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Brian Edwards CBE,
Professor of Healthcare Development,
University of Sheffield, UK
Discussions about health services in Europe moved forward decisively just before Christmas 2001 when the European Commission published a paper on the future of healthcare and care of the elderly.(1) While it does not contain a grand plan for a European health system, its analysis raises intriguing prospects for convergence in the future. The variation in spending by individual countries has been well documented, but the relative returns on their investments have never been as clear. Germany has the highest spend at 10% of its GDP (1999), but life expectancy in the UK, with a GDP spend of only 6.8%, was about the same for women but better for men. Lifestyle, living conditions and other factors play their part alongside investment in the healthcare systems.
One important variable is the extent to which health systems are publicly funded. The UK has the highest public sector spend at 84%; Greece is at the other end of the spectrum at 56%. The second aspect of this diversity is the way in which the financial burden is shared by the public authorities and the individual. The State carries 95% in the UK but less than 60% in Italy and Portugal.
One of the drivers for increased investment is the growing number of elderly people in Europe. By 2050 it is estimated that 10% of European citizens will be over 80, while life expectancy at birth will have risen to 79.7 years for men and 85.1 years for women. The traditional economic view is that per-capita spend increases sharply after the age of 65 and even more sharply after the age of 80. This may shift, however, if elderly people live longer but healthier lives, thus reducing extended dependency and postponing the age at which costs increase. Set against this may be the cost of new treatments and people’s expectations that they are entitled to access them. The economics are murky.
Technical innovation in the health sector is bound to continue, such as miniature robots for surgery, genetic therapies, growing replacement organs and tissues, as well as new medicinal products. If these new technologies can be delivered in primary care, rather than the hospital setting, the overall cost of their introduction may be manageable.
Demand for healthcare is directly linked to standards of living, and in the past 50 years it has been observed that demand increases more than proportionally to the per-capita income. As patients become better educated they demand more. The Commission points to the ease of obtaining medical information and the desire by the public and the media to access measures of outcome and success.
So, what are the Commission’s long-term objectives? First, they identify the need to improve access for people who are poor or socially excluded – the mentally ill, migrants, the homeless, alcoholics, drug addicts and prostitutes. They also want to see sick pay extended for the employed. Second, they want to improve the quality of healthcare, particularly variations in hospital beds and professional staffing. The ratio of doctors per head of population ranges from 226 per 100,000 in Ireland to 405 in Belgium. There are 47 pharmacists in France, compared with 17.5 in the Netherlands. Another fascinating variable relates to maternity care. The perinatal mortality rates in France and the Netherlands are similar (just over 8%), yet in France most children are born in hospital while in the Netherlands almost one-third are born at home. This represents a serious challenge to those who advocate 100% hospital confinement on safety grounds.
The Commission conclude rightly that many aspects of their responsibilities impact on the health of the community. They are currently restrained to “respecting the responsibilities of member states for the organisation and delivery of health services and medical care”, but this hands-off approach cannot continue indefinitely. The way forward has to be increased cooperation and collaboration. The science of medicine and the expectations of patients no longer respect national borders.
Brian Edwards CBE, Professor of Healthcare Development, University of Sheffield, UK