1. Structural Funds in Health anamnesis, diagnosis, prognosis 18. - 19. 6. 2013, Pilsen, Czech Rep. Barrie Dowdeswell Director of Research ECHAA

2. Content The economic crisis and impact on Health Emerging trends in healthcare delivery Reconciling EU Cohesion Policy and Europe 2020 with MS needs and priorities Achieving success in accessing Structural Funds for healthcare Tensions Conclusions

3. The economic crisis and impact on Health – and Healthcare

4. The current economic crisis: The need to reduce large government deficits and put public finances back on the right track and We will see public authorities freezing / contracting their spending on health services” We then face the age-gap pensions crisis – reducing resource availability and increasing demand Two factors are disrupting conventional ideas about healthcare strategy GDP and health spending ‘Health’ is of prime strategic importance and value in managing the economic crisis contributing to ‘human capital’ reducing the cost burden of healthcare contributing to managing the age–gap pensions crisis stimulating SME opportunities

5. Healthcare costs are rising faster than levels of funding available through taxation and insurance Ageing populations and the related rise in chronic disease Costly technological advances Patient demand driven by better information and by less healthy lifestyles Legacy priorities and financing structures that are not suited to today’s needs Accumulating debt Spending Available resources

6. Emerging trends in healthcare delivery

7. Re-examining the effect of current spending patterns in healthcare The hospital-centred model has too often been stimulated and sustained through easy credit facilitated by high levels of GDP growth – This now looks unsustainable Increasing Government debt – direct and PPP Increasing hospital deficits An outlook of further reductions in spending The risk of growing inequalities Evidence suggests between 25% and 50% of all acute beds are used for services for which they were never intended, in particular: Meeting the care needs of an ageing population A poor default model for much chronic illness ‘Holding on’ to services that could be devolved There has been little progress in concept change

8. Concerns about underestimating the impact of an ageing population We are here A strong consensus that managing the ageing ‘crisis’ is the key priority

9. 65 80Age Illness profiles e.g. ___ Circulatory disease ___ Cancers ___ Neurological degeneration Planning for future impact - age related illness demands will create unprecedented challenges Co-morbidities Frailty

10. Facing up to the the problem – immediate priorities Major reconfiguration of acute care Comprehensive redesign of services for age-related support through integration of care across whole systems Economies of scale – better use of resources Responsiveness to population need – more effective care Improving equity, access and quality – social cohesion Sustainability – economic value A strong shift towards ‘regional’ healthcare

11. “Pathways for Change” (Godollo, Hungary 2011) Unanimously supported by MS and endorsed by the EU Council Institutional / sector delivery Whole systems disease management Coherence Population sensitivity The patient as co-producer of care More effective commissioning Resource reallocation Workforce realignment Changing focus Integrated care Societal and economic benefit

12. New models of care - EU Council policy perspective EU Council 6 th June 2011 “Consider innovative approaches and models of care responding to challenges and develop future long-term health sector strategies with the aim of moving away from hospital centered systems towards integrated care systems, enhancing equitable access to high quality care and reducing inequalities” Note: specific reference was made to SF for investments relating to reform, infrastructure and eHealth

13. Kymenlaakso Finland The Aalto “Pareto study” An illustration of the shift from a hospital-centred model of care to a whole systems integrated strategy for healthcare Structural reform of the health system A new affordable and sustainable model of healthcare Healthy and active ageing principles Improving accessibility eHealth as a facilitating technology Integration across the whole health system

14. Epidemiological and demographic mapping A basis for assessment of future healthcare need

15. Demography as a basis for economic risk assessment

16. Future cost / affordability assessment EBITD - Earnings Before Interest, Taxes, Depreciation

17. A pathway to reform – with a supporting change in commissioning strategy The core elements of the problem The current model of healthcare / social support for the elderly will demand double the workforce over the period 2012 / 2035 – not viable on the grounds of labour supply or cost Reduced taxable income and increased demands for acute care by an ageing population will require a significant improvement in cost-efficiency and productivity by the acute hospital – not viable without major reform (integration) of the care model

18. Reform modelling The proposal for change Reform of the care of ageing and chronic illness model – current workforce levels must absorb x 2 the numbers of patients / elderly / older people Acute hospital service change - innovative redesign of the care model and pathway-led integration to deliver a cost efficiency / productivity increase target of between 10% and 15%

19. A more “natural hospital system”

20. Medical Knowledge Centre 10 000 m2 Changing the concept of the hospital – the integrated regional knowledge centre Primary Services Knowledge Centre 8 000 m2 Hot Hospital 11 000 m2 Supporting services 6 000 m2 Hotel 7 000 m2 Infections Soft tissue problems Cancer Trauma Cardio-vascular Chronic Disease Management Internal Medicine Surgery Neurology Others elective Emergency ICUCCU Stroke unit Patients in critical care Operation Imaging Delivery acute

21. Knowledge and skills diffusion through care pathways – mobility of staff and flexible teams a feature

22. Observation at A & E Rehabilitation, crises General wards without specialities Shared resource Responsibility: Internal Medicine, General Medicine? Patients in Critical Care ICU New principles for ward systems and structures Accident & Emergency OutpatientManagement of Crisesand Chronic Diseases FAST / ACUTEELECTIVECHRONIC Rehab, crises HEALTH CENTRES

23. From Stand-alone Hospital to Health Service Centre STAND-ALONE HOSPITAL ISOLATED, PROFESSION-CENTERED HEALTH SERVICE CENTRE as a part of the WELLNESS PARK INTERCONNECTED, CUSTOMER-CENTERED The Wellness Park is a Hub in the Regional Service Network, combining the Hospital with other services ACUTE CARE ELDERLY SERVICES SENIOR HOUSING HOME CARE Health SHOPPING MALL HOUSING REHABILI TATION OUTPATIENT SERVICES SOCIAL CARE SERVICE HOUSING WEL- FARE SERVICES for FAMILIES EDUCATION Wellness Park Regional Service Network Health Service Centre Design © Antti Autio 2010 Source: Autio & Vauramo, PARETO project, Aalto University 2010

24. Changing public and professional cultures and strategies for the chronic ill and elderly

25. Integration into multifunctional urban blocks Active environment that supports self-care Home care services based on the needs of the elderly living in the area day care school health care clinic housing care home common spaces grocery street multifunctional common courtyard roof terrace senior housing café services underground parking P shops Integrating Elderly Housing back to Society Design © Antti Autio 2010 Source: Autio & Vauramo, PARETO project, Aalto University 2010

26. The transforming potential of technology e.g. eHealth based dispersal strategies for outreach care The modular – dispersable hospital

27. Reform – infrastructure dispersal but service integration

28. From hospital centricity to patient centricity Integrated regional networks

29. So what are we trying to achieve? Transformational change from hospital centricity to patient centricity The modular ‘hospital’ Local accessibility Clinical WP Flow based planning Dispersal Integration

30. Worldwide trends in the delivery of heath care – responding to future need Improving access Distributing resources more equitably Improving quality of life Controlling costs Shifting the concept - Health Care to Health Maintenance Shifting of patient visits from Hospital Sites to Community Services

31. As community services expand in size and number… Demand for more primary care providers Patient care facilitators (enabling services e.g. eHealth) Patient care team development—reduce sense of isolation The medical home concept is developed to improve care of chronic conditions and improve health maintenance The challenge will be resource reallocation to support the shift

32. Reconciling EU Cohesion Policy and Europe 2020 with Member State health needs and priorities

33. EU Cohesion Policy – Investing in growth and jobs The European Regional Development Funds (ERDF) strengthening economic, social and territorial cohesion by correcting inbalances between regions The European Social Funds (ESF) the EU’s main financial instrument for investing in people Strengthened conditionalities – improving performance requirements and impact evaluation The ‘political’ (SF) climate has shifted towards more explicit contribution to economic growth, fiscal sustainability and results

34. Europe 2020 Smart growth: developing an economy based on knowledge and innovation. Sustainable growth: promoting a more resource efficient, greener and more competitive economy. Inclusive growth: fostering a high-employment economy delivering social and territorial cohesion. Flagship initiatives to catalyse progress Innovation Union Youth on the move A digital agenda for Europe Resource efficient Europe An industrial policy for the globalisation era. An agenda for new skills and jobs European platform against poverty

35. DG Regio “Approach to health in post-2013 period” “Alignment with the Europe 2020 strategy (e.g. European Platform against Poverty, EIP Active and Healthy Ageing) Focus on main bottlenecks constraining growth in lagging Member States and regions Foster structural change in health systems Sustainable investments adjusted to the changing environment Health inequalities is a priority - ensuring equal access to health services by the poor and extreme poor”

36. “Investing in Health” – “ the social investment package” Health is not a headline Cohesion Policy or Europe 2020 priority – but the document --- Establishes the role of health as part of the Europe 2020 and strengthens the link between European health policies and support for health systems reform: the economic crisis, an ageing population, increase in chronic diseases and high cost of technological progress Health is a value itself – the human capital principle Health expenditure is recognised as growth-friendly expenditure Reinforces the need for reducing health inequalities and investing in sustainable systems

37. “Investing in Health” - the health programme Geared towards measures in line with Europe 2020 to contribute to innovative and sustainable health systems; to increase access to better and safer healthcare for all EU citizens; to promote good health and prevent diseases by addressing the risk factors of most diseases; to protect people from cross-border health threats.

38. “Investing in Health” - Targets identified in the document Investing in health infrastructure that fosters a transformational change in the health system, in particular reinforcing the shift from a hospital-centred model to community-based care and integrated services; Improving access to affordable, sustainable and high-quality healthcare, in particular with a view to reducing health inequalities between regions and giving disadvantaged groups and marginalised communities better access to healthcare; Supporting the health workforce - adaptation, up-skilling and life-long learning; Fostering active, healthy ageing to promote employability and employment and enable people to stay active for longer.

39. Achieving success in accessing Structural Funds for healthcare

40. DG Regio view of health investments in the current programming period “Main Challenges Long list of priorities, no focus Lack of clear strategy No link to social inclusion policies Social and territorial inequalities are not targeted Risk of further investments in non-reformed, ineffective, not affordable health system Sustainability of investments is not ensured Political influences (planning or implementation phase) Non-transparent procedures Lobbying”

41. A results based and integrated programme strategy “Improving the quality of public expenditure in times of fiscal constraints” Meeting ‘new conditionalities’ - agreeing ‘commonsense’ success factors e.g. they are directly linked to factors which determine the effectiveness of investment; they are limited in number, focusing on the framework conditions that are perceived as most relevant; Improving monitoring and evaluation – DG Regio guidelines An integrated strategy Programme strategy Indicators, monitoring and evaluation Consistency of financial allocations Contribution to Europe 2020 strategy, and Strategic Environmental Assessment

42. Towards an integrated SF strategy Supported by relevant and measurable ‘needs & results’ indicators ObjectivesTransformative change in systems Healthy and active ageing Improving access and equity Workforce skilling and lifelong learning Reducing health inequalities Investing in people - health as human capital Sustainable systems Economic contribution

43. Tensions Overcoming legacy problems How do we value legacy infrastructure problems – backlog maintenance is rarely justification for future investment Sustaining investment while alternative models are developed – the need for pump-priming spending The time-lag problem of workforce change The ‘generational’ pay back of public health investments Weaknesses in systems indicators in particular health outcomes Overcoming the dominance of ‘process’ Risk assessment of strategy Staff capacity and competence These factors often stifle innovation

44. Conclusions – convergence on common issues across Europe The challenges are the same Unprecedented pressures in particular the economy and ageing Legacy problems that create conflict in spending priorities An acute shortage of investment funding The values are the same Improving access and equity Better public and patient engagement and accountability The answers look the same Improving efficiency and effectiveness through a shift in healthcare delivery systems – from a hospital model to a community service strategy Whole systems planning and investment – and accountability Delivering better value for money Structural funds can offer critical assistance but Health needs all the support it can get for 2014/20

45. Thank you for your attention barrie.dowdeswell@echaa.eu Skype name - barriedowdeswell Balancing macro-economics and personal care is never easy