On May 15, the ENVI Committee organised a workshop on "Sustainability of Health Systems".
Health systems contribute to preserving and restoring good health of the EU population. They also enable people to live independently through the provision of social care services. The health care sector also plays an important role in the overall economy: it accounts for 8% of the total European workforce and for 8.5% of GDP in the European Union. The sector contributes to economic prosperity through improving labour market participation and productivity.
All EU Member States face strong and growing fiscal pressures on their health and long-term care systems, driven by already high levels of public expenditure and debt in most countries, demographic pressures and technological advances.
EU Member States' future ability to provide universal and equitable access to high quality care will depend on making health systems more resilient, capable of coping with the challenges ahead and while remaining cost-effective and fiscally sustainable.
Please see below for a summary of the event.
Opening and welcome by the co-chairs Ms Soledad Cabezón Ruiz (MEP) and Mr Alojz Peterle (MEP)
Soledad Cabezón Ruiz (S&D, ES) opened the session by noting that it is an important topic for her and the EU. Health is one of the most important values for EU citizens, she said. It is important to have a discussion about this issue because the economic crises had put in place challenges for European health systems. Beyond the economic crises, the challenges faced by health systems include access to medicines and to new technologies.
Alojz Peterle (EPP, SI) thanked the participants for their presence at the event. He said that health systems contribute to preserving the good health of EU citizens, but they also contribute to economic growth. Health systems are different in EU countries, but they have a common goal. Diversity of the health systems provides an opportunity to study good practice and see how they can be transferred to other countries and regions. Health systems need to adapt to new situations and challenges, including changing demographics, HTA, personalised medicines, genetic medicines and many others. Health systems we have today are more and more difficult to finance today from public spending, he said. Finding policy solutions to make health spending more sustainable is an important issue to discuss.
Panel 1 - Main challenges of the sustainability of health systems
Professor Clare Bambra, Professor of Public Health at the Institute of Public Health at Newcastle University, gave a presentation on Sociodemographic Challenges: Aging of the Population and Determinants of Health. There are various scales of inequality of health in the EU, between countries, regions, towns and cities, she began her presentation. There are significant differences; there is a clear west-east divide, she argued. There are also differences in terms of aging populations, as the population in Western Europe is generally older than in Eastern Europe.
On the regional level, she explained that there are differences within countries in terms of life expectancy. She then noted that in England there is a clear North-South divide, with the North having lower life expectancy. In Germany, areas in the East have an older population than areas in the West.
Professor Bambra then explained that health inequalities are also present at the local level, between neighbourhoods in cities. As examples, she showed Berlin, London and Paris where the health inequality gaps in life expectancy range from 4 to 7 years. These inequalities impact the ways in which people age. These differences between neighbourhoods have increased in Europe since the 1980s.
Explanations for these inequality differences are complex, ranging from general socio-economic, cultural and environmental conditions to social and community networks to individual lifestyle factors. Health inequalities have been a priority for the European Commission, however, she said.
She explained that in Germany health inequalities have been reduced pre- and post-unification. This was due to changes in the health system, better pension plans, and better nutrition. In England, 1997-2010, inequalities in life expectancy in the poorest neighbourhoods and in average neighbourhoods were reduced. More investments were made in the health systems in poorer areas, but also other social policies were introduced.
In conclusion, she said that there are significant health inequalities in Europe as well as ageing within and between countries. These inequalities have significant costs to the EU and unequal aging also poses challenges to health systems and welfare systems, including pensions. The inequalities are socially determined but can be influenced by healthy public policies. The reduction of health inequalities requires policy cohesion across different sectors, not just healthcare, she concluded.
Alojz Peterle (EPP, SI) said that inequality is a keyword used often in the Parliament. For a politician, it is difficult to see that they have increased health inequalities. There have been inequalities everywhere and always, but then in a Union that seeks to improve the situation to face increased inequalities this should be seen as an alarm. As such, he was pleased by the last comment made by Professor Bambra, that the inequalities can be reduced.
Soledad Cabezón Ruiz (S&D, ES), spoke about New Technologies and Access to Medicines . She explained that she had been the Rapporteur on the Parliament's report on improving access to medicines. She wanted to say that 15% of public expenditure in OECD countries goes to health. There has been an increase since 1990 of 17%. In 2014, it represented 6% of GDP, and in 2060 it is projected to represent 14%.
When looking at the different healthcare systems in the EU as a whole, it is necessary to look at both quality and efficiency. We have seen an increase of life expectancy. Investment in healthcare reduces inequalities and increase productivity and growth.
There is a crisis and they need to look at what the reaction in the member states has been. In Spain, for example, in 2016, it was shown that it was more expensive for the system if access to healthcare was denied from certain groups such as migrants.
Ms Ruiz explained that health system reforms are needed because current systems are not adequate to deal with the challenges they are facing. Life expectancy is impacted by the public health system, education level and socioeconomic status, she remarked. Long-term care that is centred on hospital care is not adequate. She also mentioned environment and agriculture as having an impact on life expectancy. Only 3% of what is invested in health goes to prevention and health promotion in the EU, but it is known that lifestyle has an important role.
In terms of chronic diseases, she explained that in 2060 more people over 65 years will have chronic diseases and thus need long-term care. This is a real challenge because of the long-term care and the costs involved. By 2050, people over 80 years old will represent 10% of the EU population and 30% of them will need long-term care. There will be doubling of investment and expenditure in the sector.
Another issue is access to medicines and technology. 17% of health investment goes to pharmaceuticals in the EU, Ms Ruiz said.
In terms of innovation, quality of innovation is not all that could be desired because often it is incremental innovation with a high cost instead of real innovation. She mentioned AMR as an area of unmet needs. There are also rare diseases where the private sector does not want to invest. There are now more medicines that are under the name of orphan drugs, but the price of these drugs is high.
To improve the sustainability of health systems, she talked both about national and the European level which included fiscal measures, reforms in the organisation of health systems, health promotion and prevention as well as HTA, R&D, competitiveness, clinical trials, intellectual property, and transparency.
As to specific measures, Ms Ruiz said that there are differences between EU countries with regard to unmet needs and mortality. There are inequalities and there are areas where more work needs to be done. The European Commission carried out a study on access to health systems in the EU and found that there were a lot of inequalities. In Spain, for example, there are areas where they can improve within the country. There are fiscal measures that have been taken to contain costs, but this has not meant that quality has improved. There were a lot of inefficiencies in the system previously.
When it comes to reforms, she explained that many OECD countries have carried out reforms, such as Japan. There is high life expectancy and reforms are being carried out to have patient-centred policies with greater focus on prevention and health promotion. They are also changing the hospital system into a primary care centred system. In Japan, the population is going down but the number of people over 65 is doubling.
In the EU, HTA is a key issue which can contribute to the sustainability of systems. This means that the value of medicinal products and devices will be improved. The quality of research should go up. This means that there can be a better establishment of cost and reimbursement, she said.
On research, she thought that they need to think about the topic more, starting with the major public research programmes. 40% of health research is in the public sector and it is very important to establish criteria to have a return on public investment. Resources should not be going from the public to the private sector without a return. There needs to be affordability criteria. The public-private relationship in the EU needs to be rethought, she argued. At the very centre are the citizens, she concluded.
Alojz Peterle (EPP, SI) said that the EU and Japan have decided to define health as one of the areas of strategic cooperation. The strategic partnership agreement needs to be endorsed by the Parliament by the end of 2018. They had seen in Hiroshima how the end of life could look like with robots monitoring people and forecasting when the patient will die and would then inform the family.
Professor Barbara Prainsack, Professor at the Department of Political Science, University of Vienna, Austria, and Professor of Sociology at King's College London, gave a presentation on Genetics and Precision Medicine. She said that the topic is commonly seen as a cost-driver. People are divided on the idea of personalised medicine, because it is seen as an area that increases inequalities. However, she argued that the case was not necessarily so. If they want to utilise personalised medicine for sustainable health systems, they need to rethink the term, she argued.
Professor Prainsack first talked about the terms 'personalised' and 'precision' medicine. Doctors have said that medicine has always been personalised, but that is not what is meant with the terms nowadays. The term personalised medicine became very popular after 2000, after the mapping of the human genome. The idea was to create drugs and drug treatments that would match groups, race was also used as a proxy which made the topic very politically contentious. This was the personalised medicine of the 2000s, she said.
In parallel to the European report, in the US they made a study on precision medicine and separated different levels that could create a map to predict when people have health problems before they get them. This is the shift from the personalised medicine of early 2000s to the precision medicine of today. Now, the argument is that all possible information should be used to have personalised and precision medicine. Genetics are in there, but they are part of a bigger picture.
The ESF Forward Look in Personalised Medicine for the European Citizens saw that individual characteristics also beyond genetics should be used in prevention, diagnosis, treatment and monitoring of patients.
Key promises of personalised medicine are systemic and multi-omics approaches, closing the actionability gap between evidence-based medicine and individual patients, and moving from symptomatic and episodic medicine to continuous and pre-symptomatic medicine. This requires bringing together as many types of information as possible which can be seen as promising or scary.
In terms of the use of personalised medicine for the sustainability of health systems, she said data governance needs to be improved, including data quality, data security, data actionality. She noted that white people are over studied and there are groups that are completely missing. There are 3 types of missing data: missing populations, missing information about individuals, missing types of information (e.g. social biomarkers). In terms of data security, she mentioned the GDPR and said that better harm mitigation instruments are needed.
The second measure would be to have health included in all policies. Prevention should include housing and environmental policies, there should be a stronger relationship between health and social care, they need to ensure access to affordable and good healthcare for everyone, and to increase health 2.0 literacy of all actors, within and beyond healthcare.
The third measure is to reduce harm and waste. This should not be done through rationing, but by reducing low-value interventions. There are initiatives such as choosing wisely, preventing overdiagnosis, and realisitc medicine that help. It is also necessary to explore low-tech, high-touch practices of personalisation and 'precision' in medicine and healthcare. 'Precision medicine' can mean not to provide a medical intervention, she underlined, but also noted that this issue is not part of the 'precision' medicine debate at the moment.
Alojz Peterle (EPP, SI) thanked the speakers for the comments made and explained that they would move directly to the second panel.
Panel 2 – Experiences of reforms of health systems for the sake of sustainability
Introduction to Panel 2 by the co-chairs Ms Soledad Cabezón Ruiz (MEP) and Mr Alojz Peterle (MEP)
Soledad Cabezón Ruiz (S&D, ES) presented the speakers of the panel before giving the floor to the first speaker.
Dr Akiko Maeda, Senior Health Economist at the Organisation for Economic Co-operation and Development (OECD), gave a presentation on the Healthcare System Model of Japan. She mentioned the possibility of the EU and Japan working on healthcare and noted that it was a necessary step to take. She wanted to give a brief overview of the status quo and highlight some key features, key challenges, and the Vision 2035 that the Japanese government has embarked upon. Japan has been doing quite well in terms of general healthcare system performance, she remarked.
Japan is leading in terms of health status with the highest life expectancy and lowest obesity rate in all OECD countries. Ischemic mortality rate is very low and the smoking rate is also going down. She explained that an issue in Japan that is rising is malnutrition among pregnant women due to diets and wrong information. They have low birth weight babies and this also increases the probability of chronic diseases. Looking only at the aging population is not enough when discussing chronic diseases.
Japan has good access to quality care, but the challenges are with aging. They have the highest dementia prevalence, but they are working on how to treat Alzheimer's. Their suicide rates are also coming down after having spiked in the 1990s due to unemployment. Often the reason for suicide is not old age but the lack of work-life balance. The government is looking at how to improve work so that it is not as stressful (70% of working Japanese said that they are not happy at work).
The costs of healthcare are rising while demand for services is also increasing. The per capita spending is high, but not the highest. They have a high number of hospital beds, but they do not take full advantage of the infrastructure present. There are a lot of CT scans but they do not necessarily add value to healthcare, Dr Maeda noted. There is a question of how much of the capital investment in the health sector is spent efficiently.
Japan is suffering because they have been paying for healthcare from debt. The gross government debt is at 200% of GDP. They may not be spending as much as some other countries, but as it is being paid by debt, it is not sustainable.
In terms of meeting the Vision 2035, they need to tackle the fiscal deficit, address growing healthcare needs, changing social environments and values, increasing inequity and globalisation. The government wants to position Japan as the authority on health longevity, but this is at pilot or experimental stage at the moment.
The government wants to invest in multi-sectoral projects to create a safe and healthy living environment for the elderly, family and community. They want to strengthen coordination and management of services among medical care, long-term care and social services. Transforming investments in health and social services into employment and revitalisation of local communities is also planned. In addition, they want to ensure that investment is directed not only to expand service capacities but also to enhance productivity and quality.
Specifically, the government is working on bringing the different types of funding (healthcare, long-term care, long-term preventive care, living support, and housing services) together.
In conclusion, Dr Maeda said that they want to transform healthcare into a horizontal system that engages all sectors through a shared vision and values rather than maintaining the current system through increased cost sharing and cuts in benefits. The other part is to promote innovation in healthcare technologies and systems that drives Japan's growth and development while maintaining excellence in health. New developments in robotics and how it could be used in healthcare also require discussions on ethics, she noted.
Dr Thomas Plochg, Director of the Netherlands Public Health Federation (NPHF), gave a presentation on the Health System in the Netherlands. Dr Plochg started by saying that he wanted to stretch the debate by sharing what is emerging in the Dutch health system. First, he said that it is necessary to think outside the box to have a sustainable health system and second, this will lead to a person-led heal & deal system. This transformative change is gaining momentum in the Netherlands, he said.
When looking at the Netherlands and the rankings, the country is always on the top. This is because they have a well-performing health system; good access, good quality. However, the Dutch healthcare system is not sustainable. In the Netherlands, they have the debate to improve the functioning of the system in the box, but there are transformative changes happening outside the box.
He explained that the current system is successful in addressing acute, single diseases which creates a vacuum for chronic diseases to emerge. Over 2 million people have 2-5 diseases at the same time, accumulated with other social issues.
In the current system, they think disease-by-disease, which leads to having 10-15 specialists around one patient. However, this is unaffordable as it yields declining returns on investment. Health for a multimorbid patient cannot be generated by simply summing up all specialists' expertise, Dr Plochg underlined.
Transformative changes are needed, including the syncing the health system, specifically the organisation of professional expertise with health needs, demands and values of the Dutch population. They need to become more proactive and move away from the current siloed-approach. They have also made the patients passive instead being co-producers of their health. This debate is on the agenda in the Netherlands which is a good development, he thought.
He then wanted to highlight two areas of change in the Dutch system: concept of positive health i.e. pushing death out with joy and this idea is resonating in the Dutch population. A GP that began to work with this idea was able to decrease referrals to specialists, for example. The second area is developing business models for health as the current model is based on disease and not on health. He mentioned Spotify because he wondered if they could sell health as a long-term relationship rather than a commodity, as Spotify sells music. When looking from this angle, it is possible to see that the business-to-consumer health market is already there. The digital revolution will bypass healthcare.
The business models in the digital world are exclusive, the application is free because the person is not the customer but the product. This is dangerous for health systems. The model should be inclusive. Also, the business models do not have skin in the game which does not work for the health system either.
Finally, he said that they are building a new healthcare system. The current system is professional-led, but the transformative change is showing the early signs of a person-led, heal & deal system. This will not disrupt the current system but counterbalance it. Thinking outside the box is necessary in order to have sustainable healthcare systems. The EU could facilitate the transformative change across Europe and beyond, as a fertile strategy towards more sustainable health system, he concluded.
Dr Natividad Cuende, Executive Director of the Andalusian Initiative for Advanced Therapies, gave a presentation on The Andalusian Health System. She explained that she would talk only of one region, Andalusia, but the region is the biggest in Spain and bigger than 13 EU member states. In size, it is similar to Austria. Her presentation focused on the Andalusian drug policy and how they are trying to make the system sustainable with a focus on increased access to medicine.
To better understand the Andalusian system, Dr Cuende explained that in Spain the regional government are almost solely responsible for public spending in healthcare. Andalusia spends more in healthcare than other regions in terms of percentage of GDP, but because their GDP is one of the lowest in the EU, they are not spending a lot in healthcare in terms of euros.
She then talked about the Andalusian Public Healthcare System. She explained that there was a new law being finalised in Parliament which aims to shield the public health system guaranteeing the principles of universality, equity, social solidarity and equal access to healthcare. Article 14 of the law is related to rational use of medicines which would reinforce the pioneering policy that has been implemented in Andalusia already since 1992. The policy on rational use of medicines promotes appropriate medicine prescription through medical evaluation and evidence-based clinical guidelines and encourages competitiveness among pharmaceutical companies. Since 2001, the prescription has been according to active substance. This has also increased the use of more efficient therapeutic alternatives. Following this policy, Andalusia has the lowest hospital spending on drugs.
Dr Cuende then noted the rocketing prices of medicines and mentioned the monopolistic position of Gilead in medicine for hepatitis C. She said that the company had regrouped 25 times its initial investment in R&D in less than two years and wondered whether this could be considered as fair sharing of value between innovators and the society.
She then talked about advanced therapy medicinal products (ATMPs) which include cell therapy, gene therapy and tissue engineering. 10 ATMPs have been granted market authorisation in Europe and several more are at present being evaluated. However, the average cost of an ATMP is 400.000€/patient. Part of the price comes from the long development procedure that is required for an ATMP, but she underlined that in Europe the legislation is based on altruism, in contrast to the medicines market.
Dr Cuende explained that the procedures for the clinical use of ATMPs that are an investigational medicinal product or an authorised medicinal product are different. For an investigational medicinal product, it is the national competent authority that decides on the clinical trial and compassionate use. For an authorised medicinal product, the marketing authorisation is made by the EMA – a centralised procedure – and the hospital exemption is granted by the national competent authority. In Spain, this means that the hospital exemption can only be requested for ATMPs which have demonstrated quality, safety and efficacy under the same standards as commercial ATMPs.
In Andalusia, the Andalusian Initiative for Advanced Therapies is a publicly funded organisation that was created by the Regional Government of Andalusia and they are a part of the Andalusian Public Healthcare System. They promote the activities of R&D&I in cell therapy and regenerative medicine, clinical genetics and genomic medicine and nanomedicine to foster both cell and gene technologies and therapies. They also coordinate the provision of regenerative medicine treatments within the Andalusian Public Healthcare System. The Andalusian Initiative for Advanced Therapies is part of the Regional Health Service which represents a singular European example of an institution acting as ATMP manufacturer, clinical trial sponsor, healthcare provider and, at the same time, as funding entity, Dr Cuende explained. Andalusia is the leader in clinical trials in ATMs in Europe.
In conclusion, she said that the rational use of medicines policy can contribute to the sustainability of healthcare systems as it restraints pharmaceutical expenditure. Recent experience with cancer and hepatitis C drugs has highlighted the need to find mechanisms to make compatible the introduction of innovation within health systems without compromising sustainability.
ATMPs are hardly affordable for public health systems as they are the most expensive medicines when commercialised and they represent an important challenge for sustainability. ATMPs are 'living' products regulated by medicine legislation and also by cell and tissue transplant directives regarding donations. ATMP manufacturing and delivery encompass several procedures identical to those of cell & tissue donation and transplantation in which healthcare systems have successful experience.
The EU legal framework recognises the member states' capacity to regulate the use of non-industrially manufactured ATMPs which represents an opportunity to make industrial interests compatible with those of health systems as has been done in Andalusia. A mixed and flexible provision model of ATMPs can also benefit patients' access to innovative medicines, she noted. Mr Cuende further said that the defence of the pharmaceutical and biotechnological sector should not be made at the expense of putting health system sustainability at risk.
Soledad Cabezón Ruiz (S&D, ES) opened the floor for questions.
Professor Prainsack wanted to ask Dr Plochg about the Dutch healthcare system. She noted the criticism made by Dr Plochg on the untamed commercialisation, but she was concerned with the use of Spotify as a model for healthcare. Should not healthcare be something that cannot be sold and should they not as Europeans be proud of that, she asked.
Dr Plochg replied that it was the message that he was making. There is a healthcare market in Europe. He used Spotify as an example because they sell a relationship instead of a commodity. Health cannot be sold and the only customer is the government. His worry is that they need to be very attentive that those business models are inclusive and support the public interest. He was more referring to a system of subscription in healthcare when talking about Spotify as an example.
Dr Maeda asked about precision medicine. She wanted to know Professor Prainsack's opinion on combining high tech with high touch and on microbiomes and their possible future use in medicine.
Professor Prainsack said that high-tech is not necessarily in tension with high-touch, but she emphasised high-touch because there is already a lot of discussion about high-tech. High-touch should be brought to decision-making. It means creating systems in healthcare where different actors learn from each other, high-tech and high-touch go hand in hand, she underlined.
Simone Mohrs, European Hospital and Healthcare Employers' Association (HOSPEEM), wondered where they see precision medicine taking place, its transposition in actual healthcare settings, and how affordable and feasible it is for the local level. She also asked about what kind of skill changes this would require for healthcare professionals.
Professor Prainsack replied that it depends on the definition of precision medicine. If using a very narrow definition, then it will increasingly take place in hospitals. However, if the understanding is wider, then it needs to start outside hospitals with prevention and social policies. It starts with having a discussion with all the actors on where priorities are put. She did not believe in the argument of the cost crisis, as where the money is spent is a political decision. A new specialty will be needed, she thought, to be between the healthcare professionals and the patient. The enthusiasm about data driven medicine can create a new actionability gap and a new profession will be needed.
Ms Mohrs replied that health informatics is already a discipline and asked would the new profession be a speciality within that discipline.
Professor Prainsack said that they need someone the deal between doctors and patients and this could be within health informatics.
Dr Plochg said that they are promoting a new way of how professions develop. Professionalisation of health professions has become synonymous with specialisation and that is against this agenda. They need to think how to reverse that thinking. In the Netherlands this is what they are doing.
Alojz Peterle (EPP, SI) thought that the panels had been conceptually rich and thought outside the box. He mentioned prevention as another keyword and said that it seemed that for thinking in the box, prevention is not seen as an economic category. He asked how they could sell prevention.
Dr Maeda replied that prevention had a negative connotation. For a politician, instead of talking about prevention of a disease, they should talk about joy. OECD is looking at what is meant by well-being, it is not longer life with misery, but about having joy and better lives. She said that using positive language would be better.
Dr Plochg said that self-monitoring health and the health market of fun is already there. However, he said that he would like to have market research on this. He was unsure that they could really target it in a way that businesses can really make business. In the Netherlands, they are trying to make it a public-private cooperation.
Professor Prainsack said that practically speaking they can foster lives lived well by changing incentives in healthcare systems. More incentives need to be given to healthcare professionals for talking with patients and move to value-based reimbursements. This of course comes to the issue of what is value, she concluded.
Soledad Cabezón Ruiz (S&D, ES) said that challenges to the healthcare systems include aging, new business models, new incentives, more participation. She thanked the participants and said that they need to continue the discussions on the topic.