A personal view

The Health Consumer Blog

Euro Consumer Diabetes Index 2008
October 01, 2008

The Euro Consumer Diabetes Index 2008, a benchmark of diabetes care for the 27 EU countries plus Norway and Switzerland, shows some interesting differences in European diabetes. Here we present the main observations of the study:

 

1- Worrying lack of quality data in issues related with diabetes.

 

 

2- The countries that do perform well are the ones which treat diabetes early in the healthcare chain.

 

 

3- Effective prevention programs reduce the number of diabetics as well as the number of complications.

 

4- The number of trained and qualified staff needs to be increased especially in Eastern European countries.

 

5- Some patients, especially in the Eastern European countries, do not have enough financial resources to follow recommended therapies.

 

6- There is an urgent need for increasing patient education regarding the handling of their disease; the general public needs awareness in order to reduce diabetes incidence and stop discrimination against diabetics.

 

Beatriz Cebolla Garrofé

Project Manager Euro Diabetes Index

Obesity and Weight Loss: The Empowered Consumer

The presenters at the conference with the same name organised by the Centre for European Policy Studies engaged in a subject of more and more importance; obesity is a condition and a reality almost reaching “beyond climate change discussions”, stated Mr. Lars Hoelgaard, the Deputy Director General of the DG AGRI within the European Commission. Nevertheless, it is surprising to learn that that there are only two European patient organisations representing the needs of people attained by a condition that is such an important concern for the European Union.

 

Beyond the general information on obesity and related policies, what I found interesting was the criticism brought to the vision and policies of the European Commission regarding obesity. The first one was the exclusive focus on prevention: The Commission centers its attention on introducing instructive programs in schools, such as free distribution of fruits, agriculture lessons and information regarding nutrition. Prevention is obviously one of the most important actions within a healthcare policy. Nevertheless, the Belgian delegate of one of the lonely two existing patient associations on obesity in Europe addressed a very painful truth: what do we do with all those people already fat? His other critique to studies and policy making regarding obesity is that this condition keeps being considered a risk factor instead of an actual (chronic) disease; shifting this approach might bring a radical change in its tackling tools, method which seemed to have worked with smoking cessation. The risk is that such a shift might also entail a transfer of responsibility from (potentially) affected healthcare consumers to the health care professionals.

 

The overall conclusion was that INFORMATION is crucial to empower the consumers make the right decision when it comes to handling obesity. Also, there is a strong need of good research on the topic, which seems to be particularly rare.

 

The Health Consumer Powerhouse hopes to contribute at completing this research gap. Our interest in obesity is quite specific since it is one of the main risks for cardiovascular diseases and diabetes; consequently, obesity was considered in our Euro Consumer Heart Index, launched in June2008 and will be measured even more thoroughly within the Euro Diabetes Consumer Index to be launched on September 30, 2008.

 

Raluca Nagy

Coordinator External Affairs

It is not enough to have the best medical treatment – transparency and rights are key elements for healthcare consumers

Three Greek schools (two elementary and one public kindergarden) refused to register or forced withdrawal upon potential pupils when the parents reported that their children had developed diabetes. Furthermore, two major banks in Athens rejected young persons with diabetes, even though they were having excellent credentials (a decade or more of employment with multinational companies and graduate degrees obtained in prestigious U.S. universities), on the basis that there is a firm bank policy not to accept persons who suffer from this disease.

Professor Christos S. Bartsocas from Greece denounced these two examples of human rights and law violations against individuals with Diabetes Type 1 when representing the Hellenic Federation for Diabetes (ELODI) at the EU Diabetes Working Group Meeting held in the European Parliament on Tuesday, July 15, 2008.

 

The Health Consumer Powerhouse hopes that our ongoing work for patient empowerment and implementation of patient rights will ensure that things like this do not happen in the future.

 

Beatriz Cebolla Garrofé

Project Manager Euro Diabetes Index

 

Euro Consumer Heart Index 2008

The Euro Consumer Heart Index 2008, benchmarking care for heart disease in all the EU-27 countries plus Norway and Switzerland, published on July 3, shows some interesting differences in European cardiovascular care:

·         Prevention, such as stimulating lifestyle changes (healthier drinking habits, smoking reduction, more fruit, vegetables and exercise) is an area where many European countries could greatly improve. This would be a low-cost way to better cardiac health, particularly if  screening for heart disease, also cheap and simple, were included as has recently been decided in e.g. Slovenia and the U.K.

·         The use of vital medication for heart disease shows such a great variation across Europe that it is actually difficult to see any connection to heart disease rates. A better adherence to guidelines for the use of drugs could most probably both save lives and lower total healthcare costs!

 

 

Arne Björnberg

VP R&D, Health Consumer Powerhouse

Denmark - the champion in patients' rights and information

Google ready to launch new health service

The launch of Google Health has been discussed for almost a year. Making the storage of patient data always available would ease changes (e.g. information about their doctors). The project seems to be in a testing phase though. There is probably still a long way to go before a full scale launch.

The system seems to be highly adapted to the US and its low degree of electronic patient journals, specific insurances, many visits to the doctor and movable population.

The interesting part is not the online storage of one’s own data - which is already available here - but the possibilities of data mining. Here is a jokingly example taken from Blogoscoped:

“On the positive side the benefits to healthcare and science are also staggering. Giving scientists "aggregated" data stripped of Personally Health Information (PHI) in a large scale along with the aggregated browsing, shopping, and email habits would be enormous.

Think of the connections that could be made.

"AMA Study Shows: Porn site visitors have an 80% increase risk of suffering from Carpal Tunnel Syndrome." Turns out it isn’t the chairs and keyboards at work that is the problem, it’s the porn on the computer!”

Google has been very good at convincing people to share their search history, emails and calendars, so they should now be ready to share their medical records as well.

Oscar Hjertqvist

 

AARP conference

I am in the US  lecturing at the AARP conference Health Care ´08 in Washington DC. The hosting organisation – the American Alliance for Retired People – is the largest member-based community in the world with 40 million members – a strong stakeholder in the US  and also the international health policy development.

The Europe of Health Consumers

EHCI refered to by Swedish MOH

Smoking News

As of the first of March, the Swedish state-run pharmacy chain Apoteket has lost its exclusive rights to sell non-prescription products for smoke cessation.
 
Even though smoking in Swedish restaurants has been prohibited since a couple a years and several measures have been taken to reduce smoking among the population, it  is still easy to buy cigarettes in Sweden. But for some reason, it has not been as easy to buy nicotine patches and nicotine gums. They have only been available in pharmacies and in Sweden they are mostly keeping office hours. Until now.
 
A licence to sell is not necessary, but the local municipal authorities have to be notified (typical Swedish safety precaution; or can you imagine "under the table" sales of smoke cessation products?).
 
An estimated number of 5 000 to 6 000 shops  like supermarkets and even gas stations will supply these smoke cessation products. These shops are of course outnumbered by the places selling cigarettes, but it is a step in the right direction. It is also an example of a method of reducing smoking by offering alternatives instead of the usual prohibition. And it is the government´s first step towards dismantle the pharma sales monopoly.

Kristian Tiger

Canada ready for a performance-based system?

The Euro Health Consumer Index 2007: Bismarck Beats Beveridge!

Austria emerges as the 2007 winner of the Euro Health Consumer Index, with a generously providing healthcare system having good access for patients and very good medical results. Austria scores 806 out of 1000 maximum points closely followed by The Netherlands, France, Switzerland and Germany in 5th place with 767 points.

All public healthcare systems share one problem: Which technical solution should be used to funnel typically 7 – 10 % of national income into healthcare services?

Bismarck healthcare systems: Systems based on social insurance, where there is a multitude of insurance organizations, Krankenkassen etc, who are organizationally independent of healthcare providers.

Beveridge systems: Systems where financing and provision are handled within one organizational system, i.e. financing bodies and providers are wholly or partially within one organisation, such as the NHS of the UK, counties of Nordic states etc.

For more than half a century, particularly since the formation of the British NHS, the largest Beveridge-type system in Europe, there has been intense debates over the relative merits of the two types of system.

Looking at the results of the EHCI 2007, it is very hard to avoid noticing that the top five countries, which fall within 36 points on a 1000-point scale, all have dedicated Bismarckian healthcare systems. There is a gap of 30 points to the first Beveridge country (Sweden) in 6th place.

While not at all arguing that the Bismarck-type healthcare systems are in every way superior, it seems that for total customer value, the Bismarck model runs rings around Beveridge!

Education improves your chances to survive!

On the Eurostar train home from London I contemplate the strange language of the train manager addressing us over the intercom. This is not even broken English, rather something that could have been invented for le commissaire Clouseau in the Pink Panther movies.

 Imagine this train manager giving advice to a stressed audience how to evacuate the train under the Channel in case of emergency? Not very comforting.

Communication skills are key. That goes as well for cancer survival. A new Swedish study (built from three million cases) I read on the train shows that patients with a higher education have up to 40 percent better chances
to survive. With education comes not only a more critical and demanding mindset, you can better articulate your needs and weigh the given alternatives. 

Well educated people also seem to comply better (as doctors put it, I prefer to say that they act more as partners in the care process). This is a challenge to healthcare to communicate better to engage everybody, regardless of education, social networks and ethnic background. Low educated women are supposed to be over-represented in the group of women - 1 out of 5 - who do not show up to have a regular breast cancer screening. 

Johan Hjertqvist
President

Waitingtimes cost Sweden

The Swedish Social Insurance Agency has looked into what cross border care cost.

The agency found that between 2005 and 2006 the sum of persons reimbursed for cross border care have doubled. Total cost still just over 2 million euros. The most popular country in general to go to is Finland, then the Agency also notes that Swedes go to Germany for specialist care and to Poland, Spain and the Baltic states for dental care.

Costs lay behind the travelling for dental care and as the Agency representatives say “maybe” the waiting times for healthcare “could be” a factor to what motivates the Swedes to seek care abroad.

Yeah, maybe waiting times in Swedish healthcare worries people…

See the EHCI 2006 for more about the Swedish waiting times.

Kajsa Wilhelmsson

Director European Affairs

Health Consumer Powerhouse – comparing e-health!

Most people with computer access can make a flight reservation and buy the ticket online. It is hard to see any obvious reasons why the same thing
should not be possible when making a doctor’s appointment. There is
certainly not a lack of technology, yet such convenient services seem to be rare in European healthcare. 

New technology has facilitated during the last decade many things in our every day life. Paying the bills, buying flight tickets and getting access to new music are only a few examples.

It would be natural that the largest service industry in Europe – healthcare – embarked on the same path. This is of course happening to a degree, but not as fast as it could be possible. 

The level of development in this field varies greatly between European countries. Pioneers worth mentioning are Denmark, the Netherlands and the United Kingdom. For example, the Danish national health portal Sundhed (www.sundhed.dk) allows the health consumers to rate the hospital they visit and see the total score when making the choice of which hospital to visit. 

Sweden has also made some progress, but the level of development varies within the country.  To get an overall picture of how well Sweden is doing when it comes to e-health, Health Consumer Powerhouse will launch an e-health-index in the beginning of 2008. 

We will compare the quality of e-health-services in the different counties councils, but also offer our ideas about what services could be possible to implement quite easily. In which Swedish county council will it first be possible for the health consumers to book a doctor’s appointment as easily as booking a flight reservation?

Comparisons of this kind can make great difference. No region or county council wants to end up last in a national ranking of this kind and those county councils doing well will serve as good inspiration and examples for the others. 

Of course, the power of comparisons does not stop at the national borders.
Next step could very likely be to compare e-health on a European level. 


Kristian Tiger

Project manager

The Europeans: older – and healthier …?

Are governments in the rich countries fooling themselves about the  future need for long term care? An OECD study puts important issues on the table.

Europe is growing old. This is no secret. Every government is planning for a huge number of old people in the population. More controversial is to what extent these oldies will be in need of welfare and care support. Will they stay healthy and active in their later years – or will there be an increasing demand for long term care? Depending on the assumption two very different scenarios emerge.

During the last decade a sense of alarm has been replaced by optimism in many countries : 65+ people will increasingly stay fairly healthy which should reduce the future need for medical assistance. Many governments seem to have relaxed the long term preparations for elderly and geriatric care. But the OECD in a new report (http://www.oecd.org/dataoecd/13/8/38343783.pdf) sends a warning signal after having looked into the situation in twelve member countries in Europe, North America and Japan. There is poor evidence for such a policy, is the core message.

The study finds clear evidence of a decline in disability in only five of these countries (Denmark, Finland, Italy, the Netherlands and the US). The remaining ones show an increasing rate of severe disability (Belgium, Japan and Sweden) while in Australia and Canada the rate is stable. (Regarding France and the UK data are inconsistent and prevents any forecast, says OECD).

“It would not seem prudent for policy-makers to count on further reductions in the prevalence of severe disability among elderly people”, is the OECD warning. The ageing of the population and the greater longevity of individuals will result in increasing  numbers of people with a severe disability, is the conclusion.

Figures are important but the behaviour even more. According to my opinion, elderly care consumers of tomorrow will ask for much more influence, choice and added value. Governments will be confronted not only by growing numbers but  by a more complex and sophisticated demand as well. This will take money, fantasy and a market re-think to handle!

 

Johan Hjertqvist
President

Suicide far from painless

“Suicide is painless”, said the refrain from the popular TV hit MASH. But that is far from true. Suicide is a tragedy to almost everybody concerned and a major health threat around Europe. Suicide is the leading cause of death among Europeans below 40 years of age. There seems to be broad consensus that more systematic procedures within the healthcare systems could significantly reduce the number of people committing suicide.

Today the Swedish Board on Health and Welfare published a most critical assessment of how the public healthcare addresses suicide and suicidal behaviour around Sweden. The Board has analysed 153 out of the roughly 1 400 suicides reported during 2006. These selected cases were reported to the authorities following a specific Swedish regulation calling for a special investigation if the medical staff or relatives to a patient believe that the prescribed procedures have not been respected (“Lex Maria”).

Among these cases the Board finds remarkable evidence of insufficient and even worse, highly unsystematic, efforts to support people thinking about suicide:

- One out of two suicide victims had tried to commit suicide before the final, mortal incident, but the healthcare authorities seldom took action from this knowledge.

- In 70 percent of the cases the official treatment program (national, regional guidelines) for suicide was never applied.

- In 66 percent of the cases the care provider could not document any individual treatment plan at all.

The Board now calls for increased awareness, improved methods and better co-ordination. Comments from the medical profession following on the report indicate that prevention and counter-measures according to official guidelines fully well can reduce the present level of suicide in Sweden with one third. This would mean 500 survivors a year in Sweden only. Assume that the conditions are similar around Europe and you can imagine that tens of thousands of lifes could be saved every year. Just by doing what most people takes for granted that healthcare already does!

Johan Hjertqvist
President

Stay away from these hospitals!

In a very recent report the NHS Healthcare Commission, the UK watchdog on care quality, attacks the lack of progress on reducing MRSA (“killer bug infections”) among British wards. There is naming and shaming, delivering accurate consumer information. Let me quote the BBC Health press release:

“The Healthcare Commission found 99 of 394 healthcare trusts admitted to failing to have adequate measures in place.

Four trusts reported failing to meet any of the three core standards for hygiene:

· Royal Cornwall Hospitals NHS Trust

· Sheffield Primary Care Trust

· Sutton and Merton Primary Care Trust

· Wiltshire Primary Care Trust

Seventeen more trusts reported falling down in two out of three hygiene standards”. Also these names you can find in the NHS report.

The naming of the failures is a resolute step offering a warning to care consumers (“stay away from these high-risk trusts!”). It is worth notice that three of the worst offenders are primary care trusts. The rough language shows how serious the situation is around UK.

In the 2006 Euro Health Consumer Index UK got a red alert for its MRSA figures. October 1, when the 2007 Index is to be launched, we will learn if there has been any progress in reducing the risk of having a serious infection while treated by the NHS!

Johan Hjertqvist
President

The potential for Sweden’s largest service industry

25 percent and growing. This is the share of the Swedish export that the service sector accounts for. But the by far largest service industry – health care – accounts for only a very modest part of that portion. A part that could be bigger.

This is one of the topics covered in a recent report from Nutek, the Swedish Agency for Economic and Regional Growth.

Even though most people would like to have access to health care close to their home, the business of exporting Swedish health care still has potential. The medical standard of Swedish health care is very high, compared to most other European countries (source: Euro Health Consumer Index 2006). According to Nutek, the greatest potential does not relate to the health care services themselves, but in adjacent areas such as medicals, health care technology and know how.

There are still institutional obstacles to overcome before competition between the European health care systems could run more smoothly. One Swedish example: the law that prevented private hospitals from yielding profit from public contracts. The current Swedish government has recently changed that. Another hinder is the lack of comparative, reliable data about costs and performance within the national healthcare systems.

Until today it has been more common for Swedish patients to go to, for example, Germany to have an operation, than for German patients going to Sweden. Even though Swedish health care in many respects is better when it comes to medical outcomes (but poor regarding access and service attitudes).

If the current Swedish government keeps on promoting competition and increasing transparency in health care, the direction of the flow of patients will probably change.

Kristian Tiger
Project manager

Swedish Renal Care Index 2007

On May 21, the Health Consumer Powerhouse published a comparison of the renal disease care provided by the 21 independent Swedish counties, who operate Swedish healthcare services; the Swedish Renal Care Index 2007 (www.healthpowerhouse.se ).

The Index reflects some very noticeable differences in the way renal disease is treated in different counties. Dialysis, particularly clinic-bound hemodialysis, shows significantly better results – lower mortality – in the southern counties close to the University Hospital of Lund. This hospital was the birthplace of dialysis 60 years ago, and presumably this has led to renal care being a well-developed local speciality.

The counties in the sparsely populated northern half of Sweden, where long travel distances to dialysis treatment are common, are surprisingly underdeveloped in the use of dialysis treatments which can be administered by patients in their homes. These counties show significantly higher mortality rates for dialysis patients, which is probably linked to the fact that the average number of dialysis episodes per patient per week falls short of the generally expected level of 3 episodes.
Reversely, southern counties seem to be rather complacent with their good results in dialysis treatment, and less keen to help those patients who could get a kidney transplant to actually get one. The northern counties do noticeably better in this respect, which is also reflected in a high activity level for organ donations.

The data availability situation for Swedish renal care is somewhat unusual for European public healthcare, where most data seems to be reflecting input factors such as money, beds, staff numbers etc. Thanks to several years of work on two databases, the Swedish Dialysis DataBase (SDDB) and the Swedish Register for Active Uremia care (SRAU), there is very good data on the quality of Swedish renal care. Unfortunately, these data on county or clinic level can only be accessed by members of the national association of renal care specialists, and not either the public or by healthcare decision makers.

There seems to be interesting local differences in renal care also in other European countries. As one example, Germany shows a very low penetration of home dialysis (“PD”). The hypothesis that this is explained by generous remuneration for clinic-bound dialysis has been overheard on several occasions. A Renal Care Index for the EU might be a logical next step?

Arne Bjornberg
Director, EuroHealth Consumer Index

Romanian healthcare vs Belgian

On last year’s European Health Consumer Index, Belgium scored quite well, ranking 7th, as the wonders of the world, out of 26. For the “waiting time to have access to medical care” section Belgium shared the first place, together with France , Germany and Luxembourg.

About one month ago I ended up at the emergency room in one of Brussels ’ hospitals. I spent four hours in a completely Kafka-style space, seeing different doctors who ended up applying to me a constipation treatment even though I specifically told them I had had diarrhea the day before. I left the hospital with no diagnosis whatsoever, just a strong recommendation to see a gastroenterologist.

I got an appointment for one some days later, who after the consultation said he needed further tests in order to issue a proper diagnosis and thus a treatment. Because of Easter holidays the first available date they found to run the tests was the 18th of April. Meanwhile, I worked through about three different types of pain-killers as I would become resistant to each model after a week. When I finally got the results of the tests, the closest day possible to see my gastroenterologist again was the 3rd of May, because of the 1st of May holidays... Needless to say that everything looked all right, I am in perfect shape even though I have been in pain for more than a month now. Doctor’s order is another two weeks on a different pain killer; and if I still don’t feel better, then I will be sent to have some more “profound” tests.

In about two weeks I will get to Bucharest and go straight to a Romanian doctor that I can chose and see within hours or days, which I should have probably done a month ago. I still do not understand why Belgians believe their healthcare system is excellent and what happened to me is just normal…

Raluca Nagy
Researcher

Notes from eHealth Week in Berlin

With healthcare competing with travel and holiday services which is the largest industry of the world (both consuming roughly ten per cent each of the global resources) the eHealth Week in Berlin starting today is a showcase for the German EU presidency. The German healthcare-related IT sector is huge and well known giants like Siemens, Agfa, SAP, Bayer and others fill the large exhibition halls. Among the participant there are few consumers, though, and the players here are authority people like politicians, civil servants and representatives from the medical profession.

Welcoming the audience ms Ulla Schmidt, the Geman minister of health, this morning portrayed eHealth tools as prerequisites for the healthcare integration around Europe. Ms Vivianne Reading, the EU information commissioner, stressed that the IT development in health care must be “driven by patients and consumers to become user-friendly, not designed for experts only”. This is an important priority.

All the sophisticated medical eRecord solutions and similar improvements will remain of limited value as long as the consumer lacks the knowledge and toolbox to interpret the information and make the critical questions and decisions. And still there are no exhibitors around offering that kind of services…

Johan Hjertqvist
President

Italian nursing crisis; what is the way out?

Italy, next only to Greece, is the country where there are more doctors than nurses. The European average ratio is 8,2 nurses every thousand inhabitants According to the OECD the ratio of nurses to inhabitants in Italy is 5,4 and decreasing. Only Greece has a lower ratio in Europe. On the contrary, Italy is the country with the greater number of doctors, 4 every thousand inhabitants. The effects of this situation can be easily understood. The most important consequence is the lack of quality service for patients.

How can the current situation be explained? First, there is no financial motivation. Due to a complicated system, more seniority on the job and more responsibility, less one earns.

Secondly, nurses are in charge of additional responsibilities of no medical use which can take up to 60% of working time. Hence there are little incentives for young people to choose this profession and indeed there are less and less of them choosing this career.

So what is the solution? First, curing the flaws mentioned above, which is a long and complex internal process. Italian specialists analysing the phenomenon offer explanations and solutions. For more about this, read here, here and here.

The second option and the most accommodating for patients at the moment would be accepting nurses coming from abroad. The Employment Service (EURES) have recently facilitated the employment of several hundred Spanish nurses in Italy. This is a good first step but as it does not cover the needs, another option would be allowing more non-Community specialised nurses on the job market.

For now, this is a long and bureaucratic process. The brake on this course of action is mostly caused by suspicions that it could be used as entry door to the European Community by so-called nurses with dubious degrees. Maybe Italy should try to find a better way of solving this crisis and surpass the paralysed status quo by looking into the well-planned recruitment strategy for nurses in the United States.

Dora Olteanu
coordinator

The health consumer. Mainstreaming of a concept

So much time has been spent by the HCP staff explaining why we are using the word consumer and not only talk about patients. But it seems like we now maybe have started to get through. The Director General for DG Health, Robert Madelin, recognized today at the European Voice health policy conference that one of the challenges that need to be taken into account when preparing a new health strategy is that patients are viewing themselves as health consumers. This was further underlined by Frank Niggemeier, the German Permanent Representation to the EUs Health , who referred to himself as ”I am a consumer, a patient”. It might seem like limited statements but words are powerful and if high rank officials within the EU start to think in term of care consumers that will lead the way to real empowerment and change. Perception is reality. Kajsa Wilhelmsson, Director European Affairs

The Great Organ Donation Mysteries

Availability of donor organs is a bottleneck for transplant operations in most European countries. Frequently, this is explained in terms of global factors outside of healthcare service delivery such as religious and/or cultural phenomena, the number of traffic victims or other conditions. An example from my native Sweden is “road security has improved so much that crash victims are becoming increasingly rare as donors”, etc etc etc.

Looking at the EU member states, one can see astonishing differences in donation rates per million inhabitants: from 35 in Spain over c:a 15 in Germany, Scandinavia and The Netherlands down to 6 in Luxemburg (and less than 1 in less affluent recent member states). It seems unlikely that the high donation rates in Spain, Austria, France and Italy should be because of the risky lifestyles of their citizens creating a large number of donors!

Within Sweden, there is a 5-fold(!) difference in donation rates between the 21 counties of this small nation. It is difficult to ignore that donation rates in Sweden are fairly closely correlated with “the number of intensive care beds per million population” (a donor will need to occupy an intensive care bed longer than would have been necessary for the donor’s own sake). The relatively poor counties in the far north have much higher rates of both ICU beds and organ donations. This seems odd, until one makes the observation that northern counties believe that they need only half the staff density per bed of the southern half of the country, where ICU beds are frequently not in use due to “staff shortage”.

Kidney patient organisations confirm that Spain is a country where the donation procedure is well organised, with trained professional nurses handling the sensitive issues connected with conduction discussions with relatives.

It is difficult to avoid the conclusion that organ availability is a factor, which is mainly influenced by how healthcare services are operated in different states, not by acts of God!

Arne Bjornberg
Director, EuroHealth Consumer Index

And the indirect costs?

Yesterday in Brussels the European Summit on Allergic Disease was held. It’s obvious that there is a need for more focus on the consumer part of the cost of health. According to the European Academy of Allergology and Clinical Immunology asthma alone is estimated to cost Europe 27 billion euros per year in direct costs. Upon that the organisation calculates with around 70 billion euros in indirect costs, such as academic/professional days lost, regarding allergic diseases. That’s a lot of money normally not taken into account as healthcare costs. Probably partly because these costs usually are carried by consumers, not governments. Do we want to fool ourselves by saving on the direct healthcare costs, as all EU member governments try all the time, even if that means that the indirect costs will increase? Wouldn’t an increased spend on doctor visits and medicines actually save money for the care consumer and increase the tax revenue for the government? Kajsa Wilhelmsson, Director European Affairs

On labels

A couple of days ago I had the opportunity to add “reproductive” and “tourism” to the list of words I never thought I’d see posted together. Strange label used for shipping health customers in other countries to have access to fertility treatments and procreation practices.

The term reproductive tourism spontaneously made me think of sexual tourism and all the panoply of similar services, as opposed to the ART(istic) one – assisted reproductive technology. What I find even more bewildering is the idiom birthright tourism, as reproductive tourism is sometimes denominated. I cannot help wondering who chooses these labels, not to mention the euphemisms attached such as Womb globalization, Womb drain, Fertility Disneylands or Egg-o-lands...

Thousands of couples travel every year to another country in order to benefit from specific treatments that do not exist, are forbidden, ridiculously expensive or just have long waiting times in their own country. Some consumers can tour the world searching for advanced techniques helping them having a baby while less lucky ones will have to put up with their own destiny or home rules. Whether or not the experts or the consumers themselves want to think a birth in terms of services is up to them, everyone should be free to choose for oneself. But the labels and euphemisms used could be more inspired.

Raluca Nagy
Researcher

Tough climate, promising message II

A short while ago I gave you a frozen report from the Helsinki conference on sustainable healthcare financing. One of the topics was Health Technology Assessment. Under the expert lingo abbreviation HTA this activity is quickly becoming a name of the game, like some years ago evidence-based medicine (EBM) or information to patient (ITP). And like these functions it will prove a matter of strategy whether HTA will peak and disappear or is here to stay.

To my opinion one decisive factor will be to what extent care consumers are involved in the evaluation process. As I raised this question at the conference I was told that within the NHS nowadays there is always one patient representative involved in the HTA reference groups. Such statements rather confirm that the consumers are left aside. Having one patient person looking into the design of an assessment survey matrix together with 20 doctors and administrators most likely is not the answer.

What I am talking of - to pick one example - is 100 cancer patients and relatives giving evidence in focus groups about how the flow of treatments work in a cancer clinic, providing the consumer judgement on if and how new routines and equipment have contributed to more rapid response and user-friendly procedures. Or if a health service website is understandable and well-designed, exploiting the latest behaveoural findings and gadgets to support frequent use.
When such consumer involvement strategies becomes routine HTA will leave the mumbo-jumbo existence to become a truly valuable tool for healthcare improvement!

Johan Hjertqvist
President

Controversy on new HPV vaccine

Since 1955 when Jonas Salk's polio vaccine was declared "safe, effective and potent" and the whole world started to hope for a future without infectious disease many things have changed. Not only nature seems to be one step ahead in creating new infections but the attitude of the care consumer has transformed. The issue of vaccination is nowadays far more complex.
Until recently the decision of submitting (or not) one's children to vaccination was based mostly on the consideration of side effects but it seems the time has arrived for moral controversy.

Since last year there is a possibility to vaccinate against the human papilloma virus (HPV), which is the most common reason for cervical cancer, the second most deadly form of cancer in women. As the virus is sexually transmissible, the recent initiative of Mr Perry, governor of Texas to make the new vaccine compulsory has been widely discusses in the United States and he has been accused of encouraging promiscuity among women.

The HPV Vaccine that prevents cervical cancer is now becoming available in Europe. So will the same controversy arise in Europe as well? A care consumer, in the end, should have the right to take its own decision whether it goes against the moral constraints of the majority or not. The care consumer has the right to best and complete information about this and the right to decide according with his/her own values.

Dora Olteanu
coordinator

Tough climate, promising message

The other day I had the pleasure of attending a research conference in Helsinki (very cold outside but a most engaging discussion in the beautiful Finlandia hall; FINANCING SUSTAINABLE HEALTHCARE IN EUROPE). This was the first time I´ve heard representatives from European health ministries refer to "the market" in friendly terms, talking about the potential of health market interaction to improve efficiency and consumer information. Quite remarkable!

Another promising change of attitude: even high ranking people at the European Commission now repeats again and again that there must be patient - or even consumer - empowerment.
“Not a matter whether patient empowerment will happen, but how it can contribute to improving healthcare", was a repeated statement.

Evidently something is going on within the policy development around Europe.

Johan Hjertqvist
President

Sweden - Monopoly on Pharmaceuticals

Sweden, along with such countries as North Korea and Cuba, has a government owned monopoly providing citizens with pharmaceuticals. Two of the main reasons to keep the monopoly are to maintain a high level of security and ability to provide the consumers with appropriate information. The most important reason for keeping pharmacists on the staff is that they can give qualified information and advice regarding medicine.

According to a test carried out by the Apoteket AB itself it seems like those two objectives are not quite met. 300 persons, provided with a prescription each and pretending to be ordinary patients, were sent out shopping at different pharmacies in Sweden.

The study shows that 37 percent of the customers were not asked follow-up questions even though they claimed that it was the first time they used the medicine. 24 percent did not receive information that they should have gotten.

A monopoly is usually considered being harmful in an economy. In the case of Apoteket AB, its existence – right or wrong – is motivated by security for the consumers and the ability to give good information. When this is not the case, what is the reason for keeping the monopoly?

Kristian Tiger
Editor Din Vård - Swedish Health Consumer magazine

Yes, give the elderly better tech but train the staff first!

Having gone through the Intels Irish project a bit further we notice that the research programme signals a very advanced high-tech strategy: it "will describe the key characteristics of fallers, identify new multifactorial algorithms for fall prediction and new technologies for monitoring, feedback and intervention", to look into one of these areas. The high ambition is thrilling, but opens at the same time for many questions:

Elderly care and long-term care are traditionally low-tech services, where caring, not treatment, has been the central value. Many of the employees have poor education and a lot of care work is done by family members. A realistic perspective is that much of this "informal" care work will be done by immigrants or guest workers outside of EU. There are many examples where the introduction of new devices has failed. So, the toughest opponent will probably not prove the technique but the social and policy environment.

At the same time elderly people of tomorrow might often be used to IT-solutions and have better economic resources to pay for assistance. Many more will care for themselves, with relevant support. And maybe it will be a condition when recruiting skilled staff to the care services to offer a hig-tech workplace environment? Let´s hope so - it is high time the various kinds of elderly/long term care become more consumer oriented, better structured and competitive.

Johan Hjertqvist
President

A daring venture for the elderly

The IT giant Intel together with Irish stakeholders will run a three year healthcare project. The project aim is to "assist older people around the world to live longer from wherever they call home, while minimizing their dependence on others and improving their routine interactions with healthcare systems" (Read more).

There is a huge need for such action. In the EU, together with Japan leading the aging curve, in two generations time the most typical citizen will be a senior one. Medical progress keeps us alive longer, but more and more often with a multi-year or even chronic condition.

The project will focus on three key areas:

- improving social health and community engagement for older people,
- detecting and preventing falls in the home,
- helping seniors with memory loss to maintain their independence.

Its going to be very interesting to follow this and see how the Irish
political level meets the challenge. When we pointed out in our EHCI 2006 that their healthcare system is not very consumer friendly it became very obvious that the Minister of Health could not see any big need for change in Ireland.

Johan Hjertqvist
President

What people should know!

Do people have a clue what are the costs of medication? Evidently not, according to a new survey based on interviews with 500 health care consumers in the US (by PwC, Price Waterhouse Cooper, quoted January 23 by the Financial Times). This survey shows a lot of interesting facts – I’m sure that the result would be quite similar had the survey been conducted within the EU. It reveals for example that 97 percent of the consumers significantly overestimate the total costs of pharmaceuticals as part of the full healthcare budget. When I mention to people I meet in my job, even those involved in the healthcare debate, that the latest OECD figures show that pharmaceuticals only stand for around 15 percent of the total healthcare budget in Europe, most are very surprised. They become even more surprised if one points out that this means that a cost increase of ten percent in pharmaceuticals will raise the healthcare budget with one and a half percent. The same relation goes for cost cuttings. As the survey indicates, the common perception is that pharma takes a much bigger part of the budget and that cutting the spending on medicines would be a real solution for the growing healthcare bill. But it’s not that easy. It’s the whole set up of the healthcare systems as such that has to be changed. Recent Finnish research conducted on behalf of KELA (the social security agency of Finland) shows that maybe we ought to spend much more on pharmaceuticals and GPs in order to really save money. The KELA study has a design only too rare – it takes into account the disability costs among asthma patients! The outcomes clearly show that increased spending on curing consumers instead of keeping them waiting, getting sicker and sicker, actually pays off: With a more dynamic view on medication and out-patient treatment you can, according to this study, reduce hospital stay and – most dramatically - disability costs. Let´s hope more governments follow the Finnish leads and take a honest look at the healthcare system, its spending habits and the outcomes! Kajsa Wilhelmsson, Director European Affairs

Gigantic compromise, mostly losers

Again the huge reform plan on German healthcare is said to be set. We have heard it before. This time it might be true, as Bundestag process deadlines call for action and months of muddling through have washed out the substantial and thus controversial elements. What remains is a compromise within the SPD-CDU coalition with few winners but many losers.

Nobody knows if in some years time the federal government really will save any money. The German hospitals will have budget cuts, probably reducing the number of hospitals (fewer small hospitals might favour the medical outcomes, one of few upsides). The consumers will have to pay higher contributions, with reduced choice. The widespread frustration among German doctors and Krankenkassen, the health plan providers, will not be addressed by this "reform".

Germany has - or had - one if the best healthcare systems around Europe.
There are of course different ways to do reform, supporting the traditionally strong individual German engagement to turn patients into alert consumers making their decisions in a care market. What we now find at the Bundestag table is a depressing top-down document reflecting neither visions nor convictions. I would be surprised if it would solve any of the problems it is said to tackle, except for maybe reducing the immediate tensions within the governing coalition.

Johan Hjertqvist
President

A first step to end corruption

A year ago, in my first blog for 2006, I speculated about the impact on the EU from not only "the Polish plumber" but "the Polish dentist" as well. New dental entrepreneurs invade Western Europe offering low-price, high quality services. For the first time there seems to be real competition for consumers, was my conclusion.

Already in a year a lot has happend. Now the German and Swedish dentists have to count on the Polish or Hungarian competitors, attracting large groups of West Europeans with weekend packages mixing dental treatment with a spa holiday in Budapest or sightseeing around Cracow. The price tag is half of what similar dental surgery would cost at home.

But the power of the market is spreading, as Bulgaria and Romania enter the EU. Already Hungarian dentists learn that going to these new countries for a treatment will save Westeners another 30 percent of the Hungarian prices! I am not sure what kind of extras are included in the Romanian prices, but probably there are already competitive offers under development.

This kind of health tourism does not only save money in the pockets of the consumers but adds another significant quality to the land of the producer.
In Romania as well as Bulgaria, medical corruption is a well known fact and a plague. If you don´t pay the doctor or dentist under the table (yesterday in US dollars, today in euro) or are already well connected you won´t have any treatment at all or only a third-rate one. Opening for Western visitors will step by step make this bad habit less tolerable. Transparency is the strongest cure for corruption, eventually serving the inhabitants by providing good care without grey out of pocket contributions. In a functional market all information is known to the stakeholders.

As you can see I start the new year in an optimist mood! I hope you do the
same!

Johan Hjertqvist
President

Painful decisions in Canada

For the first time it will be possible in some Canadian provinces to access new expensive medicines approved by the care system but not reimbursed by your province. Up till now it has been illegal to purchase own medicines and to have them injected by a doctor. Now, as the Canadian global healthcare system starts cracking under the pressure from consumers, you will be allowed to buy expensive cancer drugs yourself. The Globe and Mail, Canada’s leading daily, report today about patient dissatisfaction with a system that is as expensive as in Germany or France but cannot deliver up to date treatment. For a long time Canadian politicians have attacked any privatisation idea by warning for "two tier medicine" threatening equality and fairness. The outcome is far harsher: a system where you die if you follow the official policy, i.e. staying with the treatment ordinate by the system but can live on if you buy the medicines yourself denied by Health Canada. To ask people to die for solidarity reasons shows how corrupt the official policy is!
Written quickly under travel in Atlantic Canada.

Johan Hjertqvist
President

Time for change in the prairie

-We would need this kind of comparison to describe the poor diabetes situation among our people, says the chief across the conference table. Not until then will the authorities listen!

The chief heads a group of representatives from what in Canada is called the first Nation, i.e. aborigines, or Indians. They live in a reserve - today re-amed "nation" - outside of Saskatoon in the Saskatchewan province. This is the Canadian prairie, with large snowy fields and very few people. But the ones gathering for the meeting are worried about the health conditions - the average life span among the First Nation people is a little more than 50 years. And feet amputation is a common complication from diabetes.

We are talking about comparing healthcare from the consumer point of view,
as we tour Canada to promote the Euro-Canadian Health Consumer Index, which we hope to present next year. A cross-Atlantic benchmark would be thrilling and provide a lot of information about the strong and weak spots in Canadian healthcare. The long waiting times is a known problem, the poor access to modern procedures like MRA scanning another less obvious one. In Canada you still "belong" to a hospital and lack the right to move across provincial borders to look for the best care options. To Canadians the EU right of mobility still is something to dream of.

In the few coming days we will meet with federal government representatives in Ottawa. The Harper government has promised to introduce a national waiting time guarantee to attack the poor access to services, but seems to lack a strategy how to implement such a mechanism. From Sweden and other European countries we know that it is easier to declare a "guarantee" than to make it really work.

A guarantee is a failure, admitting that the care system as such doesn’t work. There are better alternatives, like using powerful incentives to improve productivity. Health Canada - the hotly debated national healthcare system - is a reminiscence from the plan economy, monopoly days. The First Nation delegation says they would like their own healthcare clinic, operated by a private contractor, rather than depending on the public system that doesn’t deliver.

As disillusion grows, change is spreading.

Johan Hjertqvist
President

We need more healthcare staff around the world!

The new WHO leadership under dr Margaret Chan (another Chinese appointment illustrating the growing Beijing world engagement) has a number of critical issues to address. One of them - a policy on obesity - is under implementation among member state governments, another - HIV/AIDS - is an ongoing struggle. A third key topic ought to be the lack of health care staff around the world.

According to WHO there is a global staff deficit of 2.4 million doctors, nurses and midwifes. Adding different kind of support staff makes the gap even wider. There are around 60 million full-time health staff so the deficit might not look too alarmning. But as the resources are distributed in a most uneven way one midwife more or less might mean a dramatic difference in most sub-Saharan or Southwest Asian countries.

The reason for the shortage is often said to be the rich countries, mostly the US, overconsuming healthcare, hoovering the world for staff. The WHO itself points to reasons like "imperfect private markets, lack of public funds, bureaucratic red tape and political interference". You can add the strict rationing of medical education in the developed world another important factor and - sadly enough - corruption, cleptomania and incompetence as third world explanations.

To allow healthcare to grow to meet needs and demand we must have more staff. In many third world societies another doctor directly means prolonged lifes and the first chance of avoiding cronic diseases. There are no easy recipies here. The developed world can contribute by opening up for new education and training ideas. Why not let private institutions run the medical educations? And around the EU you find a clear interaction between plan economy policies in medical training and a shortage of staff. Do away with rationing and the need for importing staff to Europe will be reduced.

The third world is a far worse dilemma. As long as these governments fund guns rather than hospitals and it is a given that the presidents brother in law will be in charge of international aid not very much will happen. When the few medical students south of Sahara fear that crime and corruption will ruin their chances at home you shouldn´t be surprised that they listen to recruitment calls from Paris, Bahrein or Boston.

So, change starts at home. It would be convenient to claim otherwise but this is the fact.

Johan Hjertqvist
President

Google for diagnosis?

The British Medical Journal has tested how doctors can use search engines like Google to gather information to make a diagnosis (see here). The conclusion is that

"as internet access becomes more readily available in outpatient clinics and hospital wards, the web is rapidly becoming an important clinical tool for doctors. The use of web based searching may help doctors to diagnose difficult cases". The experiment shows that the Google search gave the correct diagnosis in 15 out of 26 cases (58 percent hit rate). This is at least as good as the accuracy using traditional methods.

We have all heard the stories (horror ones to many doctors, encouraging to many of us ordinary mortal people) of patients showing up for an appointment with heaps of printouts from search engines, confusing the poor doctor. The BMJ findings illustrate that the web can be of great use not only to the patient and consumer but to the doctor as well!

It is a jungle out there, some doctors may say! But to me it is progress when bother sides can access similar information, potentially merging into joint knowledge. This is how a critical partnership in healthcare can emerge!

Johan Hjertqvist
President

When will there be a Patient Mobility Guide?

Last week in the old city of Ghent, some hundred years ago one of the very wealthy spots of Europe, the findings of EU patient mobility project (Europe for Patients) was presented. Today the Belgian economy is in a far less radiant shape which might have influenced the minister of health, Rudy Demotte, to advocate healthcare as a Belgian growth sector. Having highlighted the need for a European change of mind in this respect for some years now, I am happy to hear also a Belgian Socialist joining in. But of course, there was a restriction coming with this package: health tourism and patient mobility must not affect the nice central planning system of the federal government. So maybe competitors in France or Thailand can relax - it might take some time before Belgium takes the lead...

More encouraging were the ideas of the working party. They no doubt contribute to the strong current of patient and consumer empowerment around Europe: the legal uncertainty regarding mobility as well as the lack of practical advice should be addressed by a "Patient Mobility Information Guide". There would be a EU framwork on crossborder contracting of care services, meeting growing demand for long term care. In Spain, where today six percent of the population are foreigners, many Brits and Scandinavians at the southern shores look for caregivers from their own countries offering care. Here better contracting regulations would be of help, as well as EU guidelines for chronic care.

Why not a joint European accreditation system, asks the mobility project team. Should not patients moving to other countries have access to information about their medication, today a blind spot in Europé? And what about "second opinion on the line"? In Ghent a great number of interesting ideas were put on the table.

The European Commission spokesman Nick Fahy stressed the reason for the project: if joint medical guidelines and best practice can improve the efficiency of European healthcare we might in the future avoid having to make the painfull choice between access and costs. And this is the strategic driver not to be forgotten when Polish dentists open up cost-effective services in the West or large enterprise groups restructure the German hospital landscape.

Johan Hjertqvist
President

The Big Divide

Lecturing around Washington DC about European healthcare systems and practice always confront you with stereotypes: most extreme, the common European view of US healthcare but also the other way around - the American attitudes to healthcare in Europe. Here is the Big Divide.

Both sides do the mistake of portraying healthcare as a monolith. Instead the European Union consists of 25 different systems and "US healthcare" is even more fragmented. Few Europeans are aware of - or would even like to hear - that half of the total US health care spending are directed to the publicly funded healthcare, the Medicare, Medicaid, healthcare for military veterans and publicly employed et cetera. The US deputy secretary of health, Alex Azar, told me the other day that the public healthcare systems turn around 600 billion USD. This makes his department the sixth largest economy in the world, bigger than the GDP of Spain! Just for those who claim that there is no public healthcare in the US...

One way to attack the lack of knowledge and mutual misunderstanding should be comparisons. Of course that will hardly affect deeply rooted prejudice but anyhow support more open-minded people to overcome the divide. As mutual learning is an important part of the development process in healthcare and both sides of the Atlantic has much to gain, transparency and benchmarking would be an advantage. Provocative to Europeans there are comparative statistics suggesting that critical healthcare outcomes as well as access rank better in the US. Which in a way is reasonable as the healthcare costs in the US are roughly double the EU level. Such huge investments should pay off.

A EU - US benchmark would provide valuable facts to replace speculations. Who would oppose debate from a solid foundation rather than the present trans-Atlantic trench fight?

Johan Hjertqvist
President

Foggy alps, distinctive signals

Last week important steps towards cross-European health consumer empowerment were taken in the beautiful Austrian alps. The IX European Health Forum, the annual informal EU health policy summit, responded to the request from the European Commission to provide input to the new EU Health Policy. This document will be presented next summer.

The response from the participants was clear: the EU would step up speed and action to facilitate patient mobility and rights, improve equality in care, increase outcomes transparency and strengthen patient safety. The conference was rather explicit about the means, revealing some dissatisfaction with the present gaps regarding access and quality of care between the member states and what many described as lack of speed.

The action list for the Commission suggests EU initiatives like:
- Gathering far better EU data on patient mobility,
- Legal clarity on mobility conditions,
- Improved consumer/patient positions through a EU ombudsman and national ombudsmen where such are missing,
- Commission initiatives on the introduction of medical guidelines around the EU to reduce care outcomes gaps and quality outcomes deficits,
- A potential EU Patient Safety Agency.

To support long term policy debate there was a call for the Commission to put together a Health Policy Vision 2020.

Regard these opinions as an input to the open consultation on the new Health Policy (everybody is invited to give advice and ideas, deadline January 2007). The Summit has no formal say. But I would be surprised if the signals from such a qualified forum as Gastein would not be taken in account. In some cases the ideas will probably conflict with the limited constitutional EU mandate on health care, in others the road is open for progress. Anyhow, the highlighting of the need for action made care consumers and patients last weeks winners among the foggy Gasteiner mountains.

Johan Hjertqvist
President

Powerhouse ideas to be implemented by new Swedish government!

October 6 we will learn about the platform of the new Swedish centre-right government. Then the new parliament opens it autumn session. But already we have a fairly good picture of key elements forming the healthcare policy of the Alliance coalition.

Fundamentals, like the equal access and public funding of healthcare, remain untouched. Nothing less seems acceptable to the Swedish electorate. As well stay the large layers of elected politicians governing the care systems (though over time we will see fewer and larger regional parliaments replacing small county councils). But other key elements are likely to change: regarding the position of the individual, competition, access and choice of treatment as well as to "consumer information"

In the short run we expect the new government to focus on:

- cutting waiting lists to implement an effective ceiling of max 90 days for a treatment
- improving access to primary care/family doctors (momentarily by better reimbursement incentives to take on visits, in the longer run also by increasing the education of family doctors)
- compulsory obligation to inform patients about waiting times and potentially better access at other providers or regions
- systems for assessing and presenting medical outcomes and care quality, with an independent national body adding to such transparency
- a coherent law on patients rights (today Swedish patients lack formal rights though the county councils have far-reaching obligations)
- the ban on selling public hospitals will disappear, opening for the restructuring of production facilities and a larger variation among owners and operators
- breaking up the government monopoly on sales of pharmaceuticals.

Here we have through our analyses and indexes pointed to the poor Swedish performance regarding timely access and the lack of consumer service, like very few family doctors open evenings or weekends. Our Indexes rate most Swedish county councils like the whole national system lacking consistent productivity incentives. Our Euro Health Consumer Index shows that Sweden lacks a patient rights law, a national quality information system and a powerful patient ombudsman function. So there is a need to empower patients to become more of consumers. And as our well-published findings indicate, healthcare works the best in countries with a mix of public and private payers and providers. Breaking up the public provision monopoly is a key step in the right direction, supporting improved access and consumer friendliness. This goes as well for the state-owned pharmacies, generally open only office hours.

Having recently inspired - or provoked - the Federation of County Councils and Municipalities to launch its own scheme for comparing the performance in public healthcare we are happy to see that the national government now plans to make ranking of systems and providers a part of the new strategy.

We assume the new government will give priority to improvements within psychiatric and cancer care. Again our Indexes prove the need for quick implementation of new cancer drugs and therapies. There are huge variations among the counties when you compare the quality of care given to people suffering from breast, colon, lung and prostate cancer.

Given back the freedom to handle the facilities for care production themselves you can expect some county councils to build "internal markets", strengthening competition and entrepreneurs. Experience shows though that it is far trickier to make such combinations work according to expectations than to just say ”reform”.

Johan Hjertqvist
President

Swedish elections landslide!

In a historic landslide Sweden turns to the market in healthcare as a centre-right government will take over. The new coalition promises to get rid of the Social Democrat ban on hospital privatisation. On the national level you can expect initiatives to deregulate the government pharmacy monopoly. Among the county councils and municipalities there will significant movements towards increased competition in healthcare and nursery care, with outsourcing, new contractors and entrepreneurs and incentives for internal market implementation. Reducing waiting times for care will be key to the new goverments on national and regional level.

I´ll be back with an election analysis.

Johan Hjertqvist
President

A first step - but not the last

Health care services should generally be available cross-border in the European market. But they are excluded from the EU Service Directive soon to become law. Thus there has been a need to find a solution. When the EU Health and Consumer protection Commissioner Markos Kyprianou the other day declared the need for a health service market he made clear three important things.

To start with, there will be a legal regulation of cross-border care (the reimbursement limits, matters of responsibility et cetera). The European Court has ruled out the typical member government call for authorisation in advance but I cannot imagine there will be much room for creative anarchy here. Secondly, patient mobility now is a given and will grow re volumes and treatment panorama. Last but probably most important, here is an strategic dimension as "health tourism" can support the development of better care. And mobility requires market information and increases competition as poor performers and methods will disappear to give room for better offers.

To the generations of care consumers to come it is good to hear that the European Commission believes in the power of markets. It improves the chances that there will be healthcare around even when the average European is a senior citizen driving a Chinese car on her way to the American fast food restaurant.

Johan Hjertqvist
President

This years bestseller?

Since we launched the 2006 Euro Health Consumer Index June 26 there have ben more than 70 000 downloads of the index report from our website! And the interest seems to remain, with many new visitors every day. This probably makes the EHCI the healthcare policy bestseller around Europe this year.

The volume of downloads illustrates not only a broad concern re. consumer aspects of health care but as well consumer activism to lobby the national governments. Using the HCP website it is an option to e-mail your ministry of health advocating improvements. Such mobilization walks hand in hand with a stronger consumer standing. We are happy to find a growing response from these ministries inviting us to discuss the index findings and further co-operation.

August 30 we are going to present a new kind of index in Stockholm, comparing how well the Swedish county councils treat people with diabetes. We hope this kind of "illness group index" will prove quite instrumental to care consumers looking for the best service and outcome (and to stakeholders like policy makers and care providers). We plan to further develop specific tools of this kind, to be used for consumer guidance at the same time building a benchmark pressure for reform. If proven succesful in Sweden we would like to take the Diabetes Care Index to the European Union level.

Which county council will prove the the least capable of implementing national treatment guidelines? And which EU-member will show the best outcome avoiding diabetes complications like blindness? These figures will impact...

Johan Hjertqvist
President

Talk of the town

Germany. Italy. Netherlands. UK. Ireland. Poland. Around Europe "healthcare reform" is the talk of the town. But only too often the main priorities among governments are to change the funding mechanisms in a way that hardly will improve access or quality outcome. In Germany last week the Grand Coalition agreed to shift the balance between a few funding parameters - this seems to be what left and right can partner around. But the far more urgent need for reform to strengthen consumer choice and access remains to be solved. As our 2006 Euro Health Consumer Index analysis shows, the quality of care in Germany could improve if many smaller hospitals close down. Such structural change takes a lot more of political courage!

Generally Germany performs quite well (with a bronze position in the Index). In the other end of the rank you find Ireland, with in average quite a poor show. Our Index findings late June provoked a government crisis and heated debates in the Irish parliament. The government tried to use the old trick of firing away at the piano player, claiming that the Index was based on outdated figures and misperceptions. When we in Irish media corrected this picture, and proved that repeated invitations to the the Ministry of Health in Dublin to work together with us were left without any answer the climate cooled down a little...

For the autumn we plan to follow up through meetings with national authorities, party groups in the EP, the European Commission, pan-European organisations et cetera. In a similar fashion the Swedish debate quickly has changed after the May launch of the third National Care Consumer Index. With the HCP a key source of inspiration - and maybe also some provocation - there now seems to be a Swedish consensus (yes, Swedes like having a joint view) on the need for better healthcare transparency and consumer information. In front of the Swedish general elections in two months time you can even expect better information to become a matter for political profiling.

For the healthcare consumers around Europe these signal are most promising. We are only at the beginning of a long journey but the traffic lights start shifting from red to yellow and in some places even green!

For a couple of weeks I´ll be having vaccation (birdwatching in the Camargue and some painting, I hope) but will be back blogging again early August. Have a nice summer!

Johan Hjertqvist
President

Keep the eyes at the ball!

Today we have the pleasure of presenting the 2006 Euro Health Consumer Index – the unique annual survey of all the EU member healthcare systems. Congrats to France, the winner, and even more to the care consumers of Europe who step by step move their positions ahead! Countries with long waiting lists are shamed and take action to speed up access, medical outcomes improve over time. Et cetera.

But let us keep our eyes at the ball: though positive trends there are still huge weaknesses and systems failures affecting the consumers:

· In three out of four national healthcare systems there is a significant risk that you have to wait more than three weeks for a cancer treatment. What does this mean to survival chances and to avoid anxiety and suffering?
· Only one out of five healthcare systems offer a national web or 24/7 healthcare information service. Is it not high time in the Internet era to make such help-lines the first line in consumer-friendly health care?
· Access to new cancer drugs really is a European post-code lottery. The other week I blogged on the NHS England change of policy re Herceptin. In some countries you can count on having the life-saving medication, in others you risk dying without it. Such consumer information is vital, to be conservative…

Part of the Index launch European can now send their opinion about the healthcare in their country to the government. We have suggested key action points for reforming each national system. Read more at this website! The time has come for consumer activism in healthcare!

Johan Hjertqvist
President

What the herceptin breakthrough means

Last week the NHS gave up according to the BBC news. Every woman in England suffering from breast cancer will have the option of being treated with herceptin, the most efficient but expensive cancer cure. Herceptin has proved superior treating a certain kind of cancer which 15-20 percent of all breast cancer patient tend to suffer from.

Up till this change of policy herceptin medication was a kind of "post code lottery". Some NHS trusts provided herceptin (and a number of other, new medications) while others refused to pay for it. This inequality has been attacked by a militant opinions campaign led by breast cancer patients and relatives.

The NHS comment is that the costs for the new medication will mean cut backs in other parts of the budget. Less articulate patients will potentially suffer, is the message. In many countries you hear this kind of remarks:

Don´t rock the boat, wait for your turn, otherwise fellow-patients will be pushed away.

This kind of arguments reveals that the system is a slow learner. In an era of immediate access to information the system advocates expect mortally ill people to behave nicely and listen to budget reasons.

"Don´t count on having this new wonder drug - we ration it and in due time you will have a brown envelope in your post box telling you about our
decision. You might be dead by then but trust us that it will be well-balanced and fair".

No way people will tolerate this any more. A new era of consumer power is
dawning. There is an accelerating stream of new therapies. It is high time for the health care systems owners to make up their mind: rationing that kills people or radical reform to improve access to life-savers?

Johan Hjertqvist
President

1.9 million die—many could still be alive

Every year 1.9 million EU inhabitants die from heart failure and other cardiovascular diseases. There are estimates that as much as half of these deadly incidents can be avoided.

What would people say if the knew that Uncle Edwin could still be alive having accessed good preventive care? Or that your mother might have left hospital recovered rather than dead if the emergency care procedures had been in accordance with modern guide lines?

This is the kind of questions I will raise in a couple of days, lecturing in Madrid. Cardiologists from around the world will be discussing the future of heart disease medical care. My theme at this European Conference on the Future of Cardiology will touch on how to empower the health care consumers by information. Here there are many sad stories to tell.

European consumers have the legal rights to move across national borders to pick the best care for their cardiovascular care. What keeps them back is especially the lack of information to build informed decisions regarding where to have a treatment. Here the European Society of Cardiology, hosts of the conference, has an important source of knowledge – but till now rather secretive about the findings. My provocative question will be: Isn’t it high time to offer the European health care consumers the full picture of outcomes allowing them to build own judgements? Wouldn’t consumer awareness about “post code lottery” behaviour and the options to take own action put a constructive pressure on European cardiovascular disease health care?

I will suggest a co-operation on developing a Cardiovascular Care Index of Europe, similar to what the Powerhouse already delivers. Such a comparison tool would open for a more stringent debate on how to improve care – not behind closed doors, but in dialogue with active, informed consumers. Learning that hundreds of thousands of people every year could survive a heart condition given appropriate care, consumers will ask for exactly such opening.

Johan Hjertqvist
President

Another good day for healthcare consumers!

Today the European Court of Justice has ruled in favour of Mrs Yvonne Watts, UK, and her compatriots in care. The essence of the court decision seems to be (when it comes to the ECJ you must read also between the lines) like this: EU citizens waiting for a medical procedure
can go abroad to have a reimbursable treatment, regarding “undue delay” in their home country.

Mrs Watts, 74, was first told to wait one year for a hip replacement. Displaying her anger the NHS offered to cut the wait till 3-4 months. But she went to France anyhow, paying herself for the treatment and then charging the NHS for the costs. Now the Court declares that she should have a refund but seems unwilling to specify what are the acceptable limits for waiting. UK courts have better look into the waiting times making national judgements, the ECJ suggests.

The ruling of today is another step in the direction of consumer power in health care. As three-four months of waiting now look unacceptable in a pan-European perspective a number of EU member care systems might need to shape up. The argument that good and timely services would cost too much does not carry, says the decision. I.e. what is good for the NHS – and other national systems – might be unacceptable to the consumer…

Mrs Watts found a suitable French clinic on her own. Most consumers look for improved information to take such a big step. Help is eventually under way though. Not by the European Commission the Health Portal of which has spent large resources to build an empty frame, exposed last week when the Portal was launched. No, it takes far more to empower the consumers to make informed choices in health care. Today, for the third consecutive year we presented our Swedish Health Consumer Index, providing comparative data on health care. As Swedish media will be displaying the next few days also in egalitarian Sweden it is important to look for the best care offers. It is a matter of service levels, quality outcomes and access. Especially as in Sweden you can buy a bottle of vodka on a Saturday but never see you doctor …

Johan Hjertqvist
President

Another tough pill to swallow

Yesterdays´ local elections in the UK took place in the shadow of not only governmental scandals but the ongoing NHS reforms as well. On of many paths to improvement concerns access to care outside of office hours. This is a typical matter for monopolistic health care systems like in the UK or Sweden, unheard of in continental Europe where family doctors make home calls when you need them.

The shake-up of the out of hours health care system in England is "shambolic" and has led to longer waits and higher costs, a committee of MPs now states, according to BBC Health.

Chairman of the public accounts committee Edward Leigh said: "The new way of providing out-of-hours medical care has so far been a costly mess that has left many sick people waiting too long for help."

The NHS Local Trusts has tried to contract providers to take on out of hour’s tasks. New providers are spending 22% more but are not meeting key targets, the public accounts committee claimed. The outcomes? Fewer than 10% of primary care trusts meet targets on assessing patients within 20 minutes of an urgent call. Not very promising…

Contracting care providers is far from easy. Experience from large scale contracting processes, like in the Greater Stockholm County, reveal that success takes much more fantasy, imagination and consumer-style thinking than public purchasing bodies are able to deliver. It tends to be only too much of copying the last tender offer and established routines. First class providers are seldom rewarded and poor ones can stay in business far too long. So the NHS problems are neither new nor surprising.

Well, so the answer is to get rid of competition and a multitude of providers, returning to the safe, monopolistic tradition? Absolutely not – on the contrary! But what it takes is not public intermediaries “translating” the “needs” of the population but ways to allow consumers to express their demand and make own choices. Here we talk of voucher systems, private insurance or saving account models ensuring the individual purchasing power.

Empowering the consumer is different from empowering public bureaucracy! The tough pill to swallow is that old medicine does not work and only radical steps will ensure real change!

Johan Hjertqvist
President

Disappointment and mobilisation

Three years ago Frida Petersson of Alingsas, Sweden, expected a letter from the Swedish king. She was to become 100 years old and it was well known that since long the king used to congratulate citizens turning 100.

But Frida didn’t get the royal letter. Why? Well, the postman wasn’t to blame - rather the demography! Evidently somebody had told the royal court that the number of 100 year old Swedes was rapidly growing. It would be too much work sending out all these letters...(When the deeply disappointed Frida learnt that she would have to wait till her 105th anniversary to receive a royal greeting she turned a republican; i.e. in the European sense - supporting the idea of Sweden a republic).

This story illustrates that 100 years of age no more is rare. In another generation reaching this high age will be quite common - to a large extent thanks to the advance of medicine. So, what will follow on such a dramatic demographic development?

Two hundred years ago, more than 80 per cent of the population would be dead by the age of 50, whereas now less than ten per cent have died by 50. Already before 2010 there will be more Europeans in the 55-70 years span than among the ones 25-40. The senior - if such labels will maintain any importance outside the field of statistics - soon will be the typical EU citizen!

It takes far more than one blog to look into the importance of this transition. Coming back to this theme later on, just a few remarks right now:

- The oldies will be large consumers of health care. Not only in the rationed sense most are used to but, more and more common, as consumer goods. Why not fix that nose that’s been irritating you for so long when you now have some money in the bank?

- The "new oldies" will as well challenge the quality of care as we still know it. They expect to be well informed and have the power to make choices.

When UK health care authorities today launched a new information system comparing the survival rate among the heart clinics the patient organisations expressed disappointment. Figures on the clinic level aren’t enough, they claim. "Not until we get performance figures of each individual surgeon the patient can take action", they argue. Quite true - and a vivid illustration of what’s waiting around the corner!

- Prevention and "self-management" in healthcare will become key values. Not the least European governments start understanding that they can transfer huge costs to the oldies by "decentralising responsibility" for care to the individual. Such a move corresponds very well with consumer values - assuming that the measures are whole-hearted and not only political ploys. For example, of course the empower