A different health future

A different health future based on five major changes was urged by Ms. Francesca Colombo, Head of Health Division, OECD, when she opened the session on the “Context for Change,” which was chaired by HMI President, Mr. Derek Greene.

Francesca Columbo
Francesca Columbo

“We need more prevention, to strengthen primary health care, to use secondary care services appropriately, to reduce unwarranted variations in intensity of care across and within countries and to manage big data to better inform patients, physicians and policy makers,” said Ma Columbo, who spoke on “The Future of Healthcare.”

“Prevention is the first thing cut in times of crisis. Prevention and public health expenditure have dropped well below the cuts in health expenditure generally.”

The challenges facing the OECD and Europe were that while we had an increasing life expectancy with a reduction in mortality from all causes, including circulatory diseases and cancer, we were increasingly living with chronic disease and obesity.

Diabetes was a prevalent across the OECD and it was anticipated that there would be a trebling in dementia across the OECD by 2050.

“We are facing these prospects at a time of fiscal challenges to our health system. The reduction in real total health spending between 2009 and 2012 has been almost 10 per cent in Ireland, third only to Portugal and Greece.

“In this situation we need to introduce more prevention. A country like Ireland still has quite a high rate of tobacco and alcohol consumption and a low consumption of fruit and vegetables relative to other developed countries in the OECD. A package of prevention could result in significant gains in lives lived without cancer and cardiovascular diseases. Prevention is also a good investment. We estimate that a prevention package for obesity could result in a per capita savings of around 126 US dollars across Europe.”

The reduction in real total health spending between 2009 and 2012 has been almost 10 per cent in Ireland, third only to Portugal and Greece.

Lifestyle policies showed great promise but were challenging to push through. “We have highly cost-effective strategies for tackling obesity. These include “Fat Taxes” and salt and sugar reduction. These require a multifaceted approach, regulation with policy makers, industry, providers and regulators working together. “Fat Taxes” have attracted criticism and we need careful design and implementation with monitoring and evaluation of effects. Salt and sugar reduction required a variety of policy instrument including public information, food labelling, taxation, regulation and marketing controls and food reformulation.”

Ms. Columbo said that public health should be backed up by primary care. There were huge expectations that integrated care would transform care for chronic conditions by avoiding delays, duplication or incompatibility in tests and treatment. More measures of the quality and outcomes of primary care were needed as well as payment systems that rewarded proactive, seamless care rather than episodic activities and a willingness to try out new roles, settings and models of care.

“We still have a long way to go, but primary care struggles to deliver consistently high quality services. For example for patients with diabetes, all guidelines suggest the use of drugs to lower cholesterol and control hypertension. The reality is that we see across a number of OECD countries a low use of cholesterol reducing drugs and considerable variation across the countries. It is turning out to be a difficult task to manage things like obesity in primary care and people go unnecessarily to hospitals.

“We find it hard to convince patients to adhere to treatments even when treatments are there. There are many patients who do not adhere to heart failure management.”

Ms. Columbo said that information was starting to improve in some countries but we needed to share data.

We also needed more appropriate use of specialised health services. More chronic diseases meant that demand for secondary care was growing. Hip replacement rates had increased by more than one third in Australia and Denmark and doubled in the UK in the last decade. Knee replacement rates doubled in Australia, Finland, Israel and the UK and multiplied by three in Denmark. Rates of cardiac revascularisation procedures increased by 25 per cent in Finland and France and by 40per cent in New Zealand and the UK.

The secondary care use variation across and within countries gave rise to the questions on whether there were inefficiencies in areas with a high usage or if there were unmet needs in areas with low usage. “We are starting to address this variation to see if we can improve inefficiencies and reduce inadequate supply and better respond to patient preferences. This is being tackled by publishing information on geographical variations in health care use, setting targets, developing and monitoring clinical guidelines to standardise clinical practices, provider level reporting, feedbacks, using financial incentives and comparing patient outcomes across geographical areas or over time.

We find it hard to convince patients to adhere to treatments even when treatments are there. There are many patients who do not adhere to heart failure management.

She concluded by saying shared decision making and patient centred outcome measurements were being introduced. Several factors challenged the way we collected and used data in health care and there was a need to better use data to improve therapies and conduct research. Data to support high quality care should support physicians in identifying the most appropriate care using predictive analytical modelling tools and enabling health care managers to plan and optimise care provision through predictive monitoring. There should be timely and accurate post-market surveillance for adverse drug events and timely monitoring of healthcare pathways, costs and outcomes, evaluation of care pathways using administrative data.