Define access by the requirements of patients, not the availability of services
17th June 2015
Equitable access – in which all patients can get care as and when needed – should be a central attribute and key measure of performance for Europe’s health systems. But before this can be realised, accessibility must be defined
The factors restricting access to Europe’s health systems are many and disparate: a lack of insurance, inability to make co-payments; short-staffed services; lack of specialists; not being able to travel for care; inflexible, unsuitable opening hours; waiting times; drug shortages; a lack of health information and health literacy, are but a few of the barriers.
Yet, while the subject has been the focus of a great deal of academic and policy research, as the European Patients’ Forum’s Patient Access Partnership recently discovered, there are no agreed definitions of access.
As a result, measuring access in health systems as they are currently constituted is not easy: A move away from the service level perspective to the patient’s eye view is required both to increase understanding of factors limiting access and to help in reshaping health systems to increase accessibility for the future.
The European Commission acknowledged the difficulties in its April 2014 communication ‘On effective, accessible and resilient health systems’ in which it noted access to healthcare is difficult to measure and there is no EU-wide detailed methodology to monitor it and promote best practice.
One commonly used indicator is the variance across the EU in the number of people reporting difficulties accessing care because of waiting times, the need to travel and a requirement to make co-payments. However, these findings derive from self-reported needs and are therefore subject to cultural bias when compared across countries.
Although currently there is no EU-wide definition of how to measure waiting times, there will be pressure for this to change as the concept of ‘undue delay’ embodied in the cross-border directive on health puts the spotlight on the of accountability of health systems for access to care.
However, waiting times are only part of the picture: Access is the sum of a far greater number of factors including health system coverage, the depth of coverage, affordability and availability.
Healthcare access is also directly affected by the organisation and management models used in health systems, with care harder to access if systems are complex and lack transparency.
The directive on cross-border healthcare is being brought to bear to broaden patient choice and reduce waiting times, and in improving transparency, requiring member states to set up national contact points and provide citizens information on their rights and entitlements and care quality standards.
In addition, the Commission is using the directive to improve access to highly specialised health care for complex or rare diseases through European Reference Networks, which provide a framework for member states to share resources and develop shared concentrations of expertise.
Access to medicines
Whilst the majority of healthcare in the EU is publicly funded, patients are increasingly asked to contribute in the form of cost sharing or co-payment, particularly for drugs. There is a school of thought that says this can help ensure that health services are used responsibly and that people are more likely to take medicines they are prescribed. However, co-payment is inevitably an obstacle and a deterrent to people getting the medicines they need, creating inequity.
Similarly, as the Commission communication notes, national decisions on pricing and reimbursement have direct and indirect impacts on the accessibility to medicines across the EU. Innovative products are invariably not made available at the same time in all member states, and in some countries they may not be accessible at all.
The pharmaceutical industry in Europe has taken steps to help member states ring fence their drugs bills whilst giving greater access to new medicines. Management of chronic diseases is seen as the fundamental challenge to Europe’s health systems because it is always viewed through the prism of cost. The key to improving access, whilst working within constrained budgets, is to design and deliver care around the needs of the patients.
Not long ago that would have seemed a paradox. Now, there is potential to involve patients from the outset, improving access without compromising sustainability.
Austerity cuts that have eroded national health budgets have exposed structural weakness in Europe’s pharmaceuticals market, with price cuts in some countries fuelling parallel trade and leading to drug shortages.
Parallel trade, or grey imports may be attractive to the countries importing drugs from member states where the reimbursed price is lower, but there is a consequence for access in lower income countries that are the source of these supplies.
Alongside parallel trade, the recession has exacerbated the more egregious problem of drugs counterfeiting, compromising patient safety. Addressing the dual threats to access posed by parallel trade and counterfeiting requires that EU laws on verification across supply chains are better enforced.
At an EU level, there is a need for better monitoring and tracking of medicines, providing manufacturers with the information they need to manage production and meet demand.
Tackling the threat to patient safety posed by counterfeiting requires commitment to enforce the identification, reporting and quality control requirements of the EU’s Falsified Medicines Directive.
It is clear the current system for pricing pharmaceutical is fuelling market distortions and limiting access to medicines for patients in lower-price countries. Action is needed to set a fair price in each country and end parallel imports.
Managing the healthcare workforce to promote access
There are significant gaps to be addressed in member states’ planning for future health workforce resource requirements, to meet expected needs and ensure access. The shortcomings in workforce planning relate both to the number of staff that will be required and to the skills mix.
Overall, the Commission’s Action Plan for the EU Health Workforce, published in 2012, estimates there will be a shortfall of one million healthcare workers by 2020. On the back of the Action plan the Commission is helping member states to better predict future skills needs and improve national planning systems, developing recommendations, common tools, indicators and guidelines.
Accessible healthcare is pre-emptive
While people may have different perceptions of their needs, accessibility requires they are in a position to take the steps necessary to make access and obtain healthcare.
But truly accessible health systems should not merely respond to a knock on the door, they must be pre-emptive in supporting health promotion and prevention, offering screening services, working to promote health literacy and in enabling people to exercise choice about where and when they receive care.
Health systems should act as channels for patients to access medical innovation, involving patients and their advocates in the conduct and assessment of clinical trials, drug appraisals, health technology assessments and commissioning.
Access to innovation also requires that health systems are open and ready to engage with pharmaceutical companies, providing a route to recruit patients, to collaborate with academic clinicians and, when approval is granted, paying for and commissioning drugs.