Spend smarter to ensure high quality healthcare for all
20th May, 2015
Despite austerity-era cuts, Europe’s health systems command significant resources. Now, these must be deployed in a smarter, evidence-based way, to extract greater value, increase efficiency and bring an end to health inequalities that exist both within and between nations
Efficiency and equality are not necessarily two sides of the same coin – but they can be. Increasing the efficiency of a health system will squeeze the maximum value from the available resources, but this will only bring an end to inequalities if systems are shaped around the needs of patients.
Inevitably, moves to improve efficiency have to start by assessing how a system performs currently. However, not only are the different models of health care across the EU associated with variations in their respective performance, but measuring and explaining the reasons for this variation is very difficult.
A number of EU-funded projects have looked at comparative efficiency and effectiveness across Europe. While these comparisons are important for singling out best practice, they leave many unanswered questions about what to measure. Many common indicators of efficiency, for example, waiting times, average length of stay, unit costs and labour hours per episode of care, ignore the variation between the needs and perceptions of individual patients.
More efficient structures
Reconfiguration of structures, with the emphasis on whole-person care, is one of the big issues with which member states are grappling in attempts to improve efficiency. Existing systems are out of date because they were set up at a time when life expectancy was shorter, and acute hospital-based care for heart attacks, strokes and infectious diseases, was the main requirement.
Now people are living longer, but they are living with long term conditions and there is a need to redesign systems, moving away from acute, last minute interventions, to a service that is built around prevention – to avoid disease in the first place – and to enable people to help themselves if they have a long term chronic disease.
In short, a lot of activity currently taking place in hospitals should be done elsewhere, and care models should be focussed on the home, with people monitoring their conditions and having community healthcare staff to support them.
A number of member states recognise the need to change the model and have embarked on this restructuring process, but it is not straightforward. In addition to challenging the status quo, there is a limited evidence base on which to reshape services, whilst introducing integrated care requires an upfront investment and does not lead to immediate savings.
How patients can contribute
Patient involvement must not be just for the sake of it, but to improve quality. This requires investment in patient empowerment, putting the diagnostic and monitoring tools in their hands and promoting health literacy to improve adherence. In addition, new metrics are needed to measure how patients contribute to improving outcomes.
Member states are putting increased emphasis on measuring various aspects of the performance of their health systems. However, it is critical that performance is not equated to efficiency, but takes in factors including quality, outcomes, equity and responsiveness.
One strand, and an area where the EU can help member states, is in promoting comparative analyses to uncover healthcare variations within and between countries that are unrelated to the amount of resources on hand. There are for example, huge variations in outcomes of cancer treatments across Europe.
While there is potential to use the differences between countries to highlight areas of efficiency, it is not straightforward to translate best practice from one country to another. The causes for differences in performance can be multiple and in some cases are not related to the health system.
EU health systems are diverse, but the cross-border directive on health care and increased mobility of healthcare professionals means they increasingly interact and the EU is working to strengthen cooperation, with the aim of helping systems to function more efficiently.
On the heels of the Vilnius Declaration, in December 2013 the EU Council of Health Ministers called for further work to provide modern, responsive and sustainable health systems. Following this, the 2014 Annual Growth Survey emphasised the need to improve the efficiency of healthcare systems as a means to ensure equity.
With this in mind, the Commission’s communication ‘On Effective, Accessible and Resilient Health Systems’ published in April 2014, notes that while measuring the effectiveness of health systems will become increasingly important, gathering information on comparative effectiveness is still at an early stage. However, in areas where there are EU-wide indicators, for example, the incidence of diseases that can be prevented with vaccines and cancer screening, there are large variations between member states. These disparities imply improvements are possible for the laggards, highlighting the role that comparisons can play in improving efficiency and promoting equity.
To provide better statistics, the Commission has supported development of the European Health Core Indicators and funded development of indicators and methods for assessing the performance of health systems in Framework Programme 7 R&D projects including Echo, Eurohope and Euroreach.
Comparing alternative technologies
Further research is required to increase understanding of what makes for efficient and resilient health systems, and of ways to build these. The EU is supporting this by helping to share best practice and designing policy measures.
One example is in health technology assessment (HTA), which by showing how well a medical innovation works in comparison to the alternatives, supports more efficient use of resources. The Commission has set the target that jointly produced HTAs are reused at a national level to avoid duplication of effort.
Increasing efficiency also requires action to improve the functioning of health systems at an operational level. To assist in this, the Commission is looking at setting out a framework for EU health information systems and encouraging member states to cooperate in developing and implementing e-health systems that increase operational efficiency.
The crisis has forced sizable cuts on health systems Overall this has increased health inequality, and there is a general agreement that this is an opportunity to adapt and re-think aspects of the healthcare policy landscape.
Generic medicines are a mainstay of public health delivery in Europe. Currently, they account for 55 percent of prescription drugs, a figure that is forecast to increase to 75 percent by 2020. “More importantly, generic medicines have doubled access to high quality medicines for patients, while reducing the cost for health care systems by 60 per cent,” says Adrian van den Hoven, Director General of the European Generic and Biosimilar medicines Associations (EGA). Without generic medicines, Europe’s health systems would be facing an additional bill of €40 billion.
Generics are of particular importance in promoting smarter spending to mitigate the impact of chronic disease, the management of which swallows up 80 percent of total healthcare budgets.
After a slow start, access to biosimilars is starting to grow. For example, use of filgrastim to reduce the chance of infection in patients undergoing chemotherapy, has increased by 30 percent across Europe since biosimilar versions became available. “We expect to see similar improvements with other biosimilars,” Mr van den Hoven said.
High cost biopharmaceutical drugs, such as enzyme replacement therapies and monoclonal antibodies, are forecast to account for more than 50 percent of the drugs budget by 2018, underlining the potential that biosimilar medicines hold to promote efficient investment of health budgets.
“This is not about savings, it is about increasing access and ensuring that doctors have more treatment options for patients, including for earlier use, when this is medically appropriate,” said Mr van den Hoven. In addition, more efficient uptake of generic and biosimilar medicines creates headroom for innovation in healthcare.
“Generics and biosimilar medicines are essential drivers of improved access to high quality medicines,” Mr van den Hoven said. Biosimilars offer the possibility of treating more people with biological drugs than currently, improving access whilst promoting financial sustainability of health systems.
Equity and efficiency after the recession
In any health system there are funding limits. Given this, it is essential to identify inefficiencies and spend smarter to extract the maximum value from resources. If the money is not spent wisely, then somewhere in the system, people are being denied services they need and health inequalities are amplified.