,only give a partial view of how successfula service is in providing for the needs of thepopulation it is supposed to serve.

Using Donabedian’s classification is noteasy. The structure of health services in theUK has one universal characteristic, indi-viduals, except in emergencies, access thehealth service via a primary care providerwho may, or may not, facilitate referral tosecondary care (hospital) or secondary(specialist) diagnosis. Entry to the tertiaryor rehabilitative services may be eitherfrom primary care or secondary care, i.e.there is a hierarchy of provision. This formof organisation is partly determined byhistorical reasons. In the 19th centurysecondary (hospital) care was largelyprovided by charitable institutions. Whenthe latter started out-patient departmentsthey were clearly in direct competitionwith general practitioners who dependedon fees from patients. To avoid this conflictbetween medical practitioners a concordatwas agreed that care/diagnosis in asecondary institution could only beprovided after referral from primary care.

This hierarchical pattern is not oftenpresent in other countries, for example, theUSA or Germany, where individuals mayapproach a specialist direct, depending onwhether they consider they need imme-diate specialist help or feel that they have‘local’ symptoms, for example, cardiac, andtherefore immediately wish for the help ofa cardiologist. There are no good studiesto determine whether the first or seconddelivers a better form of care. Mostobservers consider that the hierarchical,general practitioner (GP) type of care isbetter. The GP, as gatekeeper, may be botha better judge of medical needs and mayprevent the overuse of expensive diag-nostic or treatment services, which inthemselves, may be dangerous.5

The actual configuration of health services,whether hospital or general practice, arelargely determined by political views, andrarely, if ever, evaluated. Thus the ethos ofcontinuity of care by a general practitionerfor a defined population group in the UK

is now being challenged with the devel-opment of ‘walk-in surgeries’ in super-markets or railway stations. There is, asyet, no evidence of the advantages of onestructure compared to another.

Formal methods of assessmentThe assessment of performance by processmeasures is amenable to more formalmethods of assessment:

Acceptability

Measurement of satisfaction with anyparticular service may be made by the useof questionnaires to assess satisfaction.Many examples of these, both short andlong, have been used in the UK and USAfor many years. It is important, if they areused in a hospital, to look at specific issues,for example, catering, cleanliness, attitudeand behaviour of staff.6 GPs are now alsobeing encouraged to measure satisfactionin their service provision. One measure ofsatisfaction, not often used routinely, is thecollection of data on complaints, boththose upheld as well as those rejected.Referral to an ombudsman (independentarbiter), legal procedures and convictionscan also be used to highlight problems.

The limitation of using all of these formsof assessment is that they are restrictedonly to service users, and will not capturethe views of the general population. Theseneed to be sought by use of populationquestionnaires, for example, the GeneralHousehold Survey.

Process

The commonest measure used to assessperformance is by evaluation of theprocesses used in care. Thus it isconsidered important that certain investi-gations are done when a patient consults –and the measure of performance is whetherthese have been carried out. For example, itis considered that blood pressure ismeasured at regular intervals in adults by aGP in order to detect whether the level isnormal or high. Measures of clinicalactivity are measured and rewarded by the‘Quality and Outcomes Framework’which has been introduced for thepayment of general practitioners.

All the measures used are evidence-based.But it must be remembered that almost allinterventions cause some harm, “evenwhen effective treatments are applied to aseries of patients in clinical practice somewill be harmed (although more willbenefit).”7 The authors of the latter haverecently published a critical article which

summarises the problems in using processmeasures to assess performance. Theirarticle emphasises that clinical care is not amechanical process but needs to be tailoredto individual patient needs, for example,age.

Thus, although measures of process areeasy to collect – and there is usuallyconsensus about what diagnostic ortreatment procedures should be used for agiven diagnosis, they may easily missimportant factors which influenceoutcome. Also, of course, use of processmeasurements may imply that as long asthe appropriate processes are used caremust be adequate – but this completelyneglects the appropriate requirements ofaction to react to the findings. Mostmeasures of quality of care are, in practice,based on process measures – these are easyto measure. But it is increasingly becomingrecognised that these process measures arenot adequate for the assessment ofperformance.

Outcome

To monitor the effectiveness of a service, itmust have a defined objective againstwhich to measure the outcome of care. Ofcourse, health services are meant toimprove the current and future health ofthe population. But, the difficulty is thathealth services are complex and manyenvironmental, social and other factorsinfluence the outcome of all health careinterventions.

The easiest, and routinely available,measure is mortality, before and after, orover time. But overall mortality is not veryinformative. However, mortality ratesfrom specific conditions by age and/or sexhave been, and are, used as indicators ofparticular services.

Rates for maternal, perinatal and neonatalmortality are accepted as indicators of theoutcome of maternal services and havebeen used for many years. Confidentialenquiries of the care and processes used incases of maternal death have been used inthe UK, under the auspices of the RoyalCollege of Obstetricians, since the 1930s.They have had a major impact onmaternity care, whereas at the start therewere several thousand deaths there arenow less than one hundred in any one year.The success has largely been due to theinvestigation of each death by a respectedobstetrician with sympathetic, carefulfeedback to the clinicians responsible forthe care of the mother who had died.

Eurohealth Vol 13 No 4 2


This method can also be applied to othercauses of death. Rutstein et al,8,9 Charltonet al,10 Holland and Breeze,6 Holland etal,11 and Nolte and McKee12 have drawnup sets of conditions where mortality isavoidable. These conditions may illu-minate certain curative services andidentify defects. The method may also beused to assess the performance of surgicalservices: in the UK there are routineanalyses, under the auspices of the RoyalCollege of Surgeons, of operative deaths.

Holland et al11 Nolte and McKee12 andJozan et al,13 have used the measure of‘avoidable deaths’ to monitor the qualityof services based on routinely collectedstatistics in a variety of European coun-tries, both at one point and over a periodof time. Age standardised mortality ratios(SMR) were calculated for age ranges inwhich medical care was most likely to beeffective. A high SMR for any of theseindicators is intended to serve as a warningfor potential shortcomings in the healthcare services and a starting point for initi-ating detailed enquiry at a local level todetermine the reason behind the apparentexcess mortality. For example, hyper-tension death rates in those aged 5-64 areaffected by primary care and hospitalservices; case detection and anti-hyper-tensive medication affect mortality. Deathsfrom abdominal hernia and appendicitisare affected by both primary care and

hospital services; again case-detection andsurgery prior to complication influencemortality.

While careful examination of mortalityfrom specific causes can provide infor-mation on the outcome and effectivenessof health services, mortality is not alwaysan appropriate indicator. Deaths from‘avoidable causes’ are rare, so deficienciesin services can often not be identified.Moreover mortality may not be anadequate indicator for the performance ofa health care service, for example, for theelderly, where most of the focus is not onpreventing death but on relieving pain andimproving the quality of life.

The real difficulty in identifying outcomeindicators is the lack of clarity as to theobjectives of a particular service. Theobjective for maternity care is easy: toprevent maternal death and ensure thebirth of a healthy baby, and can bemeasured easily. The objective of someacute services, for example, surgicalservices for acute appendicitis and forhernias are similarly easy to define andmeasure, but for many others services,forexample, psychiatric or for the elderly, theobjectives are much harder to define –particularly in such a way that routine datacollection for assessment of performancecan be done.

Thus the challenge for those responsible

for health care delivery is to define precise,measurable objectives and to developmethods of data collection to assessperformance. Some illustrative examples ofpossible outcome indicators for someservices are outlined in the Table.

It must be emphasised that these are onlypossible illustrative examples butnonetheless they demonstrate the need forthe development of imaginative thinking.

ConclusionIt should be evident from this discussionthat there is no easy method to measurehealth service performance. The majorobstacles are the availability and accuracyof information, the lack of clear definitionof objectives for many of the complexservices that need to be provided and, ofcourse, the willingness of those deliveringthe services to be subject to scrutiny. Withthe increasing availability of computerisedrecords at least the availability of data hasbeen tackled. But the problems of accuracyand identification of objectives are stillpresent.

REFERENCES

1. Donabedian A. Explorations in QualityAssessment and Monitoring Volume 1: TheDefinition of Quality and Approaches to itsAssessment. Ann Arbor: Health Adminis-tration Press, 1980.

2.Donabedian A. Explorations in QualityAssessment and Monitoring Volume 2: TheCriteria and Standards of Quality. AnnArbor: Health Administration Press, 1982.

3. Donabedian A. Explorations in QualityAssessment and Monitoring Volume 3: TheMethods and Findings of QualityAssessment and Monitoring – An Illus-trated Analysis. Ann Arbor: HealthAdministration Press, 1985.

4. Doll R. Surveillance and monitoring.International Journal of Epidemiology1974:3:305–14.

5. Starfield B. Balancing Health Needs,Services and Technology. Oxford: OxfordUniversity Press, 1998.

6. Holland WW, Breeze E. Theperformance of health services. In: KeynesM, Coleman DA, Dimsdale NH (eds). ThePolitical Economy of Health and Welfare.Proceedings of the 22nd AnnualSymposium of the Eugenics Society.London: Macmillan Press, 1985.

7. Heath I, Hippisley-Cox J, Smeeth L.Measuring performance and missing thepoint? British Medical Journal2007;335:1075–76.



Table: Illustrative examples of potential outcome indicators for selected services

Service focus Objectives Indicator

Learning difficulties

Prevention: to prevent cases of Down’s syndrome babies in mothersaged 38 or more years by referral to a specialist centre

Number and proportion of referrals and terminations carried out followingamniocentesis in women over 38 years

Good Practice: to encourage those with learning difficulties to resideoutside of large institutions and liveindependently

Number of children by medical diagnosis/disability who live at home, in foster homes, hostels etc. Number ofadults who are employed

Young people with disabilities

Prevention: to reduce the number of head injuries

Number and rate of deaths anddischarges of head injuries for those aged 15–16, by sex

Prevention: to reduce cases of paraplegia

Number and rates of death anddischarges for cases of paraplegia inthose aged 15–34, by sex

Older people Prevention: to reduce loss of function Number and rates for total hipreplacement

Number and rates of cataract removed

The past decade has been an importanttime for human genetics, and many haveasserted that the wealth of knowledgeoffered by the human genome portends atime of rapid change in medicine.Genome-based medicine includes amongstits scope the use of genetic tests todiagnose, predict and determine suscepti-bility to a disease, as well as the evaluationof drug response through genetic tests(pharmacogenomics). More than fouryears after the completion of the HumanGenome Project however, researcherscontinue to express both excitement andscepticism concerning the opportunitiesfor a near-term derived application ineither preventive or curative fields.

One of the most significant promises isthat the unravelling of the genetic originsof common diseases will lead to individu-alised medicine, in which prevention andtreatment strategies are personalised on thebasis of the results of predictive genetictests. According to some enthusiasticclaims, the integration of genome-basedknowledge into health care has thepotential to change primary, secondary andtertiary prevention.1 The possibility toprovide early detection for those indi-viduals more susceptible to complexdiseases because of their genetic make-up,might in fact, theoretically result in indi-vidualised primary (for example, chemo-prevention or prophylactic surgeryinterventions) and secondary prevention(for example, assiduous monitoring)programmes. Actually some emergingtests support this promise: mutations inBRCA1 and BRCA2 genes can be used toidentify women with a higher lifetime riskof breast and ovarian cancer, thus eligible

to prophylactic surgery or assiduousbreast magnetic resonance imagingscreening; similarly, genotyping of HER-2 expressions identifies women withmetastatic breast cancer eligible fortrastuzumab drug treatment.

Nonetheless, due to the progressive releaseof results from large population-basedstudies and meta-analyses in geneticepidemiology, this great optimism has beencounterbalanced by the realisation thatmost gene variants associated withcommon complex diseases have onlymodest effects (relative risk of 1.5) thatincrease only in the presence of wellknown environmental risk factors. Theexample of BRCA genes, in fact, representsa rare mutation accounting only for a smallminority of breast cancer cases, while mostgenetic contributors to breast cancer riskhave only a small effect. With many geneseach contributing a small effect to diseaseaetiology, the question of their clinical

Assessment of genomics as apriority for public health

Walter Ricciardi and Stefania Boccia

Summary: Advances in genetic technology are increasing the availability of genetictests for common complex diseases and the evaluation of drug responses. Ensuring theappropriate use of these tests is an important challenge for health policy makers at thistime. This requires that systematic, evidence-based technology assessments andeconomic evaluations are used to guide their incorporation into clinical practice andprevention. The next decade will provide the opportunity to establish infrastructuresand educate health providers to enable genome-based technologies to be translatedinto evidence-based guidelines and policies.

Keywords: Genomics, Public health, Health technology assessment

Walter Ricciardi is Director, Departmentof Public Health, and Stefania BocciaHead of the Genetic Epidemiology Unit,Department of Public Health, CatholicUniversity of the Sacred Heart, Rome.Email: [email protected]

8. Rutstein DD, Berenberg W, ChalmersTC, Child CG, Fishman AP, Perrin EB.Measuring the quality of medical care: aclinical method. New England Journal ofMedicine 1976;294:582–88.

9. Rutstein DD, Berenberg W, ChalmersTC, Fishman AP, Perrin EB, Zuidema GD.Measuring the quality of medical care:second revision of indexes. New England

Journal of Medicine 1980;302:1146.

10. Charlton JRH, Hartley R, Silver R,Holland WW. Geographical variations inmortality from conditions amenable tomedical intervention in England and Wales.Lancet 1983;1:691–96.

11. Holland WW (Project Director).European Community Atlas of ‘AvoidableDeaths’ 1985–89. Oxford: Oxford

University Press, 1997.

12. Nolte E, McKee M. Does HealthcareSave Lives? Avoidable Mortality Revisited.London: Nuffield Trust, 2004.

13. Jozan PE, Prokhorskas R. (eds) Atlas ofLeading and ‘Avoidable Causes of Deathin countries of Central and Eastern Europe.Budapest: Hungarian CSO PublishingHouse, 1997.




utility in disease prevention managementis no doubt pertinent, and an emphasis ongenetic contributors to disease might alsoresult in the neglect of environmental riskfactors.

Additionally, among the sceptics concernhas been raised over the ethical, legal andsocial implications of genomic medicine,such as the protection of privacy andautonomy, stigmatisation, discriminationand the psychological burden of genetictesting.2 As the possibilities for investi-gating many gene variants (genomeprofiling) in the same individual become areality, these concerns will probablyrequires a different approach from thatapplied to predictive genetic testing formonogenic diseases due to the lowpredictive value of multiple genetic testing.

From this premise, it is evident that theextent of the contribution of genomics topopulation health over the next fifty yearsremains uncertain. Undoubtedly, increasedunderstanding will lead to measurableimprovements in human health, but thetime scale and extent of final impact remainunknown. At least in the preventive field,according to a more realistic forecast,genomics will help facilitate the integrationof traditional community-based activitieswith individually targeted preventivestrategies.3 So, the pressing challenge ofgenome-related technologies at themoment is to devise an efficient strategy todistinguish between innovative and clini-cally useful advances and false leads. Lastbut not least, the pace of this transfor-mation will be limited not only by the paceof discovery and the proofs of effec-tiveness, but also by the need to educatepracticing physicians and health-careprofessionals more generally in order toensure the appropriate use of genome-based knowledge.

Public health genomicsThe integration of genomics into publichealth research, practice and policy will beone of the most important challenges forhealth care systems in the future. Thus farhealth care systems and industries are notprepared for this conceptual change and allstakeholders are struggling to transferemerging knowledge into clinical and tech-nological applications. Public HealthGenomics (PHG) is an emerging multidis-ciplinary scientific approach which aims tointegrate genome-based knowledge in aresponsible and effective way into publichealth. According to the statement of anexpert group that discussed public health

genomics concepts in Bellagio, Italy, in2005, it can be defined as: ‘the responsibleand effective translation of genome-basedknowledge and technologies for thebenefit of population health’. The workinggroup in Bellagio soon after established aninternational forum to address publichealth genomics challenges, known as theGenome Based International Network(GRAPH Int). This includes participantsfrom the National Office of Public HealthGenomics in the US Centres for DiseaseControl (CDC), as well Europeanpartners.

In Europe, being aware of the futurepossible benefits of genomics for popu-lation health, in 2005 the EuropeanCommission made a call in the work plan2005 of the public health programme for anetworking exercise, aiming to identify‘public health issues linked to currentnational practices in applying genetictesting and on that basis contribute todeveloping best practice in applyinggenetic testing’. The Institute of PublicHealth North Rhine-Westaphalia (lögd) inBielefeld, Germany, as lead partner,together with the PHG Foundation inCambridge, UK, and the German Centrefor Public Health Genomics (DZPHG) atthe University of Applied Sciences inBielefeld, Germany, applied to develop a‘Public Health Genomics EuropeanNetwork’ (PHGEN) and subsequentlyreceived funding.4 PHGEN was officiallyestablished in February 2006 and involvesexperts as collaborating partners from thefields of public health and epidemiology,human genetics and molecular biology,social sciences, ethics, medicine,economics, political sciences and law. It isenvisaged that PHGEN, together with itsspin-offs, will serve the EuropeanCommission as an ‘early detection unit’ forhorizon scanning, fact finding, and moni-toring of the integration of genome-basedknowledge and technologies into publichealth.

The proper evaluation of genome technologies The development of efficient researchstrategies to investigate health outcomesassociated with genetic testing is a crucialfactor in ensuring appropriate test use.According to the ‘evidence-basedmedicine’ concept, every medical inter-vention should be recommended if: high-quality evidence shows that it results inimproving health outcomes; it delivers anet benefit; and is cost-effective. Subse-quently, evidence-based guidelines should

be developed for using genetic informationto profile disease risk or guide a pharma-cological treatment. At this point it is clearthat the proper evaluation of genome-based technologies within the HealthTechnology Assessment (HTA)framework is one of the most importantchallenges for health service researchersand health policy makers to consider atthis time.

Genetic tests for more than 1,300 diseasesand conditions are currently available inclinical practice, while many more arebeing developed in research settings.Moreover, a number of companies in theUS and UK offer genomic profilesconsisting of chips for the concurrentdetection of multiple gene variants asso-ciated with an increased risk to a particularcondition, such as the Oxidative StressProfile and Obesity Susceptibility Profile.The same can be said for pharmacoge-nomic tests, whose clinical implementationseems to be driven in some instances moreby intensive pharmaceutical companycampaigns rather than by evidence onclinical utility and cost-effectiveness.

Clearly, there is a strong need to distin-guish useful genetic tests from those thatare useless or even potentially dangerous.One approach is the ACCE frameworkdeveloped by Haddow and Palomaki in2004,5 and subsequently updated by thePHG Foundation and Eurogentest. Thatmodel takes its name from the fourcomponents of a genetic test evaluated:analytic validity (A), clinical validity (C),clinical utility (C) and ethical, legal andsocial issues (E). Unfortunately, thisapproach is unfeasible in some instancesbecause of the lack of data on which suchevaluations, especially those concerningclinical utility, depend. In fact, as describedin the methodology of the US PreventiveTask Force,6 definitive evidence of effec-tiveness requires randomised clinical trialsthat evaluate all relevant outcomes oftesting, as well as the effects of any asso-ciated intervention. While these types ofstudy design are often unfeasible orunethical for many genetic conditions,nonetheless some HTA reports on genetictests have now been released from bothAETMIS (Agence d’Évaluation des Tech-nologies et des Modes d’Intervention etSanté) in Quebec, Canada, and EGAPP(Evaluation of Genomic Applications inPractice and Prevention) inside the CDC.

Additionally, genomic technologies willinfluence not only health outcomes butalso the delivery and costs of health care.





In this era of increasing concern abouthealth care costs, it will be impossible toconsider the implications of genomicmedicines without also considering theireconomic implications.7 The use of geneticinformation to guide interventions shouldbe justified only if data demonstrateimproved outcomes, reduced costs, orpreferably both. Thus the need for a strongevidence base of efficacy, effectiveness andcost-effectiveness will be an essentialelement if resources are not to be wasted,particularly where health services arepublicly funded. Although some cost-effectiveness evaluations have beenpublished in the last few years on geneticand pharmacogenetic tests, there remainsan urgent need from health serviceresearchers for a rigorous and systematicevaluation of genome technologies. Thisrequires new collaborations betweenpublic health providers, geneticists, econo-mists and policy-makers.

The policy response and education ofhealth care providersAt this point it should be clear that it isdifficult to predict to what extent theseadvances will lead to effective andaffordable clinical and public health inter-ventions. Policy should therefore ensurethat expertise is harnessed in all pertinentfields, first beginning with public healthprofessionals, to prepare the ground andenable society and citizens to be equippedand respond responsibly. To make thishappen, the provision of education andtraining for health providers in the publichealth genomics field and related disci-plines is needed. Some research indicatesthat health care providers are poorlyprepared to integrate genetics intopractice,8 while other surveys suggest that90% of US public health schools teachhealth policy but only 15% genomics.* Inorder to achieve this goal, there needs to beadditional development in infrastructuresfor training courses in genetics, health careand health economics, targeted as appro-priate at health care providers, geneticistsand economists.

In conclusion, an unfortunate feature ofthe genomic revolution has been atendency to hype up the scope and timingof the integration of genome technologiesinto health care.9 This situation, togetherwith its commercial potential, has mani-fested itself in the widespread use of

genetic testing for susceptibility tocomplex disorders, or for drug responses,with little evidence of efficacy, effec-tiveness and cost-effectiveness.10 Since ashared methodology for the proper evalu-ation of genomic tests does not as yet exist,health service research should work hardto identify universal criteria against whichto evaluate genetic tests. This should alsotake into account the acceptability and thepotential for harm of the testing processitself. So, public health professionals andpolicy-makers in the next decade would dowell to clarify the conditions under whichthe genomic revolution, already underwayin medicine, will result in public healthbenefits.

REFERENCES

1. Collins FS. Shattuck lecture – medicaland societal consequences of the HumanGenome Project. New England Journal ofMedicine 1999;341:28–37.

2. Janssens CJW, Khoury MJ. Predictivevalue of testing for multiple geneticvariants in multifactorial diseases: impli-cations for the discourse on ethical, legaland social issues. Italian Journal of PublicHealth 2006;3:35–41.

3. Khoury MJ, Gwinn M, Burke W,Bowen S, Zimmern R. Will genomicswiden or help heal the schism betweenmedicine and public health? AmericanJournal of Preventive Medicine

2007;33:310–17.

4. Boccia S, Brand A, Brand H, KhouryM, Zimmern R. Public health genomics inEurope. (editorial). Italian Journal ofPublic Health 2006;3–4:5–7.

5. Haddow JE, Palomaki GE. ACCE: Amodel process for evaluating data onemerging genetic tests. In: Khoury M,Little J, Burke W (eds). Human GenomeEpidemiology: A Scientific Foundation forUsing Genetic Information to ImproveHealth and Prevent Disease. Oxford:Oxford University Press, 2003.

6. Harris RP, Helfand M, Woolf SH, et al.Current methods of the US PreventiveServices Task Force: a review of theprocess. American Journal of PreventiveMedicine 2001;20:21–35.

7. Varmus H. Getting ready for gene-based medicine. New EnglandJournal of Medicine 2002;347:1526–27.

8. Burke W, Emery J. Genetics educationfor primary-care providers. NationalReview of Genetics 2002;3:561–66.

9. Davey Smith G, Ebrahim S, Lewis S,Hansell AL, Palmer LJ, Burton PR.Genetic epidemiology and public health:hope, hype, and future prospects. Lancet2005;366:1484–98.

10. Col NF. The use of gene tests to detecthereditary predisposition to chronicdisease: is cost-effectiveness analysisrelevant? Medical Decision Making2003;23:441–48.

*∗ See http://www.graphint.org/events/dna2006/khoury/

International trends highlight the confluenceof economics, politics andlegal considerations in thehealth policy process.HEPL serves as a forumfor scholarship on health

policy issues from these perspectives, and is ofuse to academics, policy makers and health caremanagers and professionals.

HEPL is international in scope, and publishes both theoretical and applied work. Considerableemphasis is placed on rigorous conceptual development and analysis, and on the presentation of empirical evidence that is relevant to the policy process.

The most important output of HEPL are originalresearch articles, although readers are alsoencouraged to propose subjects for editorials,review articles and debate essays.

HEPL invites high quality contribu-tions in health economics, politicalscience and/or law, within its generalaims and scope. Articles on socialcare issues are also considered. Therecommended length of articles is6–8,000 words for original researcharticles, 2,000 words for guest edito-rials, 5,000 words for review articles,and 3,000 words for debate essays.

For instructions for contributors seewww.cambridge.org/journals/hep/ifc

Contributions and correspondenceshould be sent to: Anna Maresso,Managing Editor, LSE Health, LondonSchool of Economics and PoliticalScience, Houghton Street, LondonWC2A 2AE, UK. Email [email protected]

Health Economics, Policy and Law

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The accession of Poland to the EuropeanUnion (EU) has brought with it manychallenges as well as benefits. These chal-lenges inevitably include the migration ofhealth care professionals. The principle ofthe free movement of labour implies thathealth professionals, as a part of theEuropean workforce, can move acrossborders and work in other Member States.Free movement of health care personnelwithin the EU is permitted by EuropeanCouncil Directive 2005/36/EEC, subjectto the mutual recognition of professionalqualifications. Under this legislationdoctors, dentists and nurses are entitled tofull registration in any EU Member State.As the living standards in most of the oldEU countries continue to exceed thoseseen in Poland, the economic incentive tomove is often high.

Verification certificatesDespite these economic pressures, thereremains little information on the migrationpatterns of doctors. The principal sourceof information is the Polish Chamber ofPhysicians and Dentists which issuesprofessional verification certificates,allowing Polish doctors to apply for jobsin other EU countries. Data from thisorganisation indicates that betweenJanuary 2004 and April 2007 more than6,000 doctors received such certificates.Most were issued to doctors specialising inanaesthesiology and intensive care(17.54%), plastic surgery (14.97%) andchest surgery (13.18%).

As the Polish Chamber of Physicians andDentists collects data only within thecontext of issuing documents for potentialmigration, this does not provide a pictureof how many of these individuals actuallyleave the country. The number of certifi-

cates should be perceived only as an indi-cator of the interest of medical personnelin taking up work abroad. A better senseof the scale of migration can be obtainedfrom the competent authorities in otherEU countries responsible for the regis-tration of the medical workforce.

Migration patterns As Figure 1 indicates, between January2004 and March 2007 2,961 doctors werenewly registered to practice in the EU-15countries.* This represented a dramaticincrease on registration rates in the preaccession period. Most of these migrantdoctors were specialists in the fields ofanaesthesiology (327), internal medicine(213) and general surgery (129).

By far the most popular destination wasGreat Britain (England, Scotland andWales), which registered 1,633 doctorspost accession, compared with just fifty-three between 2000 and 2003 (Figure 2).

Substantial levels of migration were alsoseen in Sweden, Germany (wheremigration had been longstanding), Ireland,Denmark and the Netherlands.

ConclusionsClearly, the accession of Poland to the EUhas had a considerable impact on the esca-lation of the migration process for doctors.This is most notable in Great Britain whereprior to accession there were just 335Polish doctors registered compared with1,968 by 2007. Although it is also the casethat a much lower number of doctorsmigrate compared to those who obtain thenecessary professional validation certifi-cates (6,007 versus 2,961), it must bestressed that the number of migrantdoctors shown here is conservative. Thereare gaps in registration data from severalEU-15 countries which if plugged wouldincrease the number of migrant doctors.Other doctors have also migrated to theprincipal European Economic Area coun-


EUROPEAN SNAPSHOTS

Migration patterns of Polishdoctors within the EU

Joanna Leśniowska

Joanna Leśniowska recently completed aPhD at the Institute of Foreign TradePolicy and European Studies, WarsawSchool of Economics, Poland. Email: [email protected]

Figure 1. New Polish doctor registrations in the EU-15 2000–2007

* No data were available from Austria and Greece; only partial data available from Germany(1 regional medical office ‘Landesärztekammer’ out of 17 existing), Ireland (registration ofspecialists not compulsory), Italy (26 of 69 regional medical offices ‘Ordine Provinciale deiMedici Chirurghi e degli Odontoiatri’), Sweden (data from 2004–2007 only), Spain (8 of 40regional medical offices ‘Colegio Oficial de Medicos’).


Public responsibilities for health careservices have been decentralised more inFinland than in any other country.1 InFinland, 415 municipalities, with a medianof about 5,000 inhabitants, hold legislativeresponsibility for organising and fundinghealth services for their residents. In

addition to health services, municipalitiesare also responsible for organising socialservices and primary education. Munici-palities have a significant degree offreedom to plan and organise these servicesas they see fit and state-level steering isquite weak. Municipal services are fundedmainly by municipal income tax, statesubsidies and user fees.

The municipal health care system providesthe largest share of health care services inFinland (for example about 70% of outpa-tient physician visits, about 60% of outpa-

tient dentists visits and about 95% of inpa-tient care periods). In addition to themunicipal system, health care services arealso delivered by occupational health careand private health care providers; these arepartly reimbursed by the statutoryNational Health Insurance.

National legislation stipulates that everymunicipality must have a health centre thatorganises primary health services. Munic-ipalities can either have their own healthcentre or they can jointly host a healthcentre with neighbouring municipalities


EUROPEAN SNAPSHOTS

tries (Iceland and Norway), the data forwhich were not included in this analysis.

One consequence of this growing rate ofoutward migration has been to makeaccess to doctors in some medical fieldsmore difficult. Between 2003 and 2006 the

number of doctors employed in Polanddecreased by more than 10,000, with mostof this decrease (9,577) occurring in 2005.1

In 2006, the Minister of Health commis-sioned a survey across the local adminis-trative areas (voivodships) to obtain

information on workforce deficits inmedical care centres. The survey recordedthe number of vacancies on 30 May 2006.The ensuing data indicated that there were4,113 unfilled posts. The greatest numberof vacancies were for anaesthesiologists(398) and internists (312).2 These deficitsin personnel may just be a foretaste ofproblems to come; migration ratescontinue to increase, with 1,167 doctorsobtaining the necessary certification topursue professional opportunities else-where in the EU in 2006, compared with862 in 2005 and 461 in 2004.

REFERENCES

1. Ministry of Health. BiuletynStatystyczny Ministerstwa Zdrowia 2006[Statistical Bulletin of the Ministry ofHealth 2006]. Warszawa: CentrumSystemów Informacyjnych OchronyZdrowia, 2006. Available athttp://www.csioz.gov.pl/pliki/BIULETYN_2006.pdf

2. Ministry of Health. Program moni-torowania migracji polskich lekarzy, pielęg-niarek i położnych po przystąpieniu Polskido Unii Europejskiej [Programme of moni-toring of Polish doctors, nurses andmidwives migration after the Polandaccession to the EU]. Warszawa: Minis-terstwo Zdrowia, 2006. Available athttp://www.mz.gov.pl

Figure 2. Total Polish doctor registration by selected host country

Note: Data on registrations in Sweden from 2000–2003 unavailable

Restructuring municipalities andmunicipal health services in Finland

Lauri Vuorenkoski

Lauri Vuorenkoski is Senior Researcher,National Research and DevelopmentCentre for Welfare and Health(STAKES), Helsinki, Finland. Email: [email protected]

http://www.csioz.gov.pl/pliki/BIULETYN_2006.pdf

http://www.mz.gov.pl


(that is, a health centre maintained by amunicipal federation). There are altogether237 health centres in Finland, from whichfifty-eight are joint health centre federa-tions (2007, excluding the autonomousÅland islands). Legislation also divides thecountry into twenty hospital districts thatare responsible for the organisation ofmunicipal secondary health care services.Each municipality must be a member ofone of the hospital districts. Hospitaldistricts are financed and managed by themember municipalities. The catchmentpopulation of hospital districts varies from65,000 to 1.4 million inhabitants.

Decentralisation has provided a goodchance to ensure the accountability ofhealth services to the local citizens.However, population movement fromrural municipalities to cities, ageing of thepopulation especially in rural areas(increasing demand of health services and adecreasing pool of health professionals),increasing problems in balancing public-sector finances and the increasing demandsof new technology for resources and skillshave made small municipalities more andmore vulnerable when solely responsiblefor the organisation of health services.

“it is considered … that thenumber of municipalities couldbe much lower and regionalcooperation stronger”

In recent years concerns have grown thatthe problems with decentralisation of thismagnitude outweigh the advantages. Oneof the most discussed future developmentsof the Finnish public sector health caresystem has been the creation of a moresolid structural and financial basis formunicipal services by creating larger unitsto take responsibility for the organisationof health services. Although the number ofmunicipalities has already decreased inrecent years (from 452 to 415 in 2000–2008), it is considered in the state adminis-tration that the number of municipalitiescould be much lower and regional co-operation stronger.

Numerous regional development projectshave been conducted to both increaseregional cooperation in primary healthcare provision and to integrate primaryand secondary care services. Oneimportant example of such regional reform

is the administrative experiment in theKainuu region (North-East Finland)which started in 2005.2 The region coversnine municipalities and a total of 85,000inhabitants. The experiment created a newregional self-regulating mid-level adminis-trative body with its own regional council.The council is elected for a four-year termat the same time as the general municipalelections. The new administrative body hasno right to levy taxes but it gets fundingfrom member municipalities. It is respon-sible for organising several welfare servicesthat were previously organised by themunicipalities: upper secondary schoolsand vocational education, primary andsecondary health services, and a large partof social services.

The two most recent reforms of this typehave been carried out in the Itä-Savo andPäijät-Häme regions in 2007.3 Itä-Savo hasa population base of 60, 000 and Päijät-Häme 210,000. In both regions, the munic-ipalities formed a new municipalfederation to organise primary andsecondary care and some social services.However, some municipalities in bothregions still organise primary health careservices on their own instead of givingorganisational responsibility to the newmunicipal federation. The new organisa-tions replaced hospital districts thatorganised only secondary medical services.Like hospital districts, the new municipalfederations are governed and funded bymember municipalities.

National project to restructure municipalities and municipal servicesIn May 2005, the government launchedThe Project to Restructure Municipalitiesand Services.3 The goal of the project wasto create a sound structural and financialbasis for the services that municipalities arecurrently responsible for, so that therequired standard of quality, effectiveness,availability, efficiency, and technologicaladvancement are secured.

In the first phase, the project made threealternative proposals for reformingmunicipal services. The first alternativewas to merge current municipalities so thateach municipality would have a populationbase of at least 20,000 inhabitants. Thesecond alternative was to integrate organ-isational responsibility of primary andsecondary health care as well as certainsocial welfare services into new regionalorganisations with a population size ofbetween 100,000 to 200,000 inhabitants(current municipalities would still be

responsible for funding services). The thirdalternative was to introduce a new mid-level administration of twenty regionswhich would have organisational andfunding responsibility to arrange most ofthe services (somewhat similar to theLandsting in Sweden). These regionswould have their own representativeelected councils and the power to levy taxand receive state subsidies.

“mergers of municipalities canbe a difficult process for localpoliticians, municipal employeesand residents. However, thegeneral view is that this is theright direction”

In January 2007, the Eduskunta (Finnishparliament) approved an act defining howto continue the process. The act states thatorganisational responsibility for primaryhealth care and those social services closelyrelated to health services should residewith organisations covering at least 20,000inhabitants (currently only 23% of healthcentres have a population base of 20,000 ormore). This would not necessarily requiremergers of municipalities smaller than20,000 inhabitants, but rather the formingof, for example, municipal federationswhere funding liability resides with indi-vidual municipalities. According to the act,the state will financially support mergersof municipalities. Additionally, the respon-sibility for the organisation and funding offorensic psychiatry examinations andexaminations related to sexual abuse ofchildren will be transferred to the state nolater than 2009.

In autumn 2007, all the municipalitiesmade detailed plans for the state adminis-tration on how these stated goals are to beachieved. However, the state adminis-tration was satisfied only with a minorityof these plans. The majority of the munic-ipalities were required to further specifytheir plans or have been summoned fornegotiations with the state administration.Plans reveal that municipalities intend toform about seventy co-operational regionsinvolving about three hundred municipal-ities. About half of these would work asjoint-municipal federations. Anotherproposed model is that one municipalityhave the administrative responsibility oforganising services and others have a


EUROPEAN SNAPSHOTS

contract with that municipality related tothe organisation of services for their resi-dents (currently about twenty municipal-ities have arranged services according tothis model). One identified problem withthese proposals would be that social andhealth services could be dispersed todifferent regional organisations, whichcould hamper the seamless provision ofservices. Decisions on municipal mergershave already been made so that thenumber of municipalities will be reducedby sixty-two by January 2009. Addi-tionally, in January 2008 there are anothertwelve ongoing merger processesinvolving twenty-nine municipalities.

The government will produce a report tothe Eduskunta on the project’s progress in2009. Municipalities are obliged to makefinal decisions on how they will implementthe law prior to this date. The target forthis process to be completed is 2012.

ConclusionsMunicipal health services in Finland areundergoing major changes, with organisa-tional responsibility for primary healthservices being transferred to larger organ-isations. However, it is difficult to estimatewhat the outcome of this process will be.The principle of municipal autonomy hasa strong tradition in Finland. Municipal-ities value rather highly their inde-pendence to arrange basic services, so thereform will not be very easy. In particular,mergers of municipalities can be a difficultprocess for local politicians, municipalemployees and residents. However, thegeneral view is that this is the rightdirection in which to develop the organi-sation of health services in Finland.

REFERENCES

1. Häkkinen U, Lehto J. Reform, Changeand Continuity in Finnish Health Care.Journal of Health Politics, Policy & Law2005;30:79–96

2. Keskimäki I. County levelmanagement of welfare services. HealthPolicy Monitor 2003. Available athttp://www.hpm.org/survey/fi/a2/3

3. Vuorenkoski L, Wiili-Peltola E.Merging primary and secondary careproviders. Health Policy Monitor April2007. Available athttp://www.hpm.org/survey/fi/a9/1

4. Järvelin J, Pekurinen M. Project torestructure municipalities and services.Health Policy Monitor 2006. Available athttp://www.hpm.org/survey/fi/a7/1


EUROPEAN SNAPSHOTS

Observatory Venice Summer School

Hospital reengineering: New roles, tasks and structures

The European Observatory on Health Systems and Policies will hold itsannual Summer School in collaboration with the Veneto Region of Italy from3 to 8 August, 2008 on the island of San Servolo in Venice.

The theme of the summer school will focus on “Hospital reengineering: new roles, tasks and structures”. It will address how hospitals interact withthe rest of the health and care systems and with the communities aroundthem. The focus will be on the policy rather than management dimensionsof boundaries to the outside world. The implications of relationships withother actors (including patient and consumer groups) will be addressed aswell as the repercussions for the division of labour and internal organi-sation. It will help to understand and show how to support seamless linksbetween services; and how to identify, plan for and manage hospitals' placein health systems.

The summer school’s target groups are (i) senior to mid-level policy-makersand (ii) a limited number of junior professionals who are making careers inpolicy and management at a regional, national or European level. Theintention is to raise key issues, share participants’ insights, develop a greaterunderstanding of how evidence and context interact and build networks.The emphasis will be on participative approaches, complemented by someformal teaching (in English).

All participants should be in institutions with decision-making powers,whether government or non-governmental (for example, ministries,national health institutes, federal committees), relevant provider or payerassociations (such as national insurance boards, hospitals or hospital federations, management boards, physicians’ chambers) or communitystakeholder or consumer groups. Applications are welcome from all countries across the European Region.

The deadline for applications is 30 April 2008, earlier applications are encouraged. A selection process will follow and a limited number of bursaries will be available. The Summer School is accredited by the European Accreditation Council for Continuing Medical Education.

The programme will be tailored to the mix of participants and the course will be led by leading international experts and decision makers.

More information is available at www.observatorysummerschool.org

For specific questions regarding the Summer School please email [email protected]

on Health Systems and Policies

European

http://www.hpm.org/survey/fi/a2/3



http://www.observatorysummerschool.org


The recent expansion of the SchengenArea to twenty-four Member States ofthe EU runs alongside the increasingmovement of citizens across the EU forwork, tourism and study. Moreover, arising number of pensioners fromnorthern Europe are spending the winterseason and extended periods of thesummer in southern Europe and theMediterranean. Accessing health care inany European country should, theoreti-cally, be a straightforward process, but itoften creates problems, both for patientsand the health care systems involved.The experience of certain European areaswith heavy tourist inflows, such as theVeneto Region in Italy, illustrate clearlythe extent of this tourism phenomenon,implying the need for action at differentlevels (regional, national and European),involving specific legal, organisationaland regulatory approaches.

Historical backgroundThe Veneto Region has always enjoyedan important strategic geographicallocation at the crossroads of Europe (see

Figures 1 and 2). It has a population of4.8 million, which increases dramaticallytwice a year during the peak summer andwinter seasons. Travelling has played animportant role for the Venetians. In thepast, the rule of the ‘Serenissima’Republic was dominated by seafaring andtrading in the Mediterranean Sea as wellas along the Silk Road as far as China.Throughout history, therefore, Venetohas always placed great importance onprotecting the health and well-being oftravellers.1 The Venetians are renowedfor having fought vehemently against theimportation of communicable diseasesfrom far away countries, as the history ofits lazarettos (hospitals set up for thetreatment and quarantine of people withinfectious diseases) and thorough quar-antining procedures have demonstrated.

The impact of tourism on the RegionIn more recent times, Veneto has becomefamous as a major tourist destination,thanks to three main attractions: Veniceitself, as a city of art and culture, alongwith Verona, Treviso, Padua and


HEALTH POLICY DEVELOPMENTS

Health care services for touristsin the Veneto Region

Simona Bellometti and Luigi Bertinato

Summary: The combination of the area’s natural beauty, multi-purpose businessesand quality service makes tourism one of the Veneto Region’s main resources.Analysis demonstrates a proportionately high level of tourist inflows and highlightstwo phenomena: (a) the impact of mass tourism on the health system; (b) the risinglevels of tourist and patient mobility in Europe. Realising the potential and under-lying risks in the relationship between tourism and health, the Veneto Regionalgovernment has set about planning and organising specific health care services fortourists, integrating them with those already available to the resident population.The question of protecting and satisfying the health care needs of tourists is ofincreasing importance to many areas of Europe experiencing significantly highlevels of tourist inflows.

Key words: tourism, cross-border health care, patient safety, patient mobility, Italy

Simona Bellometti is a medical consultant in the area of thermal medicine and spatherapy and Luigi Bertinato is Director, International Health and Social AffairsOffice, Department of Health and Social Services of the Veneto Region, Venice, Italy. Email: [email protected]

Figure 1: Italy and the Veneto Region

Figure 2: The Veneto Region


Vicenza; the beaches of the Adriatic Seaand the lake region (Lake Garda); and theDolomite mountains.2 Economically,tourism has become one of Veneto’s mainresources. In 2006, spending by foreignvisitors to Veneto amounted to €3,845million – 15.9% of total spending byforeign visitors in Italy, second only toLazio.3 It now ranks first among Italianregions in terms of tourist flows (see Table1).

More detailed examination of internationaltourist flows to the region in 2006 indicatesthat tourists mainly from Germany(1,888,235), USA (818,262), Austria(642,886), the UK (592,926), France(521,043), Spain (387,330), Japan (280,601)and Australia (118,053) made up themajority of total overnight stays, which intotal amounted to over 59 million nights.

Consequently, Veneto makes for a veryinteresting case study of patient mobilityand health tourism in Europe. The signif-icant flow of tourists brings a series ofhealth care challenges for regional healthcare services to contend with. In somecases this is done through the organisationof specific services to respond to the highdemands arising from seasonal touristflows and long-term foreign residents(approximately 3,500 mainly Germanelderly residents living in the Lake Gardaarea, near Verona).4 Visitors to the regioncan also, in the case of a medical emer-gency, turn to a wide range of healthservices provided by Local HealthAuthorities (LHAs), in close collaborationwith the Department of Health and SocialServices and the Department of Tourism ofthe Veneto Region.

Responding to the challengesThis heavy flow of tourists brings with it aseries of health care issues. Since 2003, aspecial ‘task force’ has been operating inthe region with the aim of broadeningknowledge on this tourist phenomenonand patient mobility, as well as improving

the ability to cope with underlying admin-istrative and organisational problems.

The taskforce collects data on the scale ofpatient mobility between the VenetoRegion and other Italian regions or EUMember States. It analyses the impact ofcross-border health demands and relatedhealth issues at the regional level.Moreover, it aims to map and classify theneeds and concerns of EU citizens whorequire medical assistance when abroad bygathering information on: the patient–system interface; different aspects of healthsystem re-organisation; health servicedemands; patient orientation; access to andquality of care; patient rights and obliga-tions and financial arrangements.

The long-term objective is to establish adetailed framework of the ongoing patternof EU citizens receiving care from healthcare providers in the Veneto Region, witha special focus on: (i) tourist flows; (ii)patients requesting authorisation to accessthe health care system in another Europeancountry (using the E112 form); and (iii)long-term residents (such as the retired)from other Member States who live inVeneto for the greater part of the year.

An emphasis on patient safetyThe significant tourist flows distributedamong the various types of tourist desti-nations in Veneto (cities of culture,coastline resorts, lakes, mountains andspas) have compelled the regional healthcare system to plan and organise specifichealth care services for tourists, while atthe same time integrating them with thosealready available services provided for theresident population.

The Local Health Authorities, responsiblefor the provision of health and socialservices to the resident population, and theVeneto Region government have for a longtime been aware of the enormous potentialunderlying the relationship betweentourism and health, not only in as far as it

is the driving force of the economy, butalso in terms of the potential risks itunearths as a result of the impact of thetourist population on the resident popu-lation and the local environment.

The increasing demand for health carefrom tourists is a challenge that LHAsstrive to meet year after year.5 The seasonalpeak coincides with the main summerseason, which is more pronounced incoastal areas. Seasonality is thus animportant factor in the organisation ofhealth care services which need to beflexible in their response to the needs oftourists.6 The main reasons for foreigncitizens accessing health services in theregion include the sudden alteration inhealth (70.6% of cases); 9.5% requiringpharmaceuticals; 2.8% for medicaltreatment or surgery and 1.1% receivingdialysis.

Seaside tourism is marked by large andseasonal concentrations of individualswhich affect facilities and services set up torespond to this demand.7 Each year prepa-rations for the summer season commencein March (a similar practice takes place inthe autumn in the run up to the ski season)with the selection of specific health staffable to communicate in various Europeanlanguages. A number of specific measuresare then undertaken.

The ‘Eastern Veneto’ area (the coastal areaalong the Adriatic Sea) has extended andadapted already-existing schemes andinitiated a series of new services aimed atcoping with the impact of the influx ofsummer tourists, while health care servicesand technical know how have also beenenhanced at the main hospital in Jesoloresponsible for covering the marina.Twenty-four hour first-aid points havebeen installed in the seaside resorts ofCaorle and Bibione, where additionaldialysis services, not normally available tothe public in this area, are also provided.

Four clinics that are fully operationalduring the months of May through toSeptember have also been set up in EasternVeneto, together with eight clinics duringthe period from June to August, totalling113 opening hours per day, with twenty-two doctors and six interpreters. For somereason, clinics provided near to the beachare not readily accessed by foreign tourists;this is why one of the three tourist clinicsin Jesolo has been set up inside the mainhospital next to the emergencydepartment. This arrangement allowspatients to be registered, while making



Table 1: National and international tourist flows to the Veneto Region, 2006

Nationality Arrivals Percentage Total overnightstays

Percentage Average days of stay

Italian 5,259,736 39% 25,093,862 42% 4.77

Other 8,179,099 61% 34,266,727 58% 4.18

Total 13,438,835 100% 59,360,589 100% 4.40

Source: Veneto Regional Statistics Office data based on ISTAT 2006

them aware of the inappropriate use ofemergency services.

Within the city of Venice, in the Venezianaarea, additional health care and ambulatoryservices are also put in place over thesummer period to guarantee emergencyaid to tourists on the island. This issupported by a central unit that coordi-nates emergency services and organiseshelicopter rescue services in the region. Aspecial clinic for tourists is providedbetween mid-June and mid-September,opening from 08:00 to 20:00 daily. Theclinic, employing nine doctors and anadministrator, always has one doctoravailable (two in July and August).

In the Lake Garda area, services have beenoptimised through the opening of eightspecific tourist clinics, including dialysisservices. Foreign tourists requiring medicalattention can turn to special ‘touristmedicine’ services, as well as hospitalemergency services, and the afore-mentioned first-aid points, the latter beingavailable only from May to September.1

There are also nine outpatient clinics, sixof which are located in Lake Garda itself,and three in the surrounding mountainousareas, guaranteeing a total of thirty hoursper day availability to the public.

Safe Holidays Project During the summer season, with the aimof ensuring a prompt response to medicalemergencies, ‘Progetto Vacanze Sicure’(Safe Holidays Project) has been imple-mented along the entire Veneto coastline,incorporating a number of different initia-tives: the distribution of semiautomaticdefibrillators financed by the regionalhealth service; seven medically-equippedvehicles; three medically-equipped motor-cycles and sixteen ambulances (includingtwo water ambulances).

An additional helicopter rescue servicetailored specifically to tourists has beenput into operation, representing a furtherdevelopment within the complex system oftried-and-tested emergency servicesavailable in the Veneto Region. The heli-copter health care rescue service ensuresthat there is coverage throughout theVeneto region via four helicopter stations.Based at the Venice Lido it covers theentire 120 km stretch of Adriatic coastlineand is equipped with sea rescue facilities.In the space of ten to fifteen minutes therescue team, made up of a doctor, nurseand air pilot, are able to reach the indi-vidual in danger at the location where theemergency has occurred.

Veneto, being the number one Italianregion in terms of tourist flows, thuscontinues to be very much concerned withsafeguarding its tourist industry and setsout to combine a high quality of touristattractions with an equally high level ofhealth care services for those Europeancitizens with chronic health problems, forexample, those in need of dialysistreatment, who can pre-book healthservices before departure.8 Within thiscontextual framework, the Veneto Regionseeks to take advantage of all opportunitiesmade available to adapt its health servicesto handle the enormous impact of masstourism from Central and NorthernEurope. By doing so the region aims toincrease its appeal and attraction to bothforeign and national tourists and therebycompete effectively with other majorEuropean tourist destinations. Healthservices face important challenges from thesudden demands on health services due tomass tourism. Better marketing and moreeffective communication tactics are calledfor, as more often than not, tourists arealmost oblivious towards or else poorlyinformed about services provided by thepublic sector in their destination country.

ConclusionsPatient mobility and the provision ofcross-border health care services arethemes which are increasingly high on themajority of European policy agendas. Thechallenges facing the Veneto Region’shealth system are similar to those beingfaced in other parts of the EU affected bymass tourism. The need to developstrategies to guarantee health protectionand satisfy the health needs of tourists addfurther weight to the case for solutions toprovide access to quality health services foracute and chronic care to individuals notalready covered as part of the EuropeanHealth Insurance Card (EHIC) system.9

Special reimbursement systems have beenset up involving two major German healthinsurance companies, to cater for Germanvisitors with non-acute health problemsthat, for instance, require cardiac ormuscular rehabilitation services, or dialysistreatment.

Special training courses for health profes-sionals have been organised to facilitatecommunication with non-Italian patients,making use of appropriate supportinginformation materials. Cross-border initia-tives with the Austrian Länder ofCarinthia, the north-eastern border regionof Friuli Venezia-Giulia and Slovenia havealso contributed towards setting bench-

marking strategies for tourist healthservices, at the same time reconcilingservices provided by universal versusinsurance-based health systems. This expe-rience of organising health services fortourists at regional level can help identifyfuture solutions that Member States mayimplement to respond to the phenomenonof patient mobility in an increasinglymobilised Europe.

REFERENCES

1. Scaramagli A, Zanon D, Ronfini F,Bertinato L, Toniolo F. Health care fortourists in the Veneto Region. In: Rosen-möller M, McKee M, Baeten R (eds).Patient mobility in the European Union:Learning from Experience. Copenhagen:World Health Organization, 2006.

2. Apostolopus Y, Lewadi S, Kannakis A(eds). The Sociology of Tourism. NewYork: Routledge, 1996.

3. Veneto Region. Sharing Facts –Comparing Facts: Statistical Report 2007.Veneto: X, 2007. Available at:http://statistica.regione.veneto.it/ENG/pubblicazioni_elenco.jsp

4. Regione Veneto e Turismo. Ciset:Università Cà Foscari-Venezia,Fondazioni Enrico Mattei, 2006.

5. McKee M, Nolte E. The implicationsfor health of European Unionenlargement. British Medical Journal2004;328:1025–26.

6. Palm W, Nickless J, Lewalle H, CoheurA. Implications of Recent Jurisprudence onthe Coordination of Health CareProtection Systems. Brussels: AssociationInternational de la Mutualite, 2000.

7. Aviles NR. The mobility of citizens – acase study and scenario on the healthservices of the Costa del Sol. In: Busse R,Wismar M, Berman P (eds). TheEuropean Union and Health Services: TheImpact of the Single European Market onMember States. Brussels: IOS Press, 2002.

8. Busse R, Drews M, Wismar M.Consumer choice of healthcare servicesacross borders. In: Busse R, Wismar M,Berman P (eds). The European Union andHealth Services: The Impact of the SingleEuropean Market on Member States.Brussels: IOS Press, 2002.

9. Schemken HW, Au H, Dobrev A,Stroetmann KA, Jones T, Stroetmann VN.Access to efficient health services fortourists: an evaluation of economicbenefits. Journal of Telemedicine andTelecare 2007;13(Suppl 1):52–55.



http://statistica.regione.veneto.it/ENG/pubblicazioni_elenco.jsp



A key contextual factor which helps toexplain international retirementmigration patterns is the changing regu-latory framework of the EuropeanUnion (EU). This phenomenon isembedded in EU legislation and socialpolicy considerations, including Articles48 and 49 of the Treaty of Rome on thefreedom of movement, the SingleEuropean Act which removes barriers toproperty rights across Member States,Article 8 of the Treaty of the EU whichconfers limited electoral rights and theSocial Charter which envisages thepotential to harmonise pension andwelfare systems across the EU.1 Inaddition, in the mid 1970s the thenEuropean Economic Community recog-nised that freedom of movement shouldnot be restricted to the healthy. In 1971,Council Regulation (EC) No. 1408/71on the application of social securityschemes provided avenues for statutory

cover of treatment received outside thestate of residence or affiliation. Thisincluded EU pensioners deciding toretire to another Member State throughthe E121 scheme (See Box 1).

Some EU citizens have seen these mech-anisms as an opportunity to move toanother Member State and they arelikely to have been a factor in thegrowing numbers of northern Euro-peans retiring to southern Europe.Although this is a phenomenon that hasexisted for many years (for example,Irish people returning to Ireland afterspending their working lives in England)the numbers involved, and the destina-tions being chosen, have changed greatly.There are now many people fromnorthern Europe retiring to southernEurope, in particular to Spain, France,Portugal, Italy, Greece and Bulgaria, aswell as to candidate countries such asCroatia.2

The phenomenon of internationalretirement migration in EuropeSystematic academic interest in the studyof European international retirementmigration only emerged in the mid-1990s, mostly in the field of migrationstudies and social gerontology. The mainfocus of social gerontology is on the

The health care needs of UKpensioners living in Spain: an agenda for research

Helena Legido-Quigley and Daniel La Parra

Summary: There is a growing interest in learning how older migrants adapt to theirnew country of residence, in understanding their motivations for migration and thefactors that influence international retirement migration patterns. However, therehas been little research into the health and health care needs of internationalmigrants retiring to other countries. This paper presents findings on health status andutilisation of health services with a particular focus on UK pensioners retiring toSpain. Future research should focus on the health needs of pensioners and theirperspectives as to whether and how these health needs are met.

Keywords: Older migrants, Inequalities in access, Social security, Spain, UK

Helena Legido-Quigley is ResearchFellow, London School of Hygiene andTropical Medicine. Daniel La Parra isSenior Lecturer in Sociology, Universityof Alicante, Spain. Email: [email protected]

Box 1: Background to the E121 scheme

The process described here refers to the adminis-trative steps a pensioner has to go through when heor she decides to move to another Member State.

The individual applies for an E121 form in theirhome country so that their social rights are trans-ferred from the social security system of the homecountry to the ‘receiving country’. Together with thistransfer of rights, a lump sum of money, agreedupon in the Social Commission on Migrant Workers,is also transferred to the central government of thereceiving country to cover costs for health care. Theinformation is passed to the region or locality wherethe pensioner is planning to settle. The long-termresident receives a national health insurance card inthe new country and is thus integrated into thesystem. No distinctions are made between oldernewcomers and any other member of the socialsecurity system.

These communication routes and information flowsinvolve no direct contact between the local healthcare provider in the new country and the state-levelpublic authorities of the home country. Thus, in theevent of the death of a long-term resident, the homecountry might not be informed and will thereforecontinue to transfer money.

Through the E121 scheme long-term residents obtainthe right to health care in the new or ‘receivingcountry’ and at the same time renounce their right tohealth care at home. However, Directive 1408/71also requires that the receiving country provide thepensioner with an E112 (form for planned treatmentabroad), regardless of whether the treatment isalready available in the ‘receiving country’.


reconstruction of older people’s lives byconnecting individual biographies to thehistory of society and the study of socialchange. Through the analysis of differentcohorts of older migrants and the identifi-cation of positive attributes of retirementin later life, it has helped to challengeprevious misconceptions on retiringmigrants by providing a more solidempirical base.1

A growing literature has focused on deter-mining the number of retirees migrating inEurope, choice of location and reasons formigrating. Key socio-economic andpersonal characteristics of migrants,including life-stage, cultural, attitudinal,recreational and environmental factors andpersonal influences have been analysed.Locations of study have included coastalCroatia, Spain (Majorca, Costa Blanca,Costa del Sol), Italy (Tuscany) and Malta.

“in 2006, more than 300,000UK citizens retired to otherMember States”

This research has illustrated how there hasbeen an increase in the number of olderEuropeans migrating in retirement. Thisneeds to be understood in the context of arise in older people’s income and assets, aswell as major transformations in their pref-erences and opportunities.1 Moreover,increasing life expectancy, along with theincreasing availability of new medicinesand medical technologies, has meant that agrowing number of older people are livinghealthier and longer lives. At the same timeolder people in most northern Europeancountries are no longer expected to takecare of their grandchildren or children andare to a greater extent more concernedwith enjoying their lives.

The rise in consumption and mass commu-nication combined with the move insociety towards individualism has alsoinfluenced older individuals’ motivation tomove abroad. As Lipovetsky notes, we livein a society with unprecedented socialtemporality marked by the primacy of thehere-and-now.3 This individualism andsocial temporality also applies to olderpeople. Thus, pensioners retiring abroadcan increasingly access the internet,affordable telephone calls and ownlanguage cable television. With the advent

of low-cost airlines there are also greateropportunities for travelling between homeand host country for both migrants andtheir relatives.

Some of the evidence on patterns ofEuropean retirement migration identifies aseries of key factors encouraging olderpeople to retire abroad. Božic looking atex-patriots in Croatia identified the mostimportant factors for migration as climate,geopolitical location, level of propertyprices and familiarity with the region.4

One study of 266 retirees to Tuscany5 andanother looking specifically at UKpensioners retiring to Spain reportedsimilar factors including favourable naturalresources and landscape, respect forchildren and older people, friendly atmos-phere, security and the slow pace of life.6

In addition, older people preferred Spainover the UK because of perceived advan-tages to health, a good climate, the oppor-tunity to be active, the possibility ofspending more time outdoors and thewider availability of recreational clubs andassociations. This study also emphasisedthe lower costs of living in Spain as anadvantage over the UK in terms of value-for-money.6

Another study reported that UKpensioners form well-defined territorialand social units, benefiting from the strongvalue of their currency and previouspresence in Spain as tourists or residents.However, a lack of proficiency in Spanishhas prevented them from developing closerlinks with the local community.7 Otherstudies also suggested that these EU

pensioners tend to be isolated with few, ifany, close relationships with the localpopulation.4,7,8

The scale of the phenomenonThere has been a significant growth in thenumber of UK citizens retiring abroad.Aggregate data from the Department ofWork and Pensions indicated that, in 2006,more than 300,000 UK citizens retired toother Member States. This data is based onthe number of pensions transferred. Abreakdown of countries of destinationindicates that UK citizens have a primaryaffinity with Ireland (103,667) followed bySpain (76,357) and then to France, Italyand Germany each of which receives morethan 30,000 migrants.9

The information available on the UKpopulation in Spain is somewhat limited.The Instituto Nacional de Estadística(INE) estimates that there are currently314,098 UK citizens living in thecountry.10 That would make UK citizensthe fourth largest foreign community inSpain, following Moroccans, Romaniansand Ecuadorians. It is estimated that 53%are over the age of fifty. However, the truefigures are likely to be higher because ofthe underreporting of pensioners who staymore than three months per year in two(or three) countries. These pensioners maytravel back and forth without regularisingtheir situation each time they move.

The INE estimates, through the figuresprovided by the municipalities (thepadrón), that the total number of UK menaged over sixty-five and UK women oversixty was 87,359 in January 2007. This is



Figure 1: UK long-term residents aged over 55 years in Spain by Autonomous Community

Source: Instituto Nacional de Estadística 2006.10

possibly the most reliable source of data onforeign pensioners since migrants whowish to access health and social servicesneed to register with local municipalities.However, this register is not used to definethe administrative residential situation ofUK pensioners, since municipalities arenot responsible for processing residencepermits. In fact, only 56% of the UKpopulation registered with the padrónshold a residence permit. Figure 1 showsUK citizens resident in Spain byAutonomous Community (AC) and age inJanuary 2006. The ACs with the most UKresidents over fifty-five were Valencia with58,779, Andalucia (33,021), Canarias(10,809) and Baleares (6,520).

Health, health care arrangements andexperiences of EU pensioners retiring toSpainLooking at some studies on the health carearrangements of pensioners retiring toanother Member State, one study, based oninterviews with key informants and asurvey amongst Germans aged fifty-fiveplus living in Majorca in 1999, identifiedseveral problems impacting on theirhealth.11 These included housing anddwelling locations that were perceived notto be compatible with the requirements ofolder people; the lack of harmonisation ofthe health and social care systems betweenGermany and Spain which complicatedapplying for access to the health caresystem, and the scarcity of welfare institu-tions for those who had become frail.Another study using in-depth interviewsand focus groups obtained similar resultsafter studying the retired population inCambrils and Calvia (Spain).12

The migration of older Swiss people to theCosta Blanca (Spain) in the period from1999 to 2001 has also been analysed.13

Using a mix of methods, it suggested thatthe majority of pensioners did not wish toreturn to Switzerland under any circum-stances, not even in the event of the deathof their partner. While this information isnot directly related to the health and healthcare needs of Swiss retirees in Spain, itpoints to a potential great future demandfor health care services for this population.

In contrast, Norwegian migrants werefound to have very different views.14 Basedon interviews with eighteen people aged60 –75 years, the main concerns voicedwere the loss of social rights previouslyenjoyed in Norway and problems relatedto the process of repatriation. There was aperceived lack of nursing homes in Spain

having staff familiar with the Norwegianlanguage. These Norwegian pensionerstended to prefer to move back to Norwayto spend their ‘last days’ and be buriednear their families.

UK migrant retireesAs indicated above, there is little researchrelating specifically to the health care needsof migrants retiring abroad. We nowdiscuss the situation in respect of UKmigrants, drawing on data both from the‘Europe for Patients’ project15 whichexplored the health care arrangements oflong-term residents, including pensionersin Spain through stakeholder analysis, andfrom research carried out by La Parra andMateo.16 The latter looked at the generalhealth of UK older citizens living on theCosta Blanca and their access to and utili-sation of health care services (see Box 2).

“the lack of long-term care andhome care in Mediterraneancountries is a concern”

All the foreigners registered in the padrónin Spain, have the right to access theNational Health System. The Spanish Lawon Foreign Nationals (LE 4/2000) guar-antees this right to all EU and non-EUmigrants regardless of whether they areundocumented or legal migrants. Once amigrant has registered in a municipality,he/she can apply for a health card. Thetotal number of health cards issued inSpain for UK Citizens is difficult toestimate, as each AC manages their healthcare service independently.

As of March 2007, in the Valencian ACalone the total number of UK citizensholding a health card was 64,820, repre-senting 52% of the total UK populationregistered in the padrón .17,18 These figuressuggest that some citizens have no publicarrangements to cover their needs and mustbe using private health care in Spain or/andthe National Health Service in the UK.This has been confirmed in another studywhich stated that 67% of UK pensionerswere covered exclusively by the SpanishNational Health System or the UKNational Health Service, 17% by bothpublic health care providers and privatemedical insurance, 12% relied exclusivelyon private health-care, and 3% claimed notto be covered by public or private care.16

Among those who benefited from publichealth care services, 73% made use of theValencian Region Health Service and theremainder the UK National Health Service.

Foreign residents in Spain who do nothave a Spanish Health Card are primarilythose who spend half of the year in their‘home country’. In these cases, patients areonly registered in one of the two healthcare systems. Formally they should applyfor a new E121 every time they go backand forth, but this option creates a hugebureaucratic burden as it must be repeatedat least twice a year.



Box 2 Health status of UK pensionersretiring abroad

• UK nationals resident on the Costa scorehigher than Spaniards and UK-based citizenson some indicators, with fewer mobilityproblems and a more positive perception oftheir state of health.

• It is suggested that some residents whobecome dependent choose to return to theirhome countries to seek professional help andsupport services.

• Other indicators suggest that all age groupsare more vulnerable to mental healthproblems than the UK home population.

• Cigarette smoking and alcohol consumptionare higher among the UK ex-pats living onthe Costa Blanca; consumption of both riseswhen they move to Spain.

• The number of visits to a general practi-tioner by UK ex-pats was approximately thesame as for their Spanish neighbours.Although, admissions to hospital are higherthan for the Spanish, rates for UK ex-pats arecomparable to those seen in the UK. Thisnormal level of health service use results fromaccess to multiple providers: the ValenciaRegion Health Service, the UK NationalHealth Service, and the private sector

• UK residents on the Costa Blanca makerelatively high use of private health carecompared to the Spanish and UK popula-tions. The reasons that encourage them toturn to the private sector are likely to belanguage difficulties in the public sector aswell as the usual advantages, such as shortwaiting times, faster follow-up, fewer clinicvisits and less paperwork.19

• The most commonly cited problems involvedin using the Valencia Region Health Servicewere perceived to be communication (use ofthe Spanish language) and the administrativeprocesses (information, places, rights, proce-dures, waiting times). However, their overallperception was quite positive.

Source: 16

Some long-term residents are alsoconcerned that by applying for the E121they will lose some social welfare benefits,due to the difference in benefits providedby each Member State. For example,pensioners in the UK have supplementarysocial benefits such as a winter heatingallowance, disability allowances and careallowances. Another concern is the lack oflong-term care and home care in Mediter-ranean countries where these services havetraditionally been provided by the family.

Furthermore, the processes involved intransferring registration are perceived asbureaucratic and inflexible. Long-termresidents who have been through theprocess of transferring their rights usingthe E121 are reluctant to engage in what isseen as a lengthy and painful process toreverse their registration. They are oftenafraid of losing the option of returning totheir home country. Thus there are largenumbers of long-term residents who optnot to regularise their situation, so formingpart of the ‘floating population’.15 There isno clear provision for these groups, whichbecomes particularly problematic forpatients with chronic diseases.

“hospitals are beginning toinclude language skills as acriterion when hiring staff”

It is suggested that this ‘floating popu-lation’ of long-term residents in fact havetheir health care needs met primarily bymeans of the European Health InsuranceCard (EHIC)* while in the ‘receivingcountry’. However, this scheme isdesigned for use in emergency situationsonly and does not ensure continuity ofcare. Furthermore, the recording oftreatment provided under the EHICscheme is often poor, creating gaps in anindividual’s medical records.

It is also suggested that some pensionersdo not hold the Spanish Health Cardbecause of a lack of information or diffi-culties with administrative procedures.

Stakeholders report that patients are oftennot well informed on how the system inthe country works, partly due to the segre-gation of expatriate communities, languagebarriers and patients’ ignorance of theproblems as long as they have no real need.

Language barriers are reported by key-informants, when the patient and theprovider do not speak the same language.In countries with different linguistic andcultural traditions to the home country,these factors can constitute a barrier tonewcomers. Lack of a common languagecould lead to considerable problems incommunication between patients anddoctors. However, hospitals are becomingaware of the need to assist non-Spanishspeakers and are beginning to includelanguage skills as a criterion when hiringnew staff.15

ConclusionAnalysis to date suggests that there is agreat need for research on health needs andutilisation of health services; to exploreUK pensioners’ perceptions of the needfor health care and their health care seekingbehaviour; and to assess UK pensioners’perspectives of the responsiveness ofhealth care services in Spain. Health careneeds in this population are determined bytheir demographic situation (as the healthprofile of migrants differs somewhat fromthat of the general home and receivingcountry populations); their cultural back-ground (language acting as a determinantof their health care seeking behaviour); andtheir administrative situation in a contextof higher human mobility (‘fixed laws,fluid lives’).20 In addition, it is alsoimportant to consider how local andregional authorities are planning healthcare services and what financial compen-sation mechanisms are agreed betweenMember States. An understanding of theseissues would be beneficial for all the actorsinvolved in planning health services andassuring their financial sustainability, andfor those who wish to retire or havealready retired in another Member State.

However, these effects are complex tostudy and some contradictions can beexpected. Health status can act as a factorwhen taking the decision to move abroad,

as well as influencing how long a migrantstays in the host country. UK citizens areentitled to use the Spanish health system,but cultural barriers might prevent themfrom doing so. They might instead preferto use private health care services or theUK NHS. The relative use of healthservices by unit is low (UK pensionershave relatively good health and preferprivate and home care services), but theabsolute use of health services by thisgrowing and concentrated populationcould have an important effect on thedynamics of the health service. Ifgovernment and policy makers promoteimmigration through the urbanisationprocess, they should also plan services thattake into account the health status andhealth care needs of these newcomers.

REFERENCES

1. King R, Warnes T, Williams A. SunsetLives: British Retirement Migration to theMediterranean. Oxford: Berg, 2000.

2. Legido-Quigley H, McKee M, GlinosIA, Baeten R. Drivers of Patient andProfessional Mobility. London: LondonSchool of Hygiene and Tropical Medicine,2006.

3. Lipovetsky G, Brown A, Charles S.Hypermodern Times. Cambridge: PolityPress, 2005.

4. Božic S. Posljednja avantura: umirovl-jenicke migracije, klima i ‘ugodnosti’ [Thelast adventure: retirement migration,climate and ‘amenities’]. Migracijske ietnicke teme 2001;14(4):311–26.

5. Crescenzi S. Northern European peoplein Tuscany: Northern Maremma. Pisa:Università degli Studi di Pisa, 2001

6. O’Reilly K. The British on the Costadel Sol. London: Routledge, 2000.

7. Rodríguez V, Casado Díaz MA, HuberA. Impactos de los retirados europeos enla costa española. [The impact ofEuropean retirees on the Spanish Costa]Ofrim Supplementos 2000; 7:117–138.

8. Casado Díaz MA. Estate agents andurban growth in Torrevieja 1989–1995.Alquibla 1997;3:315-337.

9. Department of Work and Pensions.Main EU Countries of Residence of UKCitizens Receiving Pensions. London:Department of Work and Pensions, 2006.

10. Instituto Nacional de Estadistica.Padron Municipal. Madrid: InstitutoNacional de Estadistica, 2007.

11. Kaiser C, Friedrich K. DeutscheSenioren unter der Sonne Mallorcas: das



* The establishment of the European Health Insurance Card (EHIC) was decided at theBarcelona European Council (March 2002) to promote occupational mobility in thecontext of the Lisbon agenda and to demonstrate the benefits of Europe to its citizens.The EHIC, designed to replace all existing paper forms required for occasional healthtreatment when in another Member State (E111, E110, E119, E128), was presented as away to simplify procedures for patients, providers and administrations.

Since 1955, when Milton Friedmanpublished The Role of Government inEducation,1 the political right has had avirtual monopoly on choice and compe-tition in public services. Traditionalthinking on the right posited that greateruser choice of providers tied to a reim-bursement system where money followedusers’ choices would promote bothallocative and technical efficiency. Thepolitical left not only disputed the right’sefficiency claims, but went one step furtherand argued that any increase in user choicewould come at the expense of equity.

This left/right battle over choice andcompetition continued until quite recently,when left leaning policy-makers began tocome around to the notion that choice andcompetition in public services might notbe such a disaster. Not only did thepolitical left begin to argue that choice andcompetition could incentivise efficiency,they began to draw attention to the factthat injecting choice and competition intopublic services could improve the care thatis delivered to traditionally under servedusers.

We argue that this emphasis on thepotential positive impact of choice andcompetition on equity is quite justifiable.In what follows, we draw on theory, pastexperience and empirical evidence to artic-ulate a case for the equity benefits ofchoice and competition.

A new rhetoric…From 2002 onwards, Tony Blair’s LabourParty embarked on an ambitious reformagenda to modernise the English NationalHealth Service (NHS). At the core of theformer Prime Minister’s health servicereforms was a belief that greater userchoice and provider competition wouldcreate a more personalised NHS withbetter quality and less inequity than tradi-tionally collectivist public health systems.

Speaking in 2003, Tony Blair said:

“People should not forget the currentsystem is a two-tier system when thosewho can afford it go private…choicemechanisms enhance equity by exertingpressure on low-quality or incompetentproviders. Competitive pressures and

Choice, competition and thepolitical left

Zachary Cooper and Julian Le Grand

Summary: Choice and competition can no longer be viewed as an exclusive toolof the political right. Beyond creating incentives to drive up quality and increaseefficiency in the English NHS, choice and competition stand to promote equity.While many left-leaning critics are quick to point out ways in which choice andcompetition could induce inequity, few critics objectively compare the equityimplications of choice and competition to the no-choice system which preceded it.This article lays out the basic arguments for how choice and competition stand toimprove equity. If the political left is serious about reducing inequities in publicservices, the time is right for them to open their eyes to the potential for choiceand competition.

Keywords: Equity, NHS, Choice, Competition, Collectivism, England

Zachary Cooper is reading for a PhD and Julian Le Grand is Richard Titmus Professor ofSocial Policy, both at the Department of Social Policy and LSE Health, London School ofEconomics and Political Science. Email: [email protected]

Phänomen Ruhesitzwanderung. PraxisGeographie 2002;2.

12. Solé C (ed). Inmigración Comuni-taria: ¿Discriminación Inversa?[European Community Immigration:Inverse Discrimination?] Barcelona:Anthropos, 2006.

13. Huber A. Los jubilados suizos en laurbanización de Ciudad Quesada(Alicante): una investigación cualitativa.[Swiss pensioners in Quesada City(Alicante): a qualitative investigation]Alquibla 2001;7:437–51.

14. . Helset A. An Alternative PensionerLife Style? Norwegian Old-agePensioners in Spain. Oslo: NationalHealth Association and Nova’s StrategicInstitute Programme, 1999.

15. Rosenmoller M, Lluch M. Meetingthe needs of long term residents. In:Rosenmoller M, McKee M, Baeten R(eds). Patient Mobility in the EuropeanUnion: Learning from Experience.Brussels: European Observatory onHealth Systems and Policies, 2006.

16. La Parra D, Mateo A. Health statusand access to health care of Britishnationals living on the Costa Blanca,Spain. Ageing and Society2008;28:85–102.

17. CeiM. La asistencia sanitaria a lapoblación extranjera: una necesidad y underecho [health care for the migrantpopulation: a necessity and a right]Valencia: Centro de estudios para la inte-gracion socialy formacion de inmigrantes,Fundacion de la Communidad deValencia, 2006. Available athttp://www.ceimigra.net/viejaweb/ceim_home/miradas/miradas9.pdf

18. CeiM. Anuario CeiMigra 2007. Lasmigraciones en un mundo desigual[Migration in an unequal world] Valencia:Centro de estudios para la integracionsocialy formacion de inmigrantes,Fundacion de la Communidad deValencia, 2007.

19. Lurbe K. La utilizacion de losservicios sanitarios en la vejez : underecho a disposicion desigual entre laspersonas jubiladas comunitarias y autoc-tonas I [The utilisation of health careservices in old age: inequalities in accessbetween migrants and native pensioners]In: Sole C (ed). Inmigracion comunitaria:¿discriminacion inversa? Barcelona:Anthropos, 2006 pp. 47–63.

20. Ackers L, Dwyer P. Fixed laws, fluidlives: the citizenship status of post-retirement migrants in the EuropeanUnion. Ageing & Society2004;24(3):45175.




http://www.ceimigra.net/viejaweb/ceim_home/miradas/miradas9.pdf

incentives drive up quality, efficiency andresponsiveness in the public sector. Choiceleads to higher standards.

“The overriding principle is clear. Weshould give poorer patients…the samerange of choice the rich have alwaysenjoyed. In a heterogeneous society wherethere is enormous variation in needs andpreferences, public services must beequipped to respond.“2

Echoing the former Prime Minister’s senti-ments, former Health Minister John Reidsaid:

“These choices will be there for everybody…not just for a few who know their wayaround the system. Not just for those whoknow someone ‘in the loop’ – but foreverybody with every referral. That’s whyour approach to increasing choice andincreasing equity go hand in hand. We canonly improve equity by equalising as far aspossible the information and the capacityto choose.”3

What sets John Reid and Tony Blair’scomments apart from the choice andcompetition rhetoric of old is their focuson the potential of choice and competitionto promote equity. Their rhetoric was clearand consistent: the political right need nothave a monopoly on choice; choice is notexclusively related to efficiency; andgreater choice could mean better servicesfor all users, including, and perhaps inparticular, users in the lower socioeco-nomic groups.

A new rationale…But why? Choice and competition stand topromote equity largely in two ways: first,by blunting the advantage the middle andupper classes have long had in creatingadditional choices and negotiating bettercare in systems without formal choicemechanisms; and second, by sharpeningincentives for providers to becomeresponsive to all users, possibly inparticular, users from the lower socio-economic groups.

The old political left has long assumed, apriori, that collectivist public services likethe NHS are inherently equitable.Standard ‘collectivist’ thinking is thatwhen there is no choice for users, thegovernment can equalise the standard ofcare across the country and every user canhave access to the same quality services.This collectivist ideal sounds ok in theory,but fails (rather dramatically) in practice.

In particular, the faulty assumption in the

old left’s thinking was taking for grantedthat there was no choice for users insystems without formalised choice mecha-nisms. There is. Even in public servicesystems without formalised choice mecha-nisms, choice still exists for users who are(1) able to negotiate with their generalpractitioners and other medical providersfor more choices using their louder voices;(2) able to move to areas with better localservices; and (3) when all else fails, opt outof public services and enter the privatesector.

“Giving a choice of providers to all service users would takeaway the advantage that themiddle and upper classes havelong had accessing privilegedcare”

Using voice, moving to areas with betterlocal services, and paying for care in theprivate sector all favour the middle andupper classes. The wealthy and the moreeducated tend to be more articulate, moreconfident and more comfortable speakingto doctors and as a result, are morepersuasive negotiating for more care.Home prices tend to be closely correlatedto the quality of local public services, sothose users who move to areas with betterservices tend to be users with greaterincomes. Finally, middle and upper classcitizens tend to have the ability to pay forprivate sector care and live in areas wherethere is greater availability of private sectorservices.

Giving a choice of providers to all users,irrespective of their socioeconomic status,would take away the advantage that themiddle and upper classes have long hadaccessing privileged care. Now, less advan-taged users can have access to the samefleet of providers the wealthy have becomeaccustomed to.

Greater choice of provider, tied to a reim-bursement scheme where money followsuser choice can also make providers moresensitive to user preferences. Withoutchoice, if users were not happy with theirservices, their only option for improvingtheir care would be to negotiate withproviders and voice their preferences orturn to a formal complaint mechanism.The only incentive for providers to listen

to patients was appeasing unhappy users(and quieting their complaining) orheeding to their greater sense of profes-sional responsibility. When money followsusers’ choices and users have the option ofexiting their current service, providershave a financial incentive to be responsiveto their patients. In a health service withchoice of provider and a reimbursementscheme where money follows patients’choices, if providers do not listen to theirpatients, then patients can choose to seekcare elsewhere and providers will see theirincome start to fall.

The old left has two primary criticisms ofchoice on equity grounds. First, they arguethat the well off are better equipped tomake choices and will take the best optionsfor themselves, leaving what they do notchoose for everyone else. Second, the oldleft argues that choice is going to lead tocream-skimming: if providers are paid perepisode of care they deliver, then they arelikely to select patients who are thecheapest to treat. Wealthier patients areusually healthier, so the old left argues thatthis type of scheme will embed incentivesfor providers to avoid treating poorpatients.

The first equity criticism of choice issummarised by Roy Hattersley, whowrote:

“[C]hoice is an obsession of the suburbanmiddle classes. But when some familieschoose, the rest accept what is left. And therest are always the disadvantaged anddispossessed. “4

To be sure, the wealthy and educated maybe better equipped to interpret infor-mation, but that is not to say that thosewho are less well equipped to makechoices cannot be assisted in getting themost from a public service scheme withchoice. In an effort to help patients choose,provider quality information needs to bemade as accessible as possible and theremust be staff assigned to help users chooseand determine which providers andoptions are best for them.

This is precisely what was done in theLondon Patient Choice Pilots, wherepatients were assisted in choosing byPatient Care Advisers (usually speciallytrained nurses). The Patient Care Adviserswere very well liked and nearly every pieceof evidence from the London PatientChoice Pilot suggests that there was nodifference in outcomes or likeliness tochoose between social classes or agegroups.5



In addition, implicit within this old-leftcritique of choice are assumptions that (1)referral patterns will dramatically changeafter choice is introduced and (2) thatpatients need to choose in order to get thebenefits of choice. However, rather thancreating a mass exodus away from currentproviders, user choice will not dramati-cally impact current referral patterns; it ismost likely to induce change at the marginswith a small percentage of patients optingto receive care elsewhere.

Traditional micro-economic theory positsthat an ‘exit’ of five to ten per cent of userswill send sharp signals to providers to raisetheir performance. In effect, users whochoose to remain with their local servicesbenefit from the minority who choose toleave. Looking at school choice in the US,Caroline Hoxby examined the outcomesof students who did not exercise choiceand who remained in their originalschool.6 Hoxby found that students inschools with greater competition (wheremore students chose to exit) did betterthan students in schools where fewerstudents exercised their ability to exit.Essentially, Hoxby’s results suggest thatgreater choice and competition in publicservices creates a tide that lifts all boats:users who do not exercise choice are posi-tively impacted by users who do andeveryone’s public services improvetogether.

The fear that increased choice of providerand provider competition will lead toproviders cream-skimming and selectinghealthier, wealthier users is perhaps thestrongest strike against choice and compe-tition. However, cream-skimming is notinevitable. For starters, there is nothing tosay that providers should be afforded theopportunity to select their patients inadvance. Policy-makers could organisepublic services in such a way that providershad no choice of who they see.

Beyond that, a more appealing option tothwart cream-skimming might be bymaking provider reimbursements inverselyproportional to service users’ socio-economic status. Providers could be reim-bursed more for seeing less wealthypatients and reimbursed less for seeingwealthier patients. Not only would thismute any incentives for providers tocream-skim, it would create incentives forproviders to become more responsive toless advantaged service users. The morepolicy-makers weight reimbursements infavour of the less-well off, the more likelyproviders are to compete with one another

to see patients who are often marginalisedin the health system. This would prompt adramatic shift from the doctor-patientdynamic we would ordinarily expect in atraditional collectivist health system.

“Choice creates strong incentives for providers tobecome responsive to all users,not just those with the loudestvoices”

Some closing thoughts…The question before us is not whether aparticular reform is equitable orinequitable in toto; rather, the question weneed to address is whether a particularreform stands to be more or less equitablethan the structures that precede it. Criticsof choice and competition have beenravenous in their desire to point out everyconceivable way in which choice ofprovider and provider competition couldinduce inequity. While this is certainly avalid academic exercise, it is not policyrelevant. Instead of pointing out everydetectable flaw (of which there are manyin any reform, whether collectivist ormarket-based), health policy commen-tators would be better off examining theequity implications of choice-basedreforms in comparison to the collectiviststructure it replaced.

When viewed in the context of traditionalcollectivist public services, it is clear thatthere is a strong argument to be made thatincreased choice and competition have thepotential to promote equity. Greater userchoice, tied to a reimbursement scheme

where money follows user choice amelio-rates many of the ways middle and upperclass citizens have historically been able togarner more privileged care. Moreover,they create strong incentives for providersto become responsive to all users, not justthose with the loudest voices.

If the traditional left is serious aboutaddressing equity, it is time that they shakeoff their intuitive dislike of market-basedreforms and take a hard look at whetherchoice and competition has the potential toimprove the care delivered to traditionallyunderserved users. We think it does.

REFERENCES

1. Friedman M. The role of government ineducation. In: Solo R (ed). Economics andthe Public Interest. Rutgers University:Rutgers University Press, 1955. Availableat http://www.schoolchoices.org/roo/fried1.htm

2. Blair T. We must not waste this preciousperiod of power. Speech given at SouthCamden Community College, London, 23January 2003.

3. Reid J. Speech to the New HealthNetwork, London, 16 July 2003. Availableat http://www.newhealthnetwork.co.uk/Documents/Event/newhealthnetwork-choicespeechfinal16.doc

4. Hattersley R. Agitators Will Inherit theEarth. The Guardian, 17 November 2003.

5. Dawson D, Jacobs R, Martin S, Smith P.Evaluation of the London Patient ChoiceProject. Report to the Department ofHealth. York: University of York, 2004

6. Hoxby C M. School choice and schoolcompetition: evidence from the UnitedStates. Swedish Economic Policy Review2003;10:11–67.



New Health Systems in Transition (HiT)profileThe latest addition to the Health Systems in Transitionseries has just been published and is available online.

It focuses on Denmark, a small country with 5.4 millioninhabitants. Danish health care is dominated by thepublic sector, financed by local and state taxes andadministered by the regions. In recent years the focus ofhealth care reform has been on patient choice, waitingtimes, quality assurance and coordination of care.

The publication of the HiT is very timely because a major structural reform in2007 changed the political and administrative landscape dramatically.Reforms in the way health care is financed also took place.

Available at http://www.euro.who.int/Document/E91190.pdf

http://www.schoolchoices.org/roo/fried1.htm

http://www.newhealthnetwork.co.uk/Documents/Event/newhealthnetwork-choicespeechfinal16.doc

http://www.euro.who.int/Document/E91190.pdf


During the past decade health care insurersin the United States have been integratinga model of provider reimbursement calledpay-for-performance (P4P) into the tradi-tional reimbursement system, where themodels have been fee-for-service, capi-tation or budgets, case-related reim-bursement (for example, diagnosis-relatedgroups – DRGs), and salaries. Under pay-for-performance, providers are givenfinancial incentives to encourage and rein-force pre-established targets for health caredelivery.1 The overall intent is to improvethe quality of health care provision andenhance patient outcomes.

In Europe pay-for-performance withinhealth care is still a relatively new concept,with the UK being one of the firstEuropean countries to implement a systemof this kind. Given its novelty in Europe, itis important to discuss whether theoutcomes of P4P in the US have been asexpected and their relevant implicationsfor European health policy.

Introduction to health insurance anddelivery in the USHealth insurance coverage in the US isfragmented between public and private

payers. The main public organisations areMedicare, Medicaid, and other publicinsurers like the Veterans Administrationand TRICARE. Medicare is mainlyavailable to certain disabled people andindividuals aged sixty-five and above.Physician reimbursement is based on a feeschedule that is adjusted according tofactors such as the type of serviceprovided, where the service is performed,and geographical location. Hospitals arereimbursed according to the DRGmethodology, which is a system that clas-sifies hospital cases into groups withsimilar expected hospital resource use.

Medicaid covers certain low-income indi-viduals, and the programme is overseen bythe Federal government and administeredby the states. While Medicaid programmeshave considerable leeway in determiningmethods of provider reimbursement, moststates reimburse physicians via fee-for-service (adjusted by the specific serviceperformed) or capitation. Hospital reim-bursement methodologies include perdiem rates, cost-based payments, DRGpayments, and capitation.

Private insurance coverage encompassesgroup and non-group coverage andmanaged care and fee-for-serviceprogrammes. Even within these categories,physician and inpatient reimbursementmethodologies may vary considerably.Physician reimbursement is generally fee-

for-service or capitation, while inpatientreimbursement may be per diem, capi-tation, or case rates (including DRGs).

The rationale behind P4POne disadvantage of the traditional reim-bursement models is the lack of emphasison quality. For instance, there may beoveruse of medical treatment under fee-for-service, while there may be underuseunder capitation or salaries. The USInstitute of Medicine (IOM) highlightedthe importance of provider reimbursementin a 2001 report, Crossing the QualityChasm.2 The IOM argued that the qualityof US health care was well below estab-lished benchmarks based on the bestavailable evidence, and that paymentmechanisms were an importantcontributor to the poor quality of care.Other researchers have indicated thatadherence to evidence-based practices isvariable across regions and providers,3

implying that US insurers and providershave considerable scope to implementquality improvements. In response, healthplans and purchasers have put a consid-erable amount of effort into profilingproviders and publicly reporting infor-mation on the quality of differentproviders, but evidence indicates thatconsumers fail to use this informationwhen making health care decisions.3

The nature of health care delivery,

Pay-for-Performance in the US:What lessons for Europe?

Marin Gemmill

Summary: Pay-for-performance (P4P), a model of provider reimbursement linked toquality achievement or improvements, has been gaining traction in the United States.This paper examines the rationale behind P4P programmes and discusses some recentexamples of pay-for-performance initiatives within the private insurance, Medicare,and Medicaid programmes in the US. While the evidence on P4P is still relativelyscant, we are able to derive some preliminary conclusions on the design and effec-tiveness of P4P activities from the existing evidence. These considerations are thendiscussed in light of European health policy, and we provide some insight forEuropean policy makers on the adoption of P4P programmes.

Keywords: pay-for-performance, provider reimbursement, quality

Marin Gemmill is Research Officer, LSEHealth, London School of Economics andPolitical Science. Email: [email protected]

PERSPECTIVES FROM THE US


whereby a physician acts as an agent forthe patient and a third-party payer coversthe majority of costs, implies thatconsumer choice alone may be insufficientfor bringing about quality improvements.Pay-for-performance provides financialincentives to improve quality even whenconsumers are unresponsive to qualityinformation. This reimbursement model isalso expected to encourage ongoingquality improvements, for instance,through the installation of health infor-mation technology and more health carestaff. Importantly, P4P may not reducehealth care costs, but it is meant to ensurebetter value for money.

P4P methodologiesThere are multiple ways in which modelscan be designed. The main features centrearound the aspects of quality that aretargeted, the allocation of the rewards, andwhether rewards are based on qualityimprovements or target achievement. Thetargeted aspects of quality may bestructure, process, outcome, or a combi-nation of all three.3 Structure encompassesthe resources needed to deliver care (forexample, labour, facilities, and materials),process covers the completion of specifictasks or suggested procedures, andoutcome includes the effect of treatment,mainly the patient’s experience and healthstatus. Each aspect has its own advantagesand disadvantages, but essentially thechoice of which aspects to target influencesthe level of quality improvements, equity,and the amount of risk that providersexperience.

Third-party payers can also choosewhether to allocate rewards to individualproviders or groups of providers. Thedifficulty in allocating rewards to indi-vidual providers is that some providersmay have small patient groups leading toskewed outcomes, while incentives toimprove quality may be muted in providergroups. The intuition is that withinprovider groups, some providers may‘free-ride’ on the efforts of other providers.However, by rewarding provider groups,P4P programmes may create an incentivefor coordinated care, for instance, throughthe creation of multi-disciplinary providergroups. Another important aspect of P4Pis whether providers are rewarded forgood performance or for improvingquality. The former method rewardsproviders that are already high-quality butgives little incentive to low-qualityproviders to improve.

The uptake of P4P in the USPay-for-performance systems havediffused relatively rapidly throughout UShealth care insurers within the past decade,albeit on a small scale. Within privateinsurance markets more than half of healthmaintenance organisations (HMOs) haveinstituted P4P programmes, coverage thatrepresents more than 80% of HMOenrollees in the US.4 Pay-for-performance is also growing in importancewithin the public insurance arena. By July2006 more than half of the state Medicaidprogrammes had implemented pay-for-performance schedules, and it is estimatedthat by 2011, almost 85% of states willoperate Medicaid P4P programmes.5

Medicare is also embracing P4P, althoughmore detail on Medicare initiatives is givenlater in the article.

Despite the widespread use of P4P, theseprogrammes typically make up a smallproportion of provider reimbursement.Rosenthal and colleagues previously indi-cated that most payers only put 5% or lessof provider compensation at risk of profitor loss from the P4P system.3

Examples of P4P in the USWhile there are hundreds of different P4Pactivities running, it is useful to discuss themain initiatives on the part of public andprivate payers. Medicare began running aP4P demonstration project jointly withPremier, Inc. (a nationwide organisationfor non-profit hospitals) in 2003.3 Theprogramme rewarded hospitals accordingto performance in five critical treatmentareas for older people: acute myocardialinfarction, heart failure, pneumonia,coronary artery bypass graft (CABG)surgery, and hip and knee replacement.The quality determinations were based onprocess and outcome measures. Allhospitals were scored and ranked bytreatment area. Hospitals in the top 10%of performers for each condition receiveda bonus of 2% of their Medicare payments.Hospitals in the next decile received a 1%bonus. The demonstration has ended, andPremier, Inc. and Medicare are currentlydiscussing whether to extend the exper-iment. In 2007 Medicare also launched thePhysician Quality Reporting Initiative,providing a 1.5% (of total allowed chargesfor eligible services) bonus for partici-pating providers that successfully reportthe designated set of seventy-four qualityindicators.

Pay-for-performance programmes withinMedicaid are generally state-specific.

However, nine Medicaid programmes havejoined with other groups to improve pay-for-performance activities.5 A specificexample is the Oregon Health CareQuality Corporation, a group of organisa-tions (the state government, health plans,medical groups, insurers, purchasers,providers, and consumers) that areworking together to incorporate stan-dardised performance measures into P4Pprogrammes.5 Interestingly, manyMedicaid agencies are encouraging participation rather than performance intheir P4P programmes; the intent is toincentivise providers to adopt technologiessuch as electronic health records and electronic prescribing.5

In California, a group of health plans andphysician groups developed the CaliforniaPay for Performance programme,6 whichentails a set of quality performancemeasures, public report cards and financialincentives. The programme is now thelargest of its kind in the US. Performanceis measured on three main domains:clinical events (preventative measures andchronic care management), patient expe-rience, and information technologyinvestment.6 The California programmedoes not define the level of financialreward; instead this decision is left up tothe individual participating health plans.

Another P4P programme backed by largeemployers is Bridges to Excellence (BTE),which aims to incentivise physicians in anumber of target markets across the US toimprove health care quality.3 BTE has fourdistinct initiatives: the Diabetes Care Link,the Cardiac Care Link, the Spine CareLink, and the Physician Office Link.Participants are awarded points forachieving quality measures within each ofthese links, and points are translated intofinancial awards that are specific to eachlink.

Evidence from the literatureEmpirical evidence on P4P programmes isstill relatively scant, but based on onereview of the literature it is possible todraw preliminary conclusions regardingthe outcomes and design of P4Pprogrammes.7 This review indicated thatmost studies found partial or positiveeffects of P4P financial incentives onquality measures, whether the activity wasat the individual physician or physiciangroup level.

In addition, the design of incentives isimportant. A few studies have determinedthat documentation, as opposed to actual



use of preventative services, improvedunder P4P.7 While documentation isimportant, quality improvements also needto come from better use of services. Thedesign of incentives may also have influ-enced risk selection in that providers mayhave avoided sicker patients where this waspossible. Given that P4P programmes cantarget individual providers or providergroups, the authors of the review also indi-cated that the effect of P4P at the providergroup-level is small, whereas the effectseems less muted for rewards at the indi-vidual physician level. Thus, it appears thatsome providers may ‘free-ride’ on theefforts of other providers within thegroup.

As discussed earlier, there is debate overwhether providers should be rewarded formeeting benchmarks or for improvingperformance. Interestingly, providers withthe lowest baseline performance mayimprove the most even if they receive thesmallest amount of performance pay,implying that a P4P programme shouldconsider incentives for both improvementand target achievement. The size of thereward may also influence whether P4Phas any effect on the achievement of targetindicators.7 Some studies that have foundno relationship between the P4Pprogramme and quality may have obtainedthis result because of small bonuses.

The review of P4P programmes foundonly one article that examined their cost-effectiveness. This study considered incen-tives to improve access to nursing homesand patient outcomes within the nursinghome.8 This indicated that the P4Pprogramme saved an estimated $3,000 perstay. However, not only is that study overfifteen years old, but the savings that thestudy found may not have accrued to thethird-party payer. Thus, there is insuffi-cient evidence available to draw anyconclusions on the cost-effectiveness ofP4P programmes.

Pay-for-performance in EuropeThe P4P model has already made its wayinto Europe with the implementation ofthe large-scale Quality and OutcomesFramework (QOF) for primary care in theUK. Under QOF general practitioners arerewarded for chronic disease management,practice organisation, patient experience,and extra services (for example, childhealth and maternity services)9 Overall,Europe lags behind the US in implemen-tation of P4P programmes, and thus anumber of comments can be offered to

European policy makers considering P4P.

One important but unanswered questionis whether P4P is cost effective. Whileliterature on this topic is lacking, it seemsprudent for European policy makers todetermine if a P4P programme providesvalue for money in a pilot setting beforeimplementing it on a large scale. Related tothe costs of the programme, the rewardstructure that a third-party payer imposesis important. If rewards are insufficient,providers may not change their behaviour.While there are few guidelines available onthe size of rewards, some suggest that 5%of the physician’s capitation income isnecessary for behavioural change.7 Inaddition, policy makers must decidewhether the reward is for meeting abenchmark, improving the influence ofquality on outcomes, or both. The choiceof the reward is related to whether the aimis to improve the performance of thelowest-quality providers, to maintain theperformance of the highest-qualityproviders, or to achieve a combination ofboth.

Risk selection is also important toconsider. If it is more difficult forproviders to improve performance withcertain types of patients (for example,sicker patients), then providers have anincentive to select healthier patients if thisis possible. Since many European healthcare systems explicitly aim for equity,disincentives for risk selection should bebuilt into any European P4P activities.England has addressed the possibility ofrisk selection by allowing providers toexempt reports on patients whose targetswere more difficult to meet.10

There is also the question of whetherproviders shift their focus to targets underthe P4P system and pay insufficientattention to medical issues that are not partof the system. This may lead to a focus onthe disease rather than on the patient.10

The question for policy makers is whetherthis influences the overall quality of careprovided. There is also a consideration ofwhether it is possible to design a P4Psystem that encompasses more qualitymeasures or whether this type of systemwould create too much of an adminis-trative burden.

Overall, the success of a P4P programmeappears to depend crucially on theprogramme design, as this influences theachievement of quality improvements.Importantly, there may be a trade-offbetween cost and quality, although more

research on cost-effectiveness is needed tomake any definitive statements regarding atrade-off. The variety of P4P measures thatcan be adopted also implies that Europeanpolicy makers need to clearly define theaims of any P4P programme and adoptspecific P4P measures to meet these aims.

REFERENCES

1. Forrest CB, Villagra VB, Pope JE.Managing the metric vs managing thepatient: the physician’s view of pay forperformance. American Journal ofManaged Care 2006;12:83–85.

2. Institute of Medicine. Crossing theQuality Chasm: A New Health System forthe Twenty-first Century. Washington:National Academies Press, 2001.

3. Rosenthal MB, Fernandopulle R, SongHR, Landon B. Paying for quality:providers’ incentives for qualityimprovement. Health Affairs2004;23:127–41.

4. Rosenthal MB, Landon B, NormandSLT, Frank RG, Epstein AM. Pay forperformance in commercial HMOs. NewEngland Journal of Medicine2006;355:1895–902.

5. Kuhmerker K, Hartman T. Pay-for-Performance in State MedicaidProgrammes: A Survey of State MedicaidDirectors and Programmes. New York:Commonwealth Fund, 2007.

6. Integrated Healthcare Association.Advancing Quality Through Collabo-ration: The California Pay for PerformanceProgramme. Oakland: IntegratedHealthcare Association, 2006. Available athttp://www.iha.org/wp020606.pdf.

7. Petersen LA, Woodard LD, Urech T,Daw C, Sookanan S. Does pay-for-perfor-mance improve the quality of health care?Annals of Internal Medicine2006;145:265–72.

8. Norton EC. Incentive regulation innursing homes. Journal of HealthEconomics 1992;11:105–28.

9. Department of Health. Quality andOutcomes Framework. London:Department of Health, 2008. Available athttp://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm

10. Galvin R. Pay-for-performance: toomuch of a good thing? A conversation withMartin Roland. Health Affairs2006;25:w412–w419.



http://www.iha.org/wp020606.pdf

http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm



In recent years the US managed careorganisation Kaiser Permanente (KP) hasstarted to influence mindsets and policydevelopment within many Europeanhealth care systems. Delegations fromtwenty-six countries, including thirteenfrom Europe have visited the organi-sation.1 The reason for this interest is thatKP has been highlighted as a successfulmodel of integrated cost effective care.2–4

In their influential article in the BritishMedical Journal (BMJ), Feachem et al.compared the costs and performance of theEnglish NHS with those of KP in Cali-fornia. They concluded that KP providedmuch better value, largely by using onlyone third of the acute bed days used in theNHS. This was explained by better inte-gration throughout the system, efficientmanagement of hospital use, the benefits

of competition and greater investment ininformation technology.2

Taken at face value, the benefits of the KPmodel are substantial. However, the claimwas subsequently disputed and severalserious criticisms were levelled at themethods used.5.6 Seventy-five letters weresent to the BMJ.7 Forty-six tried todismantle the authors’ analysis, whiletwenty-seven letters supported the paper,but many added that the superiority of KPcould be explained by the extra resourcesat its disposal.7 To investigate further Hamet al. carried out a more detailed study ofthe KP model.3 Their findings were againin favour of KP, with much lower hospitaladmission rates and overall length of staythan the NHS. Existing studies thereforeindicate that there are important lessons tobe learned from the KP model; theevidence base, however, is not conclusive.

To inform ongoing policy debate and facil-itate competent learning processes, this

paper presents an overview of the organi-sational structure of Kaiser PermanenteNorthern California (KPNC), recentdevelopments within the system, and high-lights points of interest for Europeanhealth care systems. Finally, we brieflydiscuss the necessity for research initiativesthat critically investigate the usefulness andtransferability of the KP model to Europe.This is done in recognition of the need forhigh level policy making to be based onevidence instead of convincing rhetoricand supposition.

The Kaiser Permanente health caremodelKP is an integrated managed care organi-sation founded in 1945 by the industrialistHenry J Kaiser and the physician Sidney RGarfield. It operates in the USA wherehealth care is largely provided by a mix ofprivate insurance companies, as well asthrough government programmes

Kaiser Permanente revisited –Can European health care systems learn?

Martin Strandberg-Larsen, Michaela L Schiøtz, Anne Frølich

Summary: European health care systems are facing the challenge of macroeconomicconstraints and a rise in patients with chronic conditions demanding a continuum ofservices. The US managed care organisation, Kaiser Permanente, has been high-lighted as a successful model of integrated, cost effective care. This claim has beendisputed, but the evidence base to guide European policymakers and health systemplanners is limited. This article presents an overview of the organisational structureand developments within Kaiser Permanente to inform this debate. Research initia-tives that are still needed to critically investigate the usefulness of the KaiserPermanente model for Europe are discussed.

Keywords: Integrated health care delivery, Self Care, Disease Management,Chronic Conditions, USA

Martin Strandberg-Larsen and MichaelaL Schiøtz are PhD Fellows and AnneFrølich Clinical Associate Professor at theDepartment of Health Services Research,Institute of Public Health, University ofCopenhagen, Denmark. Email: [email protected]

* Medicaid is the United States health care programme for individuals and families withlow incomes and resources.

** Medicare is a health insurance programme administered by the United Statesgovernment, covering people who are either aged 65 and over, or who meet other specialcriteria.


including Medicaid* and Medicare**.Thus KP operates in a competitive marketacross eight regional areas and is the largestnot-for-profit managed care organisationin the United States, with 8.2 millionmembers.8

Structure of KPNC There has been a particular focus in debateon the KPNC, the largest of the eightregional entities.

This is a consortium of three separate butinterdependent groups: the Kaiser Foun-dation Health Plan and Kaiser FoundationHospitals are integrated with independentphysician group practices called Perma-nente Medical Groups. The health plan isthe insurance component of the organi-sation, while the hospitals and medicalgroups provide all clinical services.7 To thepublic these hospitals and general practi-tioner type facilities are seen as one organ-isation, commonly referred to as Kaiser.

Integrated patient pathways

Within KPNC a range of health servicesare provided, including hospital admis-sions, ambulatory, preventive, sub-acute,accident and emergency care, as well asoptometry, rehabilitation and home healthcare. Coverage provided by KPNCdepends on an individual’s chosen healthplan, ranging from low coverage healthplans with relatively high co-payments toplans providing extensive coverage butminimal co-payments.2,9 Some Europeanhealth care systems cover dental servicesand both long term psychiatric or nursingcare to a greater extent than KPNC.

“there is a strong emphasis onprimary care and preventiveservices, including screeningprogrammes”

A typical patient in need of primary carewill in the KPNC be treated and cared forsolely within an out-patient medicalcentre. The medical centre will have arange of primary care facilities available,including paediatricians, internal medicinephysicians, geriatricians, other specialists,nurse practitioners, nurses, healtheducators, administrative personnel, apharmacy and an emergency department.Physicians also have access to in-house

laboratory facilities and other advancedmedical equipment.

Patients can be admitted to hospital wherenecessary. Subsequent care and some reha-bilitation will be administered outside thehospital at a skilled nursing facility (SNIF).KPNC enters into contracts with theseindependent SNIFs. Integrated patientpathways are facilitated by a team basedapproach and by multi speciality medicalcentres. Information exchange acrossproviders is made possible by the opera-tional electronic health record ‘KP Health-Connect’. This also allows for multiplepatient panel management and two-waypatient contact.8 Furthermore, KP HealthConnect has been an important driver inquality improvement by creating compe-tition between providers inside KPNCthrough the benchmarking of performanceoutcomes.

Financial resources The financial structure of KPNC sets theframework for the integrated delivery ofcare. The health plan and hospitals operateunder state and federal not-for-profit taxstatus, while the medical groups operate asfor-profit partnerships or professionalcorporations in their respective regions.10

In 2004 member dues accounted for 71%of KP revenues, with Medicare making up

a further 22.3% and co-payment,deductibles, fees and other revenues6.7%.11 These are paid to the Kaiser Foun-dation Health Plan which contracts withthe for-profit Permanente Medical Groupsand the Kaiser Foundation Hospitals thatrun medical centres in California, Oregonand Hawaii and outpatient facilitiesthroughout KP regions. Table 1 providesan overview of the financial structure ofKaiser Permanente, NC.

Focus on primary care and diseasemanagementDue to its history of being a supportfacility for an industrial production line,the KP system focused on keepingworkers healthy and treating the earlysigns of ill health. Its prepaid, fixed budgetdesign aroused fierce opposition fromcounty, state, and national medical soci-eties. Consequently, Kaiser doctors werebarred from existing facilities, thus KP hadto build its own hospitals, this becoming aself-contained delivery system with itsown full-time doctors, nurses, and otherstaff.

KP has continued to recruit clinicians whovalue prevention, provide a whole systemsapproach to health care and embrace team-based treatment.4 This is reflected withinthe organisation by a strong emphasis onprimary care and preventive services,



Table 1. Financial structure of Kaiser Permanente

Source of finance Member dues (71%)

Medicare (22.3%)

Co-payments, deductibles, fees and other (6.7%)

Financial intermediary Kaiser Foundation Health Plan between purchaser and provider

Service provision Not-for-profit Kaiser Foundation Hospital

For-profit Permanente Medical Groups

Low income andunemployed

3.5% of Kaiser members are from California’s Medicaid programmeMedi-Cal

Kaiser provides care to uninsured people who account for 5% of admissions to the community hospitals

Medicare members can choose to obtain health care from KP

Payment of physicians Physicians are paid a salary, including 5%–10% in financial incentives

Payment of hospitals Contracting with the Kaiser Foundation Health Plan

Sources: Feachem RG, Sekhri NK, White KL2; Kaiser Permanente11

including screening programmes for arange of diseases. The electronic healthrecord in KP supports this preventiveapproach, making it possible to reach outto patients due for follow-up examina-tions. These, for instance, might includeindividuals having difficulty in managingtheir conditions, as well as those overduefor a mammogram, cholesterol check orPap smear. This outreach work is under-taken by Medical Assistants that contactKP members using the telephone or securemessaging (confidential email).

During recent decades KP has also imple-mented Disease Management (DM)programmes for coronary artery disease,heart failure, diabetes and asthma. DMprogrammes include clinical guidelines,patient self-management education, diseaseregistries, proactive outreach, reminders,multidisciplinary care teams andperformance feedback to providers. Thecomponents are integrated in a compre-hensive effort to help clinicians plan anddeliver care to help patients play an activeand informed role in caring for them-selves.12 To strengthen quality and theongoing development and implementationof evidence based clinical guidelines, KPestablished the Care Management Institute(CMI) in 1998.

Another initiative to ensure high qualitycost-effective care is risk stratification ofpatients with chronic conditions, alongthree levels according to the severity oftheir disease. The philosophy behind theseDM programmes is that they will result in

both higher quality and lower costtreatment of chronic conditions.

This idea that DM programmes can reducehealth care costs by improving quality hasbeen called into question. An investigationin KPNC revealed that actual cost savingswere elusive but that the programme mighthave sizable potential savings, since costsmight increase at a greater rate without theuse of DM programmes. The continuoususe of this approach to the treatment ofchronic conditions thus requires thatorganisational structures have the politicalwill and capital to invest in DMprogrammes even though it might takemany years for the benefits of theseprogrammes to be realised.12

“increased investment alonewill not provide health servicesthat are most beneficial to theoverall health of the Europeanpopulation”

ConclusionOne key message from the ongoing debateover KP is that policymakers, healthsystem planners and medical practitionersare increasingly realising that increasedinvestment alone will not provide healthservices that are most beneficial to theoverall health of the European population.Fundamental changes in the way thatservices are organised and managed willalso be necessary, as will be a shift in thebalance of priorities between primary andspecialised hospital care.

To direct policy efforts and assist healthsystem planners in the potential reorgani-sation of European health systems, weneed to strengthen the evidence basethrough detailed research comparing KPand similar organisations with the broadspectrum of European health care systems.Such research may enlighten us as towhether the KP approach is efficientcompared to existing European practices.One example of such comparative work ispresented in Box 1. Data sources and tech-niques for such comparative studies mustbe refined; more in depth analysis of thepotential to transfer selected programmesand system elements to different Europeansettings must be encouraged.

REFERENCES

1. Kaiser Permanente International. TheIntegrated Health Care Experience, 2007.Available at http://xnet.kp.org/kpinterna-tional/programs/index.html

2. Feachem RG, Sekhri NK, White KL.Getting more for their dollar: acomparison of the NHS with California'sKaiser Permanente. British MedicalJournal 2002;324:135–41.

3. Ham C, York N, Sutch S, Shaw R.Hospital bed utilisation in the NHS,Kaiser Permanente and the US Medicareprogramme: analysis of routine data.British Medical Journal 2003;327:1257.

4. Light D, Dixon M. Making the NHSmore like Kaiser Permanente. BritishMedical Journal 2004;328:763–65.

5. Evans DA. Hospital bed utilisation inthe NHS and Kaiser Permanente: debateabout Kaiser needs transparency and hardevidence. British Medical Journal2004;328:583.

6. Talbot-Smith A, Gnani S, Pollock AM,Gray DP. Questioning the claims fromKaiser. British Journal of General Practice2004;54(503):415–21.

7. Towill DR. Viewing Kaiser Permanentevia the logistician lens. InternationalJournal of Health Care Quality Assurance2006;19(4-5):296–315.

8. Scott JT, Rundall TG, Vogt TM, Hsu J.Kaiser Permanente's experience of imple-menting an electronic medical record: aqualitative study. British Medical Journal2005;331:1313–16.

9. Kaiser Permanente Northern Cali-fornia. Our Health Plans, 2007. Availableat https://prospectivemembers.kaiserper-manente.org/kpweb/prospectivemember-shome/entrypage.do

10. Kaiser Permanente Northern Cali-fornia. About Our Organisation, 2007.Available at https://newsmedia.kaiserper-manente.org/kpweb/structurekp/

11. Kaiser Permanente. Kaiser Perma-nente’s Financial Statement, 2004.Available at https://newsmedia.kaiserper-manente.org/kpweb/structurekp/

12. Fireman B, Bartlett J, Selby J. Candisease management reduce health carecosts by improving quality? HealthAffairs 2004;23(6):63–75.



Box 1: Research to assess the transferabilityof the Kaiser Permanente approach

Cross country comparisons are important asa driver for change but highly complex toundertake. An initiative is now underway todisseminate the results of empirical workcomparing the Danish health care system withthat of Kaiser Permanente Northern California.

The initiative has been established by aninternational research network involving bothDanish and US researchers. The network isassessing the general transferability of the KPmodel and focuses in particular on chroniccare management, self management supportprogrammes and care coordinationstrategies. Findings will be broadly dissemi-nated to policy makers and health systemplanners.

The research initiative is funded by theRockwool Foundation.

http://xnet.kp.org/kpinternational/programs/index.html

https://prospectivemembers.kaiserpermanente.org/kpweb/prospectivemembershome/entrypage.do

https://newsmedia.kaiserpermanente.org/kpweb/structurekp/

https://newsmedia.kaiserpermanente.org/kpweb/structurekp/

A significant number of parents are preoccupiedwith vaccine side-effects.1 Hundreds of anti-vaccine web sites link vaccines for once-commonchildhood diseases to sudden infant deathsyndrome, Crohn’s disease, autism, diabetes, andother diseases. Many claim the risks of vaccines arefar greater than the benefits of being immunised.2.3

Growing doubts about the benefits of vaccines areeven seen among health care providers. Forexample, one study in Quebec found more than40% of nurses do not fully agree with the opinionthat vaccines are safe, effective, or altogether usefulfor children.4 And 40% of nurses also believed thatpractices such as homeopathy and healthy eatingwere effective alternatives to vaccination.4

However, research shows vaccination has savedmore lives in Canada in the last fifty years than anyother intervention,5 and vaccination ranks as one ofthe most effective and cost-effective public healthachievements. In fact, when you consider thenumber of lives immunisations save each year, itactually costs more not to invest in vaccinationprogrammes.6.7

A calculated riskWhile no vaccine is risk-free, these interventionshave been dubbed “the safest tools of modernmedicine.”7 The large majority of vaccine side-effects are minor and temporary, such as a sore arm

or mild fever.6,8 Although more serious side-effects– such as severe allergic reactions – can occur, theseare rare, occurring less than once in every onemillion vaccine doses in Canada.6 On the otherhand, the risks of letting children get a disease likemeasles or diphtheria are far greater than anyvaccine side-effect.6,8

Take diphtheria for example – while the vaccine cancause minor and temporary redness and swelling atthe injection site or fever, the disease may lead toheart and neurological complications, not tomention a 5–10% death rate.6 In the case ofmumps, the occasional side-effects of the vaccineare a fever and mild skin rash. However, one in 200children who get mumps will develop a braindisorder.6 Other children who get mumps maybecome deaf.6 Mumps in adolescent or adult malescan cause painful swelling of the testicles and maylead to infertility.6

MMR and autism: no linkOne vaccine that has come in for serious criticismis the measles, mumps, rubella (MMR) vaccine,which critics claim is the cause of a range of devel-opmental problems in children, including autism.However, the argument made in one or two reportsthat the link exists has been highly refuted innumerous scientific studies and in major systematicreviews.9–11 A recently updated Cochrane review

Mythbusters


Myth: The risks of immunising children oftenoutweigh the benefits

Mythbusters are preparedby Knowledge Transferand Exchange staff at theCanadian Health ServicesResearch Foundation andpublished only afterreview by a researcherexpert on the topic.

The full series is availableat www.chsrf.ca/mythbusters/index_e.php.This paper was firstpublished in 2006. © CHSRF, 2006.

Comparison of effects of diseases and common side-effects of vaccines6

Disease Effects of disease Side-effects of vaccine

Tetanus (lockjaw)

One in 10 dies One in five has discomfort or swelling; one in20 has fever

Pertussis (whooping cough)

One in 100 children less than six months diesfrom pneumonia or a fatal brain disorder

One in five has discomfort or swelling; one in20 has fever

Haemophilusinfluenzae, type B disease

One in 20 dies from meningitis; 10–15% have permanent neurologicaldysfunction; 15–20% become deaf

One in 20 has discomfort and swelling; onein 50 has fever; no serious side-effects havebeen attributed to Hib vaccine

Measles (red measles)

One in 10 develops pneumonia or an earinfection; one in 1,000 develops brain inflam-mation and, of these, 10% die and 25% willhave permanent brain damage; one in25,000 develops a rare chronic brain infection

One in 20 has discomfort and fever with orwithout a rash; one in a million developsbrain inflammation

http://www.chsrf.ca/mythbusters/index_e.php


A series of essays by the Canadian HealthServices Research Foundation on the evidencebehind healthcare debates

found “no credible evidence” of an asso-ciation between the MMR vaccine andautism.9 Similarly, a 2006 Montreal-basedstudy that explored the relationshipbetween recent trends in pervasive devel-opmental disorders – a wide spectrum ofsocial and communication disorders,including autism – and exposure to MMRvaccine ruled out any association.10 Infact, there is no sound evidence what-soever that links immunisations withsudden infant death syndrome,12

diabetes,13 or Crohn’s disease.9

One thing not in doubt is the MMRvaccine’s ability to prevent the diseases itis designed for – used in more than thirtycountries, this vaccine has been given topopulations en masse, successfullydemonstrating its ability to virtuallyeliminate the target diseases.9

The key to preventing outbreaksWhile vaccination coverage data vary byprovince and territory, the 2002 NationalImmunisation Survey shows, forexample, that reported coverage of MMRin seven year-olds is just more than75%14 – well below the national goal,which is closer to 95%.15 The samesurvey shows many children are underimmunised; the rate of children receivingtheir booster of MMR vaccine falls nearlytwenty percentage points below thenational target.14

As recent history tells us, the possibleoutcomes of low vaccination rates arealarming.16,17 In Great Britain in 1974, anepidemic of more than 100,000 cases –including thirty-six deaths – of pertussis(whooping cough) followed a dramaticdrop in vaccine use for this disease. 17

Following the outbreaks, vaccinationrates rose once again, which, in turn, sawdisease rates fall.17 Similarly, a recent USstudy found that for states with lax vacci-nation laws, there is a 90% higher inci-dence of whooping cough.18

To keep measles and other once-commonchildhood diseases from spreading, a highpercentage of the population – in therealm of 95% for measles, for example –must be immunised. When vaccinationrates are close to this percentage, ‘herd

immunity’ is said to exist, where themajority (and vaccinated) portion of thepopulation protects the rest of the popu-lation.19.20 If this critical mass is notachieved, outbreaks can occur.20

ConclusionNo medical intervention is ever onehundred percent effective or comeswithout any risks. In the final analysis,vaccines for childhood diseases that wereonce common in Canada appear to beparticularly well-evaluated interventionswhere the benefits clearly outweigh therisks.

REFERENCES

1. Gellin BG, Maibach EW, Marcuse EK.Do parents understand immunizations? Anational telephone survey. Pediatrics2000;106(5):1097–102.

2. Davies P, Chapman S, Leask J. Anti-vaccination activists on the world wideweb. Archives of Disease in Childhood2002;87(1):22–25.

3.Wolfe RM, Sharp LK, Lipsky MS.Content and design attributes of anti-vaccination web sites. Journal of theAmerican Medical Association2002;287(24):3245–48.

4. Dionne M, Boulianne N, Duval N et al.Manque de conviction face à la vaccinationchez certains vaccinateurs québécois[Vaccinators'attitudes related to vaccination in Quebec]. Canadian Journalof Public Health 2001;92(2):100–104.

5. Canadian Public Health Association.The Value of Immunization in the Futureof Canada’s Health System – Submission tothe Commission on the Future of HealthCare in Canada, 2001. [www.immunize.cpha.ca/english/media/Immun_e.pdf]

6. Health Canada. Canadian Immu-nization Guide – sixth edition. Ottawa:Health Canada, 2002. [www.phac-aspc.gc.ca/publicat/cig-gci/pdf/cdn_immuniz_guide-2002-6.pdf]

7. Tengs TO, Adams ME, Pliskin JS, et al.Five-hundred life-saving interventions andtheir cost effectiveness. Risk Analysis 1995;15(3):369–90.

8. Canadian Paediatric Society. YourChild’s Best Shot: A Parent’s Guide to

Vaccination – second edition. Ottawa:Canadian Paediatric Society, 2002.

9. Demicheli V, Jefferson T, Rivetti A, PriceD.Vaccines for measles, mumps and rubellain children. Cochrane Database ofSystematic Reviews 2005;4:CD004407.DOI:10.1002/14651858.CD004407.pub2.

10. Fombonne E, Zakarian R, Bennett A, etal. Pervasive developmental disorders inMontreal, Quebec, Canada: Prevalence andlinks with immunizations. Pediatrics2006;118(1):139–50.

11. Institute of Medicine. ImmunizationSafety Review: Measles-Mumps-RubellaVaccine and Autism. Washington, D.C:National Academy Press, 2001

12. Institute of Medicine. Immunizationsafety review: Vaccinations and SuddenUnexpected Death in Infancy. Washington,D.C: National Academy Press, 2003

13. Institute of Medicine. ImmunizationSafety Review: Multiple Immunizationsand Immune Dysfunction. Washington,D.C: National Academy Press, 2004

14. Health Canada. Measuring up: Resultsfrom the national immunization survey.Canada Communicable Disease Report2004;30(5):37 –48. [www.phac-aspc.gc.ca/publicat/ccdr-rmtc/04pdf/cdr3005.pdf]

15. Health Canada. Canadian nationalreport on immunization, 1998. Paediatrics& Child Health 1999;4(suppl C).

16. Gangarosa EJ, Galazka AM, Wolfe CR,et al. Impact of anti-vaccine movements onpertussis control: the untold story. Lancet1998;351(9099):356–61.

17. Pollard R. Relation between vacci-nation and notification rates for whoopingcough in England and Wales. Lancet1980;1(8179):1180–82.

18. Omer SB, Pan WKY, Halsey NA, et al.Nonmedical exemptions to school immu-nization requirements. Secular trends andassociation of state policies with pertussisincidence. Journal of the American MedicalAssociation 2006;296(14):1757–63.

19. Anderson RM, May RM. Immunisationand herd immunity. Lancet 1990;335(8690):641-645.

20. Heymann DL, Aylward RB. Massvaccination: When and why. Current Topicsin Microbiology and Immunology2006;304:1–16.

http://www.immunize.cpha.ca/english/media/Immun_e.pdf

http://www.phac-aspc.gc.ca/publicat/cig-gci/pdf/cdn_immuniz_guide-2002-6.pdf

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/04pdf/cdr3005.pdf

This possibility has led to a number of'scare' stories in the popular press. Typi-cally, debunking the scare involvestrying to prove a negative, never an easything at the best of times. About theonly way to prove a negative is to havevery large amounts of data, but alsodemonstrating the lack of any sort ofdose-response as well as no biologicalplausibility. A large Danish study goesmost of the way to doing that for mobilephones and cancer.1

StudyIn the period 1982 to 1995 over 700,000Danish citizens subscribed to a mobiletelephone service. After eliminatingthose in which individual users couldnot be identified because they werecorporate subscriptions, had incorrectaddresses, were from Greenland or theFaroe islands, had a history of previouscancer, or were under eighteen years, thefinal cohort consisted of 420,000 iden-tified subscribers.

Because Denmark has a system ofpersonal identification numbers, cohortmembers could be linked to files of acancer registry that is virtually complete,using a nationwide system of cancer

classification. Follow up began from thefirst day of subscription, and ended ondate of diagnosis of any cancer, death,emigration, or end of 2002.

Numbers of cancers found werecompared with the number expected inthe general Danish population, for menand women, and in five-year age groups.Mobile phone subscribers were omittedfrom this comparison group.

ResultsMost (85%) of the 420,000 subscriberswere men. The median time of mobiletelephone subscription was 8.0 years.Mobile subscribers had 14,250 cases ofdiagnosed cancer, against an expectednumber of 15,000, giving an overall stan-dardised incidence ratio of 0.95 (95%confidence interval of 0.93 to 0.97).

For men and women analysed separatelythere was no difference from expected inall brain and nervous system cancers, orcancers of the salivary glands or eye. Formen and women analysed together, therewas no increased risk of any type ofintracranial cancer, with a hint of adecreased risk for parietal lobe tumours.There was no increase in brain andnervous system tumours and leukaemias

according to time from first subscription(Table 1).

There was no increased risk of any othertype of cancer for men, with hints ofdecreased risk for lung, bladder, buccal,oesophageal and liver cancers, as well asother cancers and unspecified cancers.For women the numbers of individualcancers were small, and none had anylarge increase or decrease in incidenceover expected.

CommentWhat is good about this study is that itwas large, of long duration, covered awhole population, and was performed inDenmark. Denmark has an almostunique ability to successfully linkdifferent databases through the use ofpersonal identification numbers.

The results all but eliminate the conceptthat the use of mobile phones can causecancer. And not just cancer, because thestudy allows detailed diagnosis ofparticular cancer types, includingacoustic neuromas and cancers oftemporal and parietal lobes which wouldbe the parts of the brain closest to amobile phone antenna, and hence mostat risk.

The paper has a wonderful discussion,which not only puts these results intothe context of others, but tells us thatthe authors could find no studies indi-cating any biological plausibility for alink between mobile phones and cancer.This comes as close to proving a nega-tive as we are ever likely to get, but evenmore data will come out in future fromcontinuation and extension of the study.

If you Google mobile phones andcancer, you will find links to over ninemillion sites. Some are good, some areup to date, but many are not. Theyshould all reflect on the data fromDenmark.

REFERENCE

1. Schüz J, Jacobsen R, Olsen JH, BoiceJD et al. Cellular telephone use and cancerrisk: update of a nationwide Danishcohort. Journal of the National CancerInstitute 2006;98:1707–13.


Mobile phones and cancer

Many of us use mobile telephones to a greater or lesser extent. Because mobile phonesemit radio frequencies that can penetrate several centimetres into the human brain, ithas been hypothesised that their use could possibly lead to tumours of the head and neck

Evidence-based health care

Bandolier is an online journal about evidence-based healthcare, written by Oxford scien-tists. Articles can be accessed at www.jr2.ox.ac.uk/bandolier

This paper was first published in 2007. © Bandolier, 2007

Table 1: Brain and nervous system cancers and leukaemias by years of mobile phone subscriptioncompared with non-subscribers in Denmark

Years ofsubscription

Person years Standardised incidence rate (95%CI)

Brain and nervous system Leukaemia

<1 420,000 0.9 (0.7 to 1.2) 1.1 (0.8 to 1.5)

1–4 1,656,000 1.0 (0.9 to 1.2) 1.1 (0.9 to 1.2)

5–9 1,327,000 1.0 (0.8 to 1.1) 0.9 (0.8 to 1.1)

≥10 170,000 0.7 (0.4 to 0.95) 1.1 (0.7 to 1.5)

http://www.jr2.ox.ac.uk/bandolier


NEW PUBLICATIONS

Being Healthy and Staying Healthy:A Vision of Health and Prevention

Dutch Ministry of Health, Welfare andSport, 2007

The Netherlands, The Hague.

44 pages

Freely available online at:http://www.minvws.nl/images/fo-being-healthy-_tcm20-156779.pdf

This document, detailing the vision of theDutch Ministry of Health, Welfare andSport and its partners, begins with ananalysis of the present health status of theNetherlands and its implications (sections 2and 3). It raises concerns that the Nether-lands is less healthy than many otherEuropean countries and that health inequal-ities within the country persist.

The Ministry’s vision for the future is thenpresented in the context of two key themes:the relationship between the individual andhis/her environment and the links betweenpreventive health care and other forms ofhealth care (sections 4 and 5).

The report argues that since in modernsociety people are constantly tempted tomake unhealthy lifestyle decisions, it is therole of the government to make the healthy

option easy wherever possible. This impliestailoring initiatives to the relevant targetgroups. Furthermore, the report advocatespreventive action undertaken in the curativecare sector by identifying and addressingrisk factors. In order to create an appro-priate funding structure and achieve conti-nuity, the report argues it will ultimately benecessary to fund preventive health carepractitioners through private and/or statehealth insurance schemes.

Section 6 identifies a number of ways inwhich the governmental setting must beimproved and modernised. Making the casefor moving “from public health policy to ahealthy public policy”, the report envisionsmunicipalities serving as hubs of cooper-ation, being central to the implementationof the policy.

Taking on Goliath. Civil Society’s Leadership Role in Tobacco Control

Jeff Hoover

New York: Open Society Institute, 2007

60 pages

ISBN: 978-1-891385-72-8

Freely available online at:http://www.soros.org/initiatives/health/articles_publications/publications/goliath_20070530/a_complete_report.pdf

Before briefly outlining statistics onsmoking and lung cancer prevalence andinternational policy developments intobacco control, this report turns to its maintopic, the need for more extensive tobaccocontrol in central and eastern Europe andcentral Asia. It argues that many legislativeregulations and national tobacco controlprogrammes, especially in the lessdeveloped countries farther east, are noteffectively enforced and still have seriousloopholes that prevent them from meetingWHO standards.

In many countries, civil society groups havebeen leading the way in devising, imple-menting, and demanding the enforcementof tobacco control policies and regulations.

The case studies in the report document theadvocacy efforts of non governmentalorganisations in four countries all at

different stages in tobacco control: Kaza-khstan, Moldova, Romania, and Ukraine.The report suggests that taken together, thecase studies offer important lessons forfuture tobacco control efforts in the region,but also anywhere in the world.

Among the notable lessons are thefollowing: civil society is crucial tosuccessful tobacco control efforts; effectivetobacco control efforts require compre-hensive, multi-pronged approaches andstrategies; economic research is animportant, yet often neglected, componentof effective advocacy; the media can be apowerful tool for and ally of tobaccocontrol advocates; tobacco control regula-tions and affordable ‘quit smoking’ servicesare equally important in reducing tobaccouse; expanded regional learning and coop-eration offer clear benefits to local tobaccocontrol efforts.

Eurohealth aims to provide information on new publications that may be ofinterest to readers. Contact Philipa Mladovsky at [email protected] if youwish to submit a publication for potential inclusion in a future issue.

Contents: Introduction; health in the Netherlands; stakes, responsibilities and forms ofprevention; the association between setting and behaviour; the association betweenpreventive and curative care; the administrative setting: integration, cooperation andmodernisation; conclusion.

Contents: preface; summary; introduction; case studies: Kazakhstan, Moldova, Romania,Ukraine; lessons learned; notes


http://www.minvws.nl/images/fo-being-healthy-_tcm20-156779.pdf

http://www.soros.org/initiatives/health/articles_publications/publications/goliath_20070530/a_complete_report.pdf


Please contact Philipa Mladovsky [email protected] to suggest websites

for potential inclusion in future issues.

Health Information andQuality Authority (HIQA)

http://www.hiqa.ie

Institute of Alcohol Studies(IAS)

http://www.ias.org.uk

Slovenian EU Presidency 2008

http://www.eu2008.si/en

The UK based non-governmental organisation IAS aims to serve the public interest on publicpolicy issues linked to alcohol by advocating for the use of scientific evidence in policy-makingto reduce alcohol-related harm. The English language web site provides access to many resourcesincluding: a series of factsheets which cover a broad range of topics related to alcohol; papersresponding to UK government initiatives; occasional papers; reports from European alcoholprojects; a ‘data map’of publicly available data on alcohol in the UK; Alcohol Alert, a quarterlymagazine; a Guide to Resources on the Night-time Economy which provides an overview ofacademic and policy literature on the topic; and links to other alcohol related web sites.

World Bank Human Development Network: Health,Nutrition and Population(HNP)

http://go.worldbank.org/RQU0H5VGJ0

The Health, Nutrition and Population (HNP) section of the Word Bank’s web site covers lowand middle income countries, including those in eastern Europe and central Asia. It providesinformation on the HNP strategy; links to relevant data sources, including the databaseHNPstats and its research programme; a searchable database of discussion papers; downloadabletoolkits and guidelines; details of all HNP funded projects and programmes; a list of relatedlinks; and details of relevant news and events. Most of the resources are in English and are freelyavailable to download.

International Union for HealthPromotion and Education (IUHPE)

http://www.iuhpe.org

Estblished more than fifty years ago and based in Paris, the International Union for HealthPromotion and Education (IUHPE) is the only global organisation entirely devoted to advancingpublic health through health promotion and health education. Members range from governmentbodies to universities and institutes, non-governmental organisations and individuals across allcontinents. In addition to annual reports and official responses to EU consultation papers, thewebsite provides full text access to the organisation’s journal, Promotion and Education, links totwo other official academic journals of the IUHPE and details of a series of video conversationswith individuals working in public health. Information on the organisation’s scientific activities,conferences and links to other resources are also provided. The website is available in English,French and Spanish.

News and information from the Slovenian Presidency of the European Union

The Health Information and Quality Authority (HIQA), an independent body reporting to theMinister for Health, was formally established in Ireland in May 2007. It is responsible for settingstandards in health and social care, monitoring health care quality, inspecting social care services,commissioning health technology assessments (including economic evaluations) and providinghealth information to all stakeholders. As part of its activities it is implementing a programme ofquality assurance reviews for hospitals, primary care, general practice and the provision of ambu-lance services. This includes development of a standards framework for each of these sectors,incorporating all aspects of quality and service. The website provides detailed information aboutHIQA functions, newsletters, annual reports, inspection reports and health care standards.

European Environment andHealth Information System(ENHIS)

http://www.enhis.org

This English language website hosts comparable data and information on priority environmentand health issues as reflected by international policy frameworks on environment and health. Itscontent includes: a core set of indicators; a series of fact sheets presenting indicator-based assess-ments; country information for the fifty-three Member States of the WHO European Region; anoverview of policies on core issues at both national and international levels; methodologicalguidance on the core set of indicators; and guidance on and examples of health impact assess-ments.

WEBwatch

http://www.eu2008.si/en


http://www.hiqa.ie

http://www.ias.org.uk

http://go.worldbank.org/RQU0H5VGJ0

http://www.iuhpe.org

http://www.enhis.org


MONITOR

EUROPEAN MONITOR

Slovenian Presidency healthpriorities focus on cancerSlovenian Health MinisterKukovic set out the priorities ofthe Presidency in the areas ofpublic health in the EuropeanParliament. The issue that raisedthe most interest and questionsfrom MEPs was the initiative oncancer and a conference thattook place on 7 and 8 Februaryin Brdo. Minister Kukovic saidthey also planned formal andinformal Council meetings topush forward the still awaitedlegislative proposal on cross-border health care. Slovenia alsorenewed its commitment toefforts in the fields of mentalhealth, alcohol and obesity.

Joint commitments weremutually developed within theframework of the eighteen-month programme of theGerman-Portuguese-SlovenianPresidency. They are based onthe promotion of health byencouraging a healthy lifestyle,particularly healthy nutritionand physical activity, preventionand control of communicablediseases such as HIV/AIDS andflu pandemics, innovations inhealth care and the accessibilityof health care services.

The Presidency will alsosupport a conference on 10–11March on cross-sectoral policiesin the field of nutrition andphysical activity.

More information athttp://www.eu2008.si/en/Policy_Areas/Employment_Social_Policy_Health_and_Consumer_Affairs/Health.html

High Level Conference onMental HealthFormer Health and ConsumerProtection CommissionerMarkos Kyprianou outlined hisintention to organise a high levelconference on mental health.This will be a follow-up to theconsultation on theCommission’s Green Paper onMental Health of 2005. ThisHigh Level event will take place

on the 13 June 2008 in Brussels,in the presence of the Presidentof the European Commission,Dr José Manuel Baroso. It isexpected to establish a cross-sectoral European Pact forMental Health. The Conferencewill focus on four key actionfields: suicide prevention;mental health in youth andeducation; mental health inworkplace environments; andolder people.

More information athttp://ec.europa.eu/health/ph_determinants/life_style/mental/mental_health_en.htm

Brussels presses for progress onlead markets for eHealthThe European Commission hascalled for quick action andstrengthened national cooper-ation on lead market opportu-nities for eHealth in order toincrease economic benefits andimprove the quality of healthservices. E-health, along with anumber of other products, willbenefit from the 'Lead MarketsInitiative for Europe' (LMI).Proposed by the Commission,this will foster the emergence ofthese markets by notablyimproving legislation, encour-aging public procurement anddeveloping interoperable stan-dards. European enterpriseswould profit from fair andbetter chances of entering newfast-growing worldwidemarkets with a competitiveadvantage as lead producers.LMI would also rapidly bringvisible advantage for Europe'sconsumers in key areas for theirwelfare.

“The prospective return oninvestment of eHealth is rela-tively high when compared tothe costs inherent in the healthsector,” argued a Commissionreport on the development ofthe eHealth Market in Europe,published in late December2007.

The report, drafted by aCommission eHealth task force,comprising representatives ofseveral Directorate Generals,outlines a number of policy

recommendations for areas ofintervention up to 2010. Therecommendations, directed atindustry, Member States andother eHealth stakeholders,focus on four main obstacles tothe development of the eHealthlead market.

One aim is to reduce marketfragmentation and the lack ofinteroperability through pilotactions, benchmarking, stan-dardisation and certification.Another is to improve legalcertainty and consumeracceptance by possibly adoptinga legal initiative for eHealth andtelemedicine, as well as aninitiative to enforce personaldata protection legislation,disseminating best practice andguidelines. Other key issues areto optimise funding opportu-nities through strengthenednational and communityresearch and development co-operation on eHealth; and toimprove procurement by facili-tating the expression of publicdemand through more inno-vation-friendly procurementactivities and networking publicprocurers.

Just days before the publicationof the report, the Commissionadopted a new strategy oninvesting public money in high-risk technological research. Theinitiative seeks to clarifypossible conflicts on this type ofinvestment with EU state aidrules and procurement regula-tions and envisages flexibilityfor the Member States to co-operate with suppliers acrossborders in risk-benefit sharing.

The report Accelerating theDevelopment of the eHealthMarket in Europe is available athttp://ec.europa.eu/information_society/activities/health/docs/lmi-report-final-2007dec.pdf

Guidance on obtaining 11-yearmarketing protectionNew guidance has been issuedby the European Commissionon the elements required tosupport a significant clinicalbenefit of a new therapeutic

New

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Press releases andother suggestedinformation forfuture inclusion can be e-mailed tothe editor David [email protected]

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indication in order to obtain an elevenyear marketing protection. Under Regu-lation (EC) 726/2004 (Article 14(ii)) andDirective 2001/83/EC (Article 10(i)),authorised medicinal products aregranted a ten year period of marketingprotection during which genericmedicinal products cannot be placed onthe market. This period can be extendedto eleven years if the marketing authori-sation (MA) holder obtains an authori-sation for one or more new therapeuticindications that bring a significantclinical benefit in comparison withexisting therapies. The authorisation ofthe new indication should take placewithin eight years from the date of thefirst authorisation. The aim of theEuropean Commission's guidance is tooutline the level of evidence required todemonstrate a significant clinical benefit.

To request an extension of the period ofmarketing protection, a MA holder isrequired to prepare a report to enablethe relevant competent authority toassess if a new indication is of significantclinical benefit. This report shouldinclude justification of the proposed newindication compared to the therapeuticindications already authorised for themedicinal product in question, details ofexisting therapies relating to theproposed new indication and justifi-cation as to why the new indication is ofsignificant clinical benefit compared tothe existing therapies. TheCommission's publication providesguidance on each of these elements.

The guidance states that a new thera-peutic indication may refer to eitherdiagnosis, prevention or treatment of adisease and could include a new targetdisease, different stages or severity of adisease, an extended target population ora change from treatment to preventionor diagnosis of a disease. The justifi-cation of the new indication by the MAholder should be supported by appro-priate scientific information.

When providing details of the existingtherapies, the MA holder shouldconsider other satisfactory methods ofdiagnosis, prevention or treatment of thedisease in question. This should includeother authorised medicinal products andnon-pharmacological approaches such assurgical interventions or radiologicaltechniques. The MA holder should referto scientific and medical literature todescribe the value of such methods.

To establish that a new indication has asignificant clinical benefit in comparisonwith existing therapies, the MA holdershould provide scientific data and docu-mentation, supported by results ofcomparative clinical studies. The newindication should provide a clinicallyrelevant advantage or a major contri-bution to patient care. This can bedemonstrated by greater efficacy,improved safety profile or morefavourable pharmacokinetic properties.

A copy of the guidance can be obtainedat http://ec.europa.eu/enterprise/pharmaceuticals/eudralex/vol-2/c/guideline_14-11-2007.pdf

European Commission investigates thepharmaceutical sectorOn 16 January 2008 the EuropeanCommission launched a sector inquiryinto competition in the pharmaceuticalssector (under Article 17 of Regulation1/2003), and is conducting inspections atthe premises of a number of innovativeand generic pharmaceutical companies.

Sector inquiries are investigations thatthe European Commission may decideto carry out into sectors of the economy,when a sector does not seem to beworking as well as it should. TheCommission uses the informationobtained in the inquiry to better under-stand the market from the point of viewof competition policy, as analysed in itsreport on the sector. Should there begrounds for doing so, the Commissionmay – at a later stage – assess whether itneeds to open specific investigations toensure the respect of Community ruleson restrictive agreements and abuse ofdominant market position (Articles 81and 82 of the EC Treaty).

The use of surprise inspections as part ofthis inquiry is unprecedented and comesas a response to indications that compe-tition in pharmaceutical markets inEurope may not be working well: fewernew pharmaceuticals are being broughtto market and the entry of generic phar-maceuticals sometimes seems to bedelayed. The inquiry will therefore lookat the reasons for this.

In particular, it will examine whetheragreements between pharmaceuticalcompanies, such as settlements in patentdisputes, may infringe the EC Treaty'sprohibition on restrictive business prac-tices (Article 81). It will also look intowhether companies may have created

artificial barriers to entry, whetherthrough the misuse of patent rights,vexatious litigation or other means, andwhether such practices may infringe theEC Treaty's ban on abuses of dominantmarket positions (Article 82).

Vigorous competition in this sector iscrucial for the public, as it ensures bothaccess by patients to state-of-the-artmedicines, and value for money forhealth spending by individuals, privatehealth schemes and government healthservices in Europe. An interim report isplanned for autumn 2008 and finalresults are expected in the spring of2009. The inquiry's findings will allowthe Commission, or national compe-tition authorities, to focus any futureaction on the most serious competitionconcerns, and to identify remedies toresolve the specific competitionproblems in individual cases.

Competition Commissioner NeelieKroes said that “individuals and govern-ments want a strong pharmaceuticalssector that delivers better products andvalue for money. But if innovativeproducts are not being produced, andcheaper generic alternatives to existingproducts are in some cases beingdelayed, then we need to find out whyand, if necessary, take action.”

Unlike cartel cases, where theCommission carries out inspectionswhen it has indications that specificcompanies have committed competitionlaw infringements, these inspections arenot aimed at investigating practices ofcompanies where the Commission hasalready positive indications of wrong-doing. They are just the starting point ofthis general sector inquiry and aim toensure that the Commission has imme-diate access to relevant information thatwill guide the next steps in the inquiry.The kind of information theCommission will be examining, such asthe use of intellectual property rights,litigation and settlement agreementscovering the EU, is by its nature infor-mation that companies tend to considerhighly confidential. Such informationmay also be easily withheld, concealedor destroyed. This is why inspectionshave been considered appropriate.

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action will therefore complement, notchallenge, intellectual property law, asboth systems share the objectives offostering innovation, and increasingconsumer welfare. The inquiry will alsotake due account of the specificities ofthe relevant regulatory frameworks. Itwill not in any way put into question thevarious health schemes in force in theMember States. The inquiry is limited tomedicines for human consumption.

To carry out the inquiry, theCommission can use a wide range ofinvestigative tools to gather informationfrom companies and trade associations,including requests for information.During the inquiry, the Commission willmaintain an open dialogue with all stake-holders, and will keep the sectorinformed about progress.

More information athttp://europa.eu/rapid/pressReleasesAction.do?reference=MEMO/08/20&format=HTML&aged=0&language=EN&guiLanguage=en

NEWS FROM THE ECJ

European Court of First Instance upholdsCommission’s Decision to approveIreland’s risk equalisation system for PHIOn 12 February 2008, the EuropeanCourt of First Instance issued itsjudgement confirming the Commission'soriginal decision approving Ireland’s riskequalisation system (RES) for the privatehealth insurance (PHI) sector, anddismissing the challenge to this decisionby the private health insurer BritishUnited Provident Association Ltd(BUPA). In dismissing the BUPA action,the Court declared that “such a mech-anism is a necessary and proportionatemeans of compensating the insurersrequired to cover, at the same price, allpersons living in Ireland, independentlyof their state of health, age or sex”.

In January 2003, the Irish authorities hadformally notified the RES to theCommission, in accordance with theCommunity rules on state aid. Inpractice, operation of the RES wouldmean the transfer of funds from BUPAto the long established semi-state organi-sation VHI healthcare which has about80% of the private health insurancemarket in Ireland. On 13 May 2003, theCommission decided not to raise objec-tions to the establishment of the RES. Itdecided that the compensation provided

for by the RES constituted an amountintended as compensation for the obliga-tions associated with a service in thegeneral economic interest (SGEI),namely obligations aimed at ensuringthat all persons living in Ireland wouldreceive a minimum level of PHI servicesat the same price, independently of theirstate of health, age or sex (the PHI obli-gations).

This latest judgement is the result of aformal Application for Annulmentagainst the Commission’s decision in2003 which was lodged with the Courtof First Instance of the EU and heard inMarch 2006.

In reaching its judgement, as a prelim-inary point, the Court noted thatMember States have wide discretion asto the definition of SGEIs, particularlyin the field of health, which falls almostexclusively within their competence. Inthat context, the control which theCommunity institutions are authorisedto exercise is limited to ascertainingwhether there is a manifest error ofassessment. However, where a MemberState invokes the existence and the needfor protection of an SGEI mission,certain minimum criteria must besatisfied, in particular, the presence of anact of a public authority entrusting theoperators in question with an SGEImission and the universal andcompulsory nature of that mission.

The Court considers that in the presentcase those conditions are indeedsatisfied. The Irish legislation, whichdefines the PHI obligations in detail,was an act of a public authority.Furthermore, the fact that the insurersare required to cover any personrequesting insurance means that the PHIservices are compulsory and universal.

The Commission was thus entitled, inthis case, to consider that the imposition,in the public interest, of the PMI obliga-tions on the PHI insurers relates to anSGEI mission.

Finally, the Court finds that BUPA hasnot shown that the Commission haderred in concluding that the compen-sation system provided for by the RESwas necessary and proportionate byreference to the costs incurred indischarging the PMI obligations. TheCourt considers that there is no error inthe finding that risk equalisation isnecessary on a PHI market whereinsurers are required to cover any person

at the same price and independently ofthe individual risk in order to ensure thecross-subsidy of premiums between thegenerations and to permit every PHIinsurer to bear only the burdens linkedwith the average market risk profile. Inaddition, the RES seeks only tocompensate PMI insurers for thefinancial consequences arising from thePMI obligations, which prohibit themfrom setting premiums according to therisk insured and from rejecting the ‘bad’risks.

Commenting on the decision, theMinister for Health and Children , MaryHarney, said “the government, mydepartment and I have always seen riskequalisation as important and necessaryin the provision of an equitable andcompetitive health insurance market inIreland. We are pleased to have thisupheld by the judgement of theEuropean Court of First Instance. Riskequalisation enables the provision of alevel playing field for all consumers andinsurers and allows for the protection ofthe consumer by facilitating communityrating and open enrolment. I amcommitted to protecting equality andencouraging competition in the healthinsurance market in this way”.

VHI Healthcare, which has a notablyolder customer profile than itscompetitors, welcomed the decision.According to its Chief Executive,Vincent Sheridan, “the decision of theEuropean Court to dismiss the BUPAaction is very good news for consumersin Ireland since a negative judgementcould have meant the end of communityrating for health insurance in thiscountry. Community rating has been thebasis of health insurance in Ireland forthe past fifty years. Indeed the decisionwill be welcomed right across Europe asevidenced by the involvement of theDutch government in the case".

He continued that the “decision is badnews for those who wish to usecommunity rating as a means of gener-ating windfall profits by way of regu-latory arbitrage. It also marks anotherfailed attempt by BUPA to destroyCommunity Rating in Ireland.” BUPAhas declined to make any comment untilit has studied the judgement further, butOliver Tattan, Chief Executive of rivalIrish private health insurance company,VIVAS Health, said that “while we aredisappointed that the Commission hasendorsed a system of subsidisation of the


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most dominant player in the market andhas deemed that this form of state aid islegal, it should be recognised that thiscase was just one of many legal investi-gations underway at a local andEuropean level. The outcome of theother cases may not be known for asubstantial period of time. Until allinvestigations are resolved the marketwill continue to suffer from a lack ofinvestment and from limited compe-tition.” Tattan called for urgent reformin the health insurance system and, inparticular, to look at ways in which toreduce VHI’s dominant market share.

In coming to its decision the EuropeanCourt of First Instance ordered BUPAto pay the EC and the VHI’s legal costsin the action. VHI healthcare is due€33m from BUPA and €1m from it’ssuccessor Quinn healthcare in riskequalisation payments. However, it willhave to await the verdict of anotherSupreme Court challenge before it canhope to receive any payments

More information at http://curia.europa.eu/en/actu/communiques/cp08/aff/cp080008en.pdf

Germany failed to fulfil obligations inrespect of psychotherapistsIn December 2007 the European Courtof Justice (ECJ) declared that Germanyfailed to fulfil its obligations underArticle 43 EC by applying ‘establishedrights’ in its Law on Psychotherapists.The Law provides that, from 1 January1999, psychotherapists wishing topractise under the statutory sicknessinsurance scheme have been subject to aquota system structured on a regionalbasis. According to the law, psychother-apists who establish themselves in aparticular region may practise under thestatutory sickness insurance scheme onlyif the number of psychotherapists in thatregion does not exceed a number whichcorresponds to the needs of the region.

However, the German Law onPsychotherapists contains provisionsunder which psychotherapists alreadyestablished in a region and who practiseunder the statutory sickness insurancescheme may continue to practise underthat scheme, even in the case where thenumber of psychotherapists required inthe region has been exceeded, if theyfulfil certain conditions. Among these isthat they took part, in the period from25 June 1994 to 24 June 1997, in thepsychotherapeutic out-patient treatment

of individuals insured under thecompulsory sickness insurance scheme.

However, by refusing to grant the possi-bility of continuing to practice topsychotherapists who are already estab-lished in a region but who actuallyworked in the health care system ofanother Member State, in theCommission’s view, Germany failed tofulfil its obligations under Article 43 EC.It had not treated previous activitycarried out in another Member Stateworthy of the same protection as thatgiven to professional activities carriedout under the German compulsorysickness insurance schemes. Article 43 ofthe Treaty establishing the EuropeanCommunity declares that restrictions onthe freedom of establishment ofnationals of a Member State in theterritory of another Member State shallbe prohibited.

Further details can be accessed at:http://curia.europa.eu/jurisp/cgi-bin/form.pl?lang=EN&Submit=Rechercher$docrequire=alldocs&numaff=C-456/05&datefs=&datefe=&nomusuel=&domaine=&mots=&resmax=100

Garlic Preparations in capsule formdeemed not to be medicinal productsOn 15 November 2007, the EuropeanCourt of Justice issued a judgement oncase C-319/05, European Commissionversus the Federal Republic of Germany,pursuant to which Germany hadwrongly classified garlic preparations incapsule form as medicinal products,thereby imposing a restriction on thefree movement of goods as prohibitedby Article 28 of the EC Treaty.

In 2005, the German authorities hadrefused to allow the importation andmarketing of ‘garlic extract powdercapsules’, i.e. capsules containing puredried garlic powder, as food supple-ments, on the grounds that they werenot regarded as foodstuffs but medicinalproducts within the meaning ofDirective 2001/83/EC on theCommunity Code relating to MedicinalProducts for Human Use (the MedicinalProducts Directive).

The European Commission, however,took the view that the garlic preparationin question was not a medicinal product.The Commission stated that the classifi-cation as a medicinal product imposed aburden on importers of the product inGermany which constituted an obstacle

to the free movement of goods contraryto Article 28 of the EC Treaty. Hence,the Commission brought an actionagainst the Federal Republic ofGermany before the ECJ for failure tofulfil its Treaty obligations concerningthe free movement of goods.

In its ruling the ECJ determined that thegarlic preparation in question could notbe classified as a medicinal product as itdid not fall within one of the two defini-tions of medicinal products, i.e. by pres-entation or by function. A medicinalproduct by presentation is a product"presented for treating or preventingdisease" within the meaning ofMedicinal Products Directive "when it isexpressly indicated or recommended assuch, possibly by means of labels,leaflets or oral representation". In thiscase, the ECJ held that no aspect of thepackaging of the garlic preparation madethe product resemble a medicinalproduct and the capsule form was notexclusive to medicinal products.

A product can be considered as amedicinal product by function takinginto account "all the characteristics ofthe product, in particular its compo-sition, its pharmacological properties tothe extent to which they can be estab-lished in the present state of scientificknowledge, the manner in which it isused, the extent of its distribution, itsfamiliarity to consumers and the riskswhich its use may entail". In this case,the ECJ stated that the garlic preparationdid not contain any substances otherthan natural garlic and had no additionaleffects, either positive or negative,compared to those derived from theconsumption of garlic in its natural state.Therefore, the effect of the garlic prepa-ration was no more than the effect of afoodstuff containing garlic consumed ina reasonable quantity. In contrast, amedicinal product must have the‘function of treating or preventingdisease’. Beneficial effects for health ingeneral, such as those of garlic, are notsufficient.

The ECJ further held that Germany'sclassification of the garlic preparationcreated an obstacle to intra-Communitytrade since garlic products legallymarketed as foodstuffs in other MemberStates could be marketed in Germanyonly after having been subjected to theauthorisation procedure for the placingon the market of a medicinal product.According to the ECJ, this obstacle


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could not be justified for reasons relatingto the protection of health and life ofhumans in accordance with Article 30EC.

As a result, the ECJ held that the FederalRepublic of Germany had failed to fulfilits Treaty obligations concerning the freemovement of goods under Article 28 ECand Article 30 EC. This judgment laysdown very specific criteria with respectto the classification of borderlineproducts containing botanicals. As aconsequence, the former practice ofsome Member States to classify productscontaining specific botanicals automati-cally as medicinal products by functionbecomes obsolete. Pending procedureswith respect to the classification ofproducts containing garlic might meanthat this ruling is introduced as a basison which to reinforce the marketabilityof the product as a foodstuff.

COUNTRY NEWS

Tajikistan: severe cold and energysupply crisis threatens healthTajikistan is facing a growing humani-tarian crisis. United Nations agencieswarn that the health of large parts of thepopulation is already affected, as thecountry struggles with a cold and energyemergency. The central Asian republic,home to about seven million people, iscurrently experiencing its harshestwinter for three decades. The averagetemperature is around -15°C, droppingto as low as -25°C at night. Roadsbetween several districts are blocked byheavy snowfall, affecting supplies offood and other basic products.

The cold wave has also led to severeproblems with the water supply system,as supply lines either break or freeze.The energy problems are seriouslyaffecting the health sector: 50% of allhealth facilities in the four majordistricts of Tajikistan – Kulyab, Rashtvalley, Kurgan-Tube and Sogd oblast –report severe power shortages andcomplete blackouts. According to aWHO assessment, all hospitals in theKulyab district are without a watersupply. Hospitals and heath facilities inother districts are facing serious watershortages. Maternal morbidity and cold-related diseases are reported to be on theincrease.

Together with the government, UnitedNations partners present in the country,

including WHO, are urgently assessingthe immediate needs that must be met assoon as possible. WHO has alreadystarted making medical supplies availableto the people who are most at risk. “Theenergy crisis puts thousands at risk.There is particular concern for the healthof elderly people, children and pregnantwomen,” says Dr Marc Danzon, WHORegional Director for Europe. “Everyeffort must be made to get medical andenergy supplies to the country.” TheUnited Nations is preparing a jointappeal for international assistance toaddress the most urgent needs.

More information athttp://www.euro.who.int/emergencies/fieldwork/20080208_1

UK government seeks 10% cut in drugprices from industryDiscussions between UK healthministers and the pharmaceuticalindustry are ongoing as the Pharmaceu-tical Price Regulation Scheme (PPRS) isrenegotiated. Representatives of theindustry had previously agreed to anaverage 7% cut in the cost of pharma-ceutical products in 2005 during the lastrenegotiation of the PPRS. The 2005PPRS was originally planned to run forfive years, but at the end of 2007 HealthMinister Alan Johnson told the Parlia-mentary Health Select Committee thathe had reopened the PPRS negotiations.

Mr Johnson emphasised the influence ofthe PPRS on the NHS budget as awhole. He said the negotiations on thePPRS were a “very big and importantpart of achieving these flexibilities andachieving these efficiencies.” TheFinancial Times (7 January 2008)reported that Mr Johnson had told thepaper that he planned to generate“substantial savings” in the drugs budgetduring talks on the PPRS. The extent ofthese savings has not been made officialyet, but it has been widely reported inthe UK press that government officialshave presented plans to industry toreduce the £11 billion annual medicinesbill by at least 10%.

The Association of the British Pharma-ceutical Industry (ABPI) and theDepartment of Health issued a jointpress release on 8 January 2008, clari-fying that negotiations on a potentialnew PPRS agreement have begun, butthat neither party is commenting on anyspeculation on the content of the negoti-ations, although any new agreement will

be based upon the government's fourprinciples made in response to the 2007Office of Fair Trading (OFT) report:Value for Money, Reward for Inno-vation, Accelerated Uptake of NewMedicines and Sustainability.

As well as the government's desire to cutthe UK's drugs bill, there are additionalpressures on the PPRS. One reportpublished by the OFT in February 2007recommended that the PPRS ‘should bereformed, to deliver better value formoney from NHS drug spend and tofocus business investment on drugs thathave the greatest benefits for patients.’In December 2007, the OFT published afurther report recommending that medi-cines distribution in the UK bereformed, arguing that “any future wide-spread use of exclusive distributionarrangements might lead to longer-termcompetition concerns.” The OFT alsoconcluded that there is a significant riskthat the 'direct to pharmacy' arrange-ments will result in greater costs to theNHS. Furthermore, a High Court rulinginvolving Glaxo SmithKline in June 2007held that the PPRS was not an informalagreement but a formal legal contract,prompting calls that this rulingwarranted a review of the PPRS.

The negotiations over the PPRS areexpected to continue until June 2008.

England: Payment by Results success-fully implemented but needs to developto achieve more for patientsPayment by Results (PbR), one of theEnglish government's key nationalhealth service (NHS) modernisationreforms, has been embedded across theNHS and has helped hospitals to bemore business-like according to theAudit Commission report published on14 February, The Right Result? Paymentby Results 2003–07. It should start todeliver the significant increases inproductivity and efficiency across theNHS that the policy was designed toachieve.

The Payment by Results policy, whichwas introduced four years ago, is asystem of paying hospitals nationally setprices for the number of patients andtypes of conditions they treat. It isdesigned to encourage hospitals to treatmore patients, more efficiently withoutcompromising the quality of care. Mean-while, primary care trusts (PCTs) havebeen expected to find ways of reducingunnecessary hospital admissions by


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commissioning new, more cost-effectiveservices, for example from general prac-titioners.

The report concludes that Payment byResults has been embedded across theNHS. Most hospitals have improvedtheir financial management and nowhave a better understanding of howmuch it costs them to treat patients. Thefear that patient care would sufferbecause hospitals would be tempted tocut costs at the expense of quality hasnot materialised.

There are some indications that the NHSis providing care more efficiently. Forexample, there has been an increase inthe number of patients treated as daycases and the length of time patientsspend in hospital has fallen. Spurred onby Payment by Results incentives, PCTshave reduced the number of avoidableadmissions to hospitals

The report sets out a number of prior-ities for future development of thepolicy and the implementation issuesthat need to be addressed at the nationallevel if Payment by Results is to deliverfurther improvements. These includestrengthening the quality of informationavailable on how much each patientcosts to treat so that it is more accurate,precise and timely.

The report The Right Result is availableat http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=30321654-7A78-4be6-ADA3-C2FC1AD3B515&fromREPORTSANDDATA=NATIONAL-REPORT

Scotland: Free personal and nursingcare needs to be better planned,managed and fundedAn Audit Scotland report published on 1February, A Review of Free Personal andNursing Care, says demand for FreePersonal and Nursing Care (FPNC) willgrow with the projected increase in theolder population in Scotland. Scottishministers decided to introduce FPNC inearly 2001 and set the Scottish Executive(now known as the ScottishGovernment) and councils a challengingtimetable for developing and imple-menting the policy. The Executive andall councils met this deadline and hadsystems in place to deliver FPNC fromJuly 2002. The policy was introduced atthe same time as several other significantchanges in health and social care, making

it difficult to isolate the impact ofFPNC.

The Auditor General for Scotland,Robert W Black, said that “free personaland nursing care is an important policyfor older people in Scotland. It is welldocumented that Scotland has a growingolder population, and demand for freepersonal care will grow. There needs tobe better planning and better funding ofthis policy. Because of the limited infor-mation at the time the ScottishParliament did not receive sufficientlyrobust and comprehensive financialinformation and risk assessments. TheParliament should require this as amatter of course to enable it to properlyscrutinise all major policy proposals.”

The report finds that continuing ambi-guities in what constitutes free personalcare mean the policy has been appliedinconsistently across the country. Forexample, eight councils charge for foodpreparation, whereas others do not.Older people are often unclear aboutwhat they can receive under FPNC.Accounts Commission chairmanProfessor John Baillie said that “theScottish Executive and Scotland’scouncils were set a tight deadline fordeveloping and implementing thispolicy. They were successful in doing so.However, there is variation across thecountry in how the policy has beenimplemented.”

“Councils and the Scottish Governmentshould work together as a matter ofurgency to clarify the current ambigu-ities and ensure FPNC is consistentlyapplied across Scotland. Councils shouldalso provide clear information to olderpeople about what care they are entitledto under the policy.”

The total cost of FPNC in its first fouryears was an estimated £1.8 billion.Councils would have spent around £1.2billion of this even if the policy had notbeen introduced, as older people werepreviously means-tested for free care.The report indicates that there is likelyto be a growing shortfall in funding forFPNC. Working with the existing dataAudit Scotland estimates this shortfall at£46 million or £63 million for 2005/06.However, there are continuing limita-tions in the available financial infor-mation about FPNC, and no long-termprojections of the costs.

More information at http://www.audit-scotland.gov.uk/media/article.php?id=68

France: Church calls for embryos to begiven clear legal statusFrance's Roman Catholic Church hascalled for embryos to be given a clearlegal status following a court decisionthat let the parents of miscarried foetusesenter them with a name in the officialcivil registry. Previously in France, amiscarried foetus or stillborn child couldonly be registered if it was once viable,this being defined as more than twenty-two weeks of pregnancy or weighingmore than five hundred grams. Anybelow that age have usually been treatedas hospital waste and incinerated. Threecouples whose miscarried foetuses fellbelow the age limit sued to register andbury them. The Cour de Cassation,France's highest appeals court, ruled onFebruary 6 that the limits were notlegally binding and a miscarried foetuscould be entered into the civil registry ifa couple wished to commemorate it thatway.

The Catholic Church has always statedthat an embryo is human life from themoment of conception and must beprotected. Most legal systems protect theunborn after a fixed number of weeks ofpregnancy but only grant full legal statusto live-born babies. Groups opposed toabortion in many countries havetherefore long argued for a legal statusfor embryos as the first step towardshaving courts rule that abortion is aform of murder.

Abortion rights supporters vigorouslyoppose any such status. Cardinal AndreVingt-Trois, head of the French bishops'conference, said establishing this statuswould not undermine legal abortion inFrance because of the way the lawallowing the termination of pregnancieswas constructed. Speaking of the ruling,the Cardinal said that “this means that afoetus has a status. The Church'sposition is that we must act as if theembryo were a person," he told theRennes daily Ouest-France. “We protectendangered animals so we shouldprotect people too.”

Abortion rights campaigner Marie-Fran-coise Colombani, columnist for thewomen's magazine Elle, said the courthad opened a Pandora's box by trying toaccommodate grieving parents. “Whydon't we give legal status to whatdevelops in a test tube during in vitrofertilisation?” she asked. “The law issupposed to be a safeguard, but it hasproduced sheer folly.” Defining


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‘personhood’ for the unborn is acomplex medical and ethical issue.Opinions differ widely on when anembryo or foetus feels pain or takes ontraits that show it is developing into afull human being.

Ireland: Independent body to assess afair community pharmacy dispensingfeeOn 18 February 2008, the Minister forHealth and Children, Mary Harney,announced a new Independent Body tobegin work immediately to assess aninterim, fair community pharmacydispensing fee of at least €5 to be paid inrespect of the General Medical Service,Drugs Payment and other communitydrug schemes. This three man body willbe chaired by Seán Dorgan, formerHead of the Industrial DevelopmentAgency Ireland. It will take submissionsfrom all sides, carry out its own analysisand is expected to make its recommen-dations by the end of May on an appro-priate dispensing fee that wouldrepresent a fair and reasonable price tobe paid for the pharmaceutical servicecurrently being provided by communitypharmacists to the Health Service Exec-utive (HSE). Its recommended fee level,subject to Government approval, will bebackdated to 1 March 2008.

In announcing the body, the Ministersaid that “the government is firm in itsview that the wholesale mark-up paid onthe price of drugs should be reduced to alevel that is fair to both taxpayers andwholesalers. The existing mark-up ofalmost 18% is neither reasonable norsustainable and the HSE’s plan to pay an8% mark-up from 1 March, and 7%from 1 January 2009, is to go ahead.”

The new body will make its recommen-dations having regard to (i) the overallpublic interest including the issues ofpatient safety and continuity of supply;(ii) the fee of €5 per item which hasalready been offered; (iii) the reasonablecosts incurred by pharmacists inproviding services under the schemesand the value of the professional serviceof dispensing; and (iv) the statutory obli-gation on the HSE to use the resourcesavailable to it in the most beneficial,effective and efficient manner toimprove, promote and protect the healthand welfare of the public.

Minister Harney acknowledged that thegovernment had “listened to issuesraised by the Irish Pharmaceutical

Union about retail pharmacies.” Theseconcerned the practice by wholesalers ofpassing on part of their mark-up to retailpharmacies by way of discounts, withlarger discounts given to larger phar-macies. The Minister stated that “whole-saler discounting has been described bypharmacists as a method ‘to prop up’ thefees paid on medical card prescriptions. Ibelieve dispensing fees should stand intheir own right, without external, arti-ficial props. We are concerned, inparticular, to support pharmacies whichhave a high proportion of medical cardpatients and where a dispensing fee of€3.27 applies for most transactions.Many of these pharmacies are in rural orinner city areas and provide animportant social and health service. Withmy support, the HSE has indicated it isprepared to offer a higher fee, of no lessthan €5 per item dispensed, tocommunity pharmacists, on the basis ofan interim contract which would beessentially the same as the existingcontract.”

Each pharmacist will have three options:to avail of the interim contract immedi-ately; to accept the interim contractupon the report of the IndependentBody; or to stay with the existing retailfee structure until the agreement of asubstantive new contract. The devel-opment of a substantive new contract isnow also underway; this will be deter-mined under the auspices of an agreedfacilitator and it too will be priced by theIndependent Body.

More information at http://www.dohc.ie

Netherlands: Health Minister seeksEuropean consensus on e-cigarrettes Health Minister, Ab Klink, wants EUcountries to take a common stance onthe e-cigarette’s status. He plans topressure the European Commission totake action.

The e-cigarette is a new device that takesthe form of a tiny rod which is slightlylonger than a normal cigarette. Themouthpiece of the device contains areplaceable cartridge filled with liquid.The main substances contained in theliquid are nicotine and propylene glycol.When air flows through the device, it isdetected by a microprocessor. Thismicroprocessor then activates anatomiser which injects tiny droplets ofthe liquid into the flowing air. Thisproduces a vapour mist which is inhaledby the user. The addition of propylene

glycol to the liquid makes the mist betterresemble normal cigarette smoke. Themicroprocessor also activates an orangelight emitting diode at the tip to simulatereal smoking. This not only simulatescigarette smoke but also the temperatureof common cigarette's smoke (50–60°C).The units use a rechargeable battery as apower source. Energy produced by thebattery is enough to heat the nicotineinside and produce smoke like usualcigarettes do. No harmful tars; onlynicotine, in small concentrations.

In a letter submitted to the Dutch Houseof Representatives, Klink stated thatconsumers need to know that there areno safety issues regarding the e-cigarette.To this end, he suggested that theproduct be submitted to the MedicinesEvaluation Board for assessment.

Until that happens, we must proceed onthe assumption that the e-cigarette is amedicinal product, which means thatadvertising is no longer permitted. TheNetherlands Health Care Inspectoratehas issued a warning regarding the e-cigarette’s potential health risks. Thosewho violate the advertising ban riskbeing fined up to €150,000 by theInspectorate. At the moment, however,there are no plans to pull the e-cigarettefrom the shelves.

The e-cigarette is currently classified as amedicinal product in a number ofEuropean countries, including Austriaand Belgium. Other countries, such asthe UK, have not yet taken a stance onthe product’s status. In the USA, theFood and Drug Administration (FDA)has chosen to classify the e-cigarette as amedicinal product due to the health risksinvolved.

If the e-cigarette is indeed classified as amedicinal product, then the manufac-turer must register the product with theMedicines Evaluation Board in order tobe able to market it legally. The Boardwill assess the product’s safety and willdetermine whether it should be availableover the counter, sold exclusively atpharmacies and chemists, or available onprescription only.

Sweden: New plans for mentally illoffendersAs reported by the English languagedaily, the Local, the Swedish governmenthas stated that it wants to discard theban on prison sentences for those withserious psychological problems.


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Currently, mentally ill offenders are sentto mental health facilities. Under thegovernment's new plan, courts wouldhave the option of prison sentences incertain cases, allowing for more flexi-bility in the sentencing process.

According to the proposed changes,courts would be required to consider anumber of factors in deciding whetheror not to sentence a mentally ill offenderto prison. The factors include theseverity of the crime, whether thesuspect requires long-term hospitali-sation, and whether the suspect wasunder the influence of drugs when thecrime was committed.

Under the new guidelines, a prisonsentence would be possible in the case ofa very serious crime committed whilethe suspect was in a temporary state ofpsychosis. The government hassubmitted the suggestion to the Councilon Legislation (Lagrådet) for exami-nation and hopes to implement thechanges by 1 July 2008.

Russian Federation: Health chief signsdirective to accelerate the fight againstTBOn 2 January 2008, Russian Chief PublicHealth Officer Gennady Onishchenkosigned a directive to scale up efforts tofight tuberculosis (TB) in the country.As reported by the Russian news agency,Interfax, the incidence of TB has‘stabilised at a high level’ during the pastfive years, according to a release fromthe government's Consumer RightsProtection service. The TB death ratealso ‘remains high,’ the release said,noting that about 80% of deaths frominfectious diseases result from TB.

Onishchenko, in his directive, hasproposed that the heads of municipal-ities throughout the country organisemass TB screenings; take additional stepsto examine children and young people;and organise regular medical examina-tions as part of prevention efforts.According to the directive, a significantpart of the population currently goestwo years or more without receiving aTB test. Screening among high-riskgroups is inadequate and early detectionof TB among children and teenagers isincomplete, Onishchenko said.

Only 9% of TB hospitals meet currenthygiene standards, 60% need capitalrepairs, 21% lack either hot or coldrunning water, and 11% lack a sewage

system, the government release said. Therelease also noted that 42% of hospitalshave inadequate medical equipment andthat 20% have a shortage of TB drugs

More information at http://www.global-healthreporting.org/article.asp?DR_ID=49568

Finland: New national framework forservices for older peopleThe Ministry of Social Affairs andHealth and the Association of FinnishLocal and Regional Authorities havetogether published a new nationalframework for high-quality services forolder people. The framework is a recom-mendation intended for the local author-ities as an instrument for thedevelopment and assessment of theservices they provide for older people.Furthermore, the recommendationincorporates ethical principles for theservices.

The new framework is further recog-nition that the population in Finland willbe ageing rapidly in the next fewdecades. It would be difficult to curbexpenditures without reforming theservice structures and manner of serviceprovision. In recent years, qualityrecommendations developed for variousservices have served as new instrumentsin guiding the development of welfareservices at the national level. TheMinistry of Social Affairs and Healthand the Association of Finnish Local andRegional Authorities issued the firstNational Framework for High-QualityCare and Services for Older People in2001. In municipalities the frameworkhas been considered a necessary anduseful tool in the development ofservices for older people. It is howeverimportant to include assessment data as apart of the implementation of the recom-mendation.

The new framework outlines the mostimportant strategic sub-areas to improvethe quality and effectiveness of servicesfor older people. Those are thepromotion of wellbeing and health,development of the service structure,staffing, staff skills and management, aswell as living and care environments.The recommendations cover the servicesused by older people on a regular basis,such as home care, support for informalcare, long-term care in units of inten-sified service housing and in institutionsand, more generally, measures topromote the wellbeing and health of

older people. They also set the nationalquantitative and qualitative targets forthese services, on the basis of which thelocal authorities should define their ownobjectives taking into account the localneeds.

The importance of actions to promotehealth and prevent illness is stressed.Independent living of older people intheir own homes will be supported andservice needs assessed individually.Advice and other preventive services willdiversify the choice of services. Health,functional capacity and rehabilitation aresupported in the context of all services.

The framework describes the criteria forstaffing and gives recommendations forthe minimum staffing levels in twenty-four-hour care. Other importantelements are enhancing the personnel’swellbeing at work, development ofgerontological skills and knowledge, andmanagement skills. It also includesmonitoring indicators for measuringhow the targets have been achieved inthe different sub-areas both according tomunicipality and nationally and empha-sises the importance of partnershipsbetween the public, private and thirdsector. The revised recommendationstake into account national objectives ofgovernmental policy on ageing,outcomes of the assessment of qualityrecommendations, the latest researchfindings, changes in the operating envi-ronment, and the ongoing restructuringof local government and services.

More information in English athttp://www.stm.fi/Resource.phx/publishing/documents/14084/index.htx

Ukraine: New measures to combatHIV/AIDS approvedThe Ukrainian Ministry of HealthMinistry has approved measures aimedat combating HIV/AIDS in 2008. Themeasures are part of PresidentYushchenko's instruction to draft andapprove a national HIV/AIDSprogramme for 2009 to 2013.Yushchenko, previously in December2007 had ordered ministers in thecountry's cabinet to develop measuresfor conducting large-scale HIVprevention programmes, as well as forproviding access to HIV testing andtreatment.

More information athttp://www.tpaa.net/news/regionalnews/?id=3220


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http://www.stm.fi/Resource.phx/publishing/documents/14084/index.htx

http://www.tpaa.net/news/regionalnews/?id=3220

EU study on deinstitutionalisationand community living published

A new report entitled ‘Deinstitutionali-sation and Community Living – Out-comes and Costs’ was recently launchedin Prague. It is the result of a projectfunded by the European Commissionand implemented by a European consor-tium led by the Tizard Centre at theUniversity of Kent and the Personal Social Services Research Unit at theLondon School of Economics. The aimof the project was to collect available information on the number of disabledpeople living in residential institutions intwenty-eight European countries, and toprovide Member States with recommen-dations and strategies for replacing insti-tutions with community-based services.

According to the report, in Europe, wellover one million disabled people still livein some form of institutional care, whichis often of an unacceptably poor qualityand represents a serious breach of inter-nationally accepted human rights standards. Community-based services,when properly established and managed,deliver better outcomes in terms of qual-ity of life and ensure that disabled peo-ple can live as full citizens. They neednot be more expensive than institutionalcare once proper account has been takenof the needs of residents and the qualityof care.

The report can be accessed athttp://www.kent.ac.uk/tizard/research/DECL_network/Project_reports.html

Commission to continue financingCommunity Tobacco Fund

The European Commission has pro-posed to extend the financing of theCommunity Tobacco Fund for a furthertwo years. Since the reform of the Com-mon Market Organisation for Tobaccoin 2004, the Fund has financed informa-tion policies to improve public aware-ness of the harmful effects of tobaccoconsumption. In the current funding period, the Fund gave support to the‘HELP – for a life without tobacco’campaign (www.help-eu.com). The 2004reform put in place a gradual phasing-out of tobacco subsidies between 2006and 2010. In the transitional period

before the disappearance of tobacco subsidies, it also set aside for the Tobacco Fund 5% of the annual budgetfor direct payments to tobacco produc-ers. However, this originally only was inplace until the end of 2007. The Fundcould be worth up to €16,897 millionper year.

More information athttp://ec.europa.eu/agriculture/markets/tobacco/index_en.htm

OECD: Health at a Glance 2007

Progress in the prevention and treatmentof diseases has contributed to remark-able improvements in life expectancyand quality of life in OECD countries inrecent decades. At the same time, spend-ing on health care continues to climb,consuming an ever-increasing share ofnational income: health expenditure nowaccounts for 9% of GDP on average inOECD countries, up from just over 5%in 1970. This fourth edition of Health ata Glance provides updated comparabledata and trends on different aspects ofthe performance of health systems inOECD countries. For the first time, italso includes a chapter on new compara-ble indicators of quality of care, showingvariations across countries in measuressuch as survival rates after heart attack,stroke and cancer.

More information athttp://www.oecd.org/health/healthataglance

World Health Day 2008: protectinghealth from climate change

The health impacts of climate change arealready evident in different ways: morepeople are dying from excessive heat,changes are occurring in the incidence ofvector-borne diseases, and the pattern ofnatural disasters is altering. On 7 April2008, World Health Day will focus onthe need to protect health from the adverse effects of climate change. Manyof the steps needed to prevent climatechange have positive health benefits. Forexample, the increased use of bicyclesand public transport instead of personalcars in industrialised countries will reduce greenhouse gas emissions. It will

also improve air quality and lead to better respiratory health and fewer pre-mature deaths. The increase in physicalactivity from cycling and walking willlead to less obesity and fewer obesity-related illness.

More information athttp://www.who.int/world-health-day/en/

Call for expression of interest for alist of experts

A call for expressions of interest waslaunched by the European Commissionon 9 February 2008 to draw up a list ofexperts to assist in activities related tothe second programme of Communityaction in the field of health (2008–2013).Activities will include reviewing applica-tions for Community financial support(for projects, conferences, operatinggrants, joint actions); reviewing technicaland/or financial reports on completed orongoing projects; and monitoring andevaluating activities under the programme.

Further information on how to apply isavailable athttp://ec.europa.eu/health/ph_programme/ami/ami_036831_en.htm

Updated information on the AlcoholForum

The EU’s multi stakeholder body on alcohol has updated its section of theDG Health and Consumer Protectionwebsite. This includes reports of its latest meetings and working groups,plus the first meeting of Member Stategovernments on the subject.

More at http://ec.europa.eu/health/ph_determinants/life_style/alcohol/Forum/alcohol_forum_en.htm

eurohealth Vol 13 No 3 40

News in Brief

Additional materials supplied by

EuroHealthNet

6 Philippe Le Bon, Brussels.Tel: + 32 2 235 03 20Fax: + 32 2 235 03 39Email: [email protected]

http://www.kent.ac.uk/tizard/research/DECL_network/Project_reports.html

http://www.help-eu.com

http://ec.europa.eu/agriculture/markets/tobacco/index_en.htm

http://www.oecd.org/health/healthataglance

http://www.who.int/world-health-day/en/

http://ec.europa.eu/health/ph_programme/ami/ami_036831_en.htm

http://ec.europa.eu/health/ph_determinants/life_style/alcohol/Forum/alcohol_forum_en.htm


Eurohealth is a quarterlypublication that provides a forum for researchers, experts and policy makers to express their views onhealth policy issues and socontribute to a constructivedebate on health policy inEurope

ISSN 1356-1030