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Volume 11 Number 4, 2005
eurohealth
EU action on health inequalities
Government action to tackle mental health inequalities in Scotland
Mental health green paper: a timely opportunity
Going smoke free
Health ageing across Europe
Addressing health inequalities and promotingpatient safety under the UK Presidency
Health Ministers from across Europe – EU Member States, accession countries (Bulgaria and Romania), candidate countries (Turkey and Croatia) – at the Informal Ministerial Meeting held on 20/21 October 2005
Health under the UK Presidency:much progress made
Addressing health inequalities and improving patientsafety were the two central health themes of theUK’s Presidency of the Council of the EuropeanUnion. Chief Medical Officer for England, Sir LiamDonaldson, writing here on progress achieved onthese themes is quick to emphasise the importance ofgood intelligence and the need for sharing of infor-mation across Europe. Europe can play a key role incoordinating Member States efforts on patient safety.This was one of the areas for exploration during amajor summit on patient safety held in November.Another important step was the political agreementreached on the European Commission’s proposal forthe ‘Regulation on Medicinal Products for PaediatricUse’ at the Council of EU Health Ministers inDecember.
In terms of knowledge generation two importantindependent reports on health inequalities werecommissioned by the UK Presidency. The firstHealth Inequalities – Europe in Profile is yet furthertestament, as Sir Liam notes that ‘many Europeancitizens do not benefit from the health improve-ments their countries have made in recent decades.’The second Health Inequalities: A Challenge forEurope identifies systematic and comprehensivestrategies to tackle health inequalities in someMember States, recognising that others still have along way to travel. Elsewhere in this issue theimportance of health inequalities across the life spanremains visible with discussion of actions taken bothby the European Commission and a look at stepstaken to address inequalities in mental health inScotland.
Intelligence sharing also needs to be a key feature ofwhat we do here at Eurohealth. Regular readers willnotice that we have expanded the amount of spacefor news on health policy and public health develop-ments at both the European institutional and nation-al levels. Further exciting changes will also be phasedin to keep us at the cutting edge of the policy debateand I am especially pleased that our new DeputyEditor Sherry Merkur will be a great driving force ininstigating these changes – so watch this space!
David McDaidEditor
MENT
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see: www.lse.ac.uk/collections/LSEHealthAndSocialCare/documents/eurohealth.htm
Published by LSE Health and Social Care and the EuropeanObservatory on Health Systems and Policies, with the finan-cial support of Merck & Co and the European Observatoryon Health Systems and Policies. News section compiled byEurohealth with some additional input from EurohealthNet.
Eurohealth is a quarterly publication that provides a forumfor policy-makers and experts to express their views on healthpolicy issues and so contribute to a constructive debate onpublic health policy in Europe.
The views expressed in Eurohealth are those of the authorsalone and not necessarily those of LSE Health and SocialCare, Merck & Co, EuroHealthNet or the EuropeanObservatory on Health Systems and Policies.
The European Observatory on Health Systems and Policies isa partnership between the WHO Regional Office for Europe,the Governments of Belgium, Finland, Greece, Norway, Spainand Sweden, the Veneto Region of Italy, the EuropeanInvestment Bank, the Open Society Institute, the World Bank,CRP-Santé Luxembourg, the London School of Economicsand Political Science and the London School of Hygiene &Tropical Medicine.
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eurohealthCOM
Contents Volume 11 Number 4
UK Presidency
1 Health inequalities under the UK Presidency Liam Donaldson
2 Patient safety under the UK PresidencyLiam Donaldson
Health Inequalities
4 Action by the European Union on health inequalitiesMichael Hübel and Charles Price
6 Government action to tackle mental health inequalities in ScotlandLewis Macdonald
Green Paper on Mental Health
9 Promoting mental health in Europe: a timely opportunityEva Jané-Llopis and David McDaid
11 The EU Mental Health PlatformClive Needle
13 Enhancing the policy relevance of mental health related research inEuropeKristian Wahlbeck and David McDaid
Healthy Ageing
15 A long life – and all of it healthy: the ideal of healthy ageing in EuropeRodney Elgie, June Crown and Michael Tremblay
Going Smoke Free
21 The medical case for clean air in the home, at work and in public placesRichard Edwards and Tim Coleman
M y t h b u s t e r s
25 “Myth: An ounce of prevention buys a pound of cure”
Monitor27 Publications
28 Web Watch
29 European Union Newsby Eurohealth with input from EuroHealthNet
Tim Coleman is Senior Lecturer inGeneral Practice, School ofCommunity Health Sciences, Queen’sMedical Centre, Nottingham, UK.
June Crown is Vice President, AgeConcern England.
Sir Liam Donaldson is Chief MedicalOfficer, England, Chief MedicalAdvisor, UK and Chairman, WHOWorld Alliance for Patient Safety.
Rodney Elgie is President of TheEuropean Patients' Forum, Bruxelles,Belgium, Vice President of TheEuropean Men's Health Forum,Bruxelles, Belgium and Immediatepast President of GAMIAN-Europe
Richard Edwards is Senior Lecturer inEpidemiology, Department of PublicHealth, Wellington School ofMedicine and Health Sciences,University of Otago, Wellington, NewZealand.
Eva Jané-Llopis is responsible for theprogramme for Mental Health Promo-tion and Mental Disorder Prevention,Mental Health Programme, WorldHealth Organization, Regional Officefor Europe, Copenhagen.
Michael Hübel is Head of Unit C4Health Determinants at the EuropeanCommission, Directorate GeneralHealth and Consumer Protection,Luxembourg.
Lewis Macdonald is Deputy Minister forHealth and Community Care, ScottishExecutive, Scotland, UK.
David McDaid is Research Fellow LSEHealth and Social Care and EuropeanObservatory on Health Systems andPolicies, London School of Economicsand Political Science.
Clive Needle is Director ofEuroHealthNet and Chair of the EUMental Health Platform.
Charles Price is a National Expert atthe European Commission, DirectorateGeneral Health and ConsumerProtection, Luxembourg.
Mike Tremblay is Partner, TremblayConsulting, Kent, UK.
Kristian Wahlbeck is ResearchProfessor, Mental Health Group,STAKES, Helsinki, Finland.
The UK Presidency of the Council of theEuropean Union has placed particularemphasis on two key health issues: address-ing health inequalities and improvingpatient safety. Both these issues require acoordinated effort across Europe in orderto make a real difference to the health ofcitizens of all Member States.
In addressing the issue of health inequali-ties, the UK Presidency commissioned twogroundbreaking expert independentreports, published in October. The first,Health Inequalities: Europe in Profile,1
reached some stark conclusions. Mostmajor causes of premature death, such ascardiovascular disease and cancer, are morecommon among people with lower levelsof education, income and occupational sta-tus. The health gap in life expectancy istypically five years or more. The reportalso highlighted that many European citi-zens do not benefit from the healthimprovements their countries have made inrecent decades.
The second report commissioned by thePresidency, entitled Health Inequalities: AChallenge for Europe,2 helps to identify away forward in addressing these inequali-ties. The report found that in someMember States, systematic and comprehen-sive strategies to tackle health inequalitiesare already in place. Other Member Stateshave policies, but without an overarchingframework, and some are still in a pre-measurement stage. If all Member Statescontinue to work together, and share bestpractice, good health could become a reali-ty for everyone.
The ‘Tackling Health Inequalities’ Summit,which was held in October to coincidewith the publication of the reports, was asignificant step in this process as it broughttogether European and international exper-tise, including the World HealthOrganization (WHO) and theOrganisation for Economic Co-operationand Development (OECD). The Summitwas an inspirational event, with keynoteaddresses from Ministers and leading inter-national experts, specific workshops toshare experience and develop policy, andopportunities to discuss current issues and
network with colleagues. Speakers includedEuropean Health Commissioner, MarkosKyprianou, UK Secretaries of State,Patricia Hewitt (Health) and Hilary Benn(International Development) and MarkDanzon, Regional Director of the WHO.The outcomes of the Summit are expectedto inform the policy development work ofthe Commission, as well as Member States.
A key factor in this policy developmentwill be to improve the collection and dis-semination of information on healthinequalities, in order to help Member Statesto identify health gaps and to develop andimplement appropriate policies to addressthem.
If this information is shared throughout theEuropean Union, and Member States pooltheir resources and intelligence, the goal ofeliminating health inequalities will bebrought significantly closer. Enlisting glob-al support in tackling the problem world-wide will also speed up the process and forthis reason, the UK is supporting theWorld Health Organization’s Commissionon Social Determinants,3 chaired byProfessor Michael Marmot, which will helpensure that knowledge informs practiceacross the globe.
A number of specific examples of wherecooperation is required have also beenhighlighted during the UK Presidency. Thefirst is the illicit trade in tobacco and thelegal cross-border shopping from lowtobacco duty countries. Illicit trade, andvastly fluctuating prices of tobacco acrossthe European Union, are underminingeffective tobacco control programmes.Young people, and those on low incomes,are more likely to purchase cheap tobaccofrom smuggled sources, leading to continu-ing high smoking rates among thesegroups, with a significant impact on healthand health inequalities. This issue was alsohighlighted in my Annual Report 2004.4 AGlobal response to tackling this smugglingis the WHO’s Framework Convention onTobacco Control. There is also significantscope for further collaborative actionbetween health, customs and other agen-cies.
eurohealth Vol 11 No 41
UK PRESIDENCY
Health inequalities under the UKPresidency
Sir Liam Donaldson is ChiefMedical Officer, England,Chief Medical Advisor, UKand Chairman, WHO WorldAlliance for Patient Safety.
Liam Donaldson
“many European
citizens do not benefit
from the health
improvements their
countries have made
in recent decades”
eurohealth Vol 11 No 4 2
UK PRESIDENCY
The manner in which alcohol is marketedwas also highlighted during the Presidencyas a particular concern for health inequali-ties. Across the European Union, there is atrend towards increased consumption byyoung people, and there is a need for coor-dinated action to minimise the impact ofalcohol marketing on young people, withan effective balance of regulation and self-regulation - for example, through the ‘TVWithout Frontiers’ directive. In future,alcohol marketing may need to be moni-tored by an independent body.
Attention must also be focused on improv-ing what people are eating, particularlyamong young people. The number of over-weight children in Europe is rising by400,000 a year. The Presidency Summitraised the need for a harmonised approachacross Europe to tighten controls on adver-tising and the promotion of less healthyfoods to children, that is foods high in fat,sugar and salt. The new Commission GreenPaper, Promoting Healthy Diets andPhysical Activity: Towards a EuropeanStrategy for the Prevention of Overweight,Obesity and Chronic Diseases, and the EUPlatform for Action on Diet, Physical
Activity and Health provide importantopportunities for strategic and effectivepan-European action.
The overarching goal of the UK Presidencyhas been to leave a legacy that ensureshealth inequalities are reduced in Europeand throughout the world for generationsto come. At the Summit, CommissionerMarkos Kyprianou announced a newEuropean Union Expert Working Groupon Social Determinants for HealthInequalities, which will bring togetherMember States in the future and continuethe work begun by the current Presidency.The Commissioner said: “for my part, Ipledge my full support as EuropeanCommissioner for Health to the task ofreducing health inequalities acrossEurope”. This bodes well for the continuedwork of the Commission in tackling thisproblem.
The Summit has significantly raised theprofile of health inequalities as an issue forthe European Union and for MemberStates. The challenge now is to sustain thispurpose and to deliver the changes that willhelp narrow the health gap.
References
1. Mackenbach J. HealthInequalities: Europe in Profile.October 2005. Available atwww.dh.gov.uk/assetRoot/04/12/15/84/04121584.pdf
2. Judge K, Platt S, CostongsC, Jurczak K. HealthInequalities: A Challenge forEurope. October 2005Available at www.dh.gov.uk/assetRoot/04/12/15/83/04121583.pdf
3. WHO Commission onSocial Determinants of Healthwebsite. www.who.int/social_determinants/en/
4. Donaldson L. On the stateof the Public Health: AnnualReport of the Chief MedicalOfficer 2004. London:Department of Health, 2004.Available at www.dh.gov.uk/assetRoot/04/11/57/81/04115781.pdf
Patient safety under the UK Presidency
Patient safety has been a priority theme ofthe UK Presidency of the EU. Throughour Presidency we have aimed to:
– Establish patient safety as a key priorityon the European health agenda, both atEU level and in individual MemberStates and agree priorities for action.
– Initiate concrete mechanisms and practi-cal programmes of activity at theEuropean level to take forward actionon agreed priorities.
– Promote greater alignment of Europeanpatient safety initiatives with interna-tional developments to add value to theefforts of Member States to facilitate realand lasting improvements in the safetyof patient care across the EU.
Much has been achieved in a relatively
short time. A highlight has been an inspira-tional and highly successful Patient SafetySummit which took place on 28–30November 2005. The Summit highlightedEuropean and world action on patient safe-ty bringing together hundreds of interna-tional and European politicians, experts,patients, clinicians and many other stake-holders. The role for Europe in facilitatingand coordinating Member States efforts toimprove patient safety was also explored.Discussions focused on a number ofimportant areas including:
The global patient safety agenda – what arethe international priorities for action? Howcan we best link action at country level andcollaboration across Europe with workunderway internationally?
Patient safety from the perspective of
Liam Donaldson
The full Proposals for Action from the Summit, which went to the Health Council of Health Ministers meeting in December,and fuller details of the Summit, including copies of the presentations and a newsletter, can be found on the Department ofHealth website at: www.dh.gov.uk/eupresidency
patients – how do we empower patients toplay an active role as agents of their ownsafety and that of their families?
“Knowledge is the enemy of unsafe care” –where are our gaps in knowledge and whatare the priorities for research effort whichreally make a difference to the safety offront line health care?
Learning from other ‘high-risk’ industries:how can we learn from the best of experi-ence in industries such as aviation, oil andtransport to systematically reduce risks inhealth care?
Today’s students, tomorrow’s safe practi-tioners: where should we be investing ineducation and training to create a genera-tion of ‘error wise’ health care practition-ers?
Addressing clinical priorities and risk focus-ing on diverse issues such as medical devicesafety, changing organisational cultures,safer practitioners, and tackling healthcarerelated infection.
Opening the event, Secretary of State forHealth in England, Patricia Hewitt calledfor ongoing action towards “a lasting legacy of safer healthcare.” She told thosepresent, that “patient safety is a globalissue, and countries throughout the worldmust get better at working together to pro-vide safer healthcare for their patients”.
“Personally, I find it heartening that patientsafety is now recognised as a major globalhealth challenge. During the UKPresidency of the European Union, wehave been conscious of the opportunity tostrengthen existing initiatives and todemonstrate our support for the interna-tional effort being spearheaded by WHOthrough the World Alliance for PatientSafety.”
Fernand Sauer, Director for Public Healthof the European Commission, added:“European collaboration can provide ideasand tools to help EU Member Statesimprove the safety of their patients. Byworking together, we can reduce harm topatients throughout the European Union.This will also give patients confidencewhen they seek healthcare elsewhere inEurope.”
The Summit has led to renewed commit-ment, stronger engagement and a deeperunderstanding of patient safety issuesacross Europe. Patient safety is an increas-
ingly high-profile issue at the Europeanlevel. There was consensus that the case forgreater action on patient safety is com-pelling. As people move freely across bor-ders, they expect the care that they receivein any country to be safe and of good qual-ity. Research suggests errors are as likely infee-for-service or insurance based systemsas in state-funded systems.
And of course, the Summit has not beenthe only focus of our activity. On otherfronts, political agreement on the EuropeanCommission proposal for Regulation onMedicinal Products for Paediatric Use hasbeen secured at the Council of EU HealthMinisters meeting on 9 December 2005.This will ensure that medicines will be rou-tinely tested and appropriately formulatedfor use with children.
The UK Presidency has also spearheadedthe development of a coherent package ofongoing work on patient safety at theEuropean level. This builds on the out-comes of the Patient Safety Summit as wellas the groundswell of support fromMember States generated by the 2005Luxembourg Presidency in which patientsafety also featured. Strong links have alsobeen made to the emerging patient safetyrecommendations from the Council ofEurope, and the broader international pro-gramme of work led by the World HealthOrganization through the World Alliancefor Patient Safety.
High-level discussion between the MemberStates in 2005 has prioritised a concreteprogramme of action and practical toolsthat from the European Union perspectiveset out a substantive work programme forthe next few years. A major emphasis hasbeen on action areas that help countriesestablish their own patient safety pro-grammes. This has the potential to facilitatereal and lasting improvements on the safetyof patient care across Europe.
We are of course, still only at the start ofthe journey. Much remains to be done.However, safe heath care cannot just be anoption. It is the right of every patient whoentrusts their care to a health care systemand the responsibility of those who lead. Iam hopeful that 2005 will be recognised asthe year when a growing commitment topatient safety across Europe, and a growingwillingness to collaborate, is consolidatedinto solid programmes of action.
eurohealth Vol 11 No 43
UK PRESIDENCY
Further information, including details of the Patient Safety Summit held in London in November, can be found on theDepartment of Health website at: www.dh.gov.uk/eupresidency
“As people move
freely across borders,
they expect the care
they receive to be safe
and of good quality”
eurohealth Vol 11 No 4 4
HEALTH INEQUALITIES
IntroductionInequalities in health have been an impor-tant part of the work of the EuropeanUnion (EU) since 1992 when specific com-petencies for public health were included inthe Maastricht Treaty. This has been takenforward in three main ways:
1. Through the EU Public HealthProgramme.
2. By facilitating the exchange of informa-tion and best practice between MemberStates and other organisations.
3. Development of key EU policy areaswhich can contribute to reducing healthinequalities.
Public Health ProgrammeThe EU Public Health Programme pro-vides financial support to projects whichcontribute to programme objectives.Within the first stage of the Public HealthProgramme, reducing health inequalitieswas part of the health promotion pro-gramme which ran from 1996 until 2002.Today it is an overall aim of the currentPublic Health Programme 2003 to 2008.1
Key objectives are firstly the developmentof strategies on social and economic healthdeterminants in order to identify and com-bat inequalities in health and secondly thecreation of a sustainable health monitoringsystem paying special attention to inequali-ties in health.
In the last ten years there have been some15 projects on health inequalities with atotal amount of EU support of over €5 mil-lion. Outputs from these projects include:
– A detailed overview of the healthinequalities situation in Europe and thesituation of disadvantaged groups.2
– An overview of actions on reducinginequalities in health. 3
– A network of agencies in Member Statesdeveloping strategies to tackle healthinequalities.4
– Support to the 2005 UK PresidencySummit on Health Inequalities andrelated background papers.
Facilitating exchange of informationand best practice by Member Statesand other organisationsThe EU supported a European Conferenceon Health Determinants as part of thePortuguese presidency in 2000. A review ofthe role of health promotion in tacklinghealth inequalities was reported to theHealth Council under the Belgian presi-dency in 2002. In 2003 the Commissionpublished The Health Status of theEuropean Union: Narrowing the Gap.5
The Commission has developed a varietyof formal and informal mechanisms for dia-logue with Member States and other stakeholders which have considered andexchanged information on social determi-nants of health and health inequalities aspart of their work. These include the EUHealth Forum with representatives of keynon governmental organisations; the HighLevel Committee on Health and the HighLevel Group on Health and HealthServices both of which consist of seniorofficials from ministries responsible forhealth in all Member States.
In 2004 Commissioner Byrne addressedhealth inequalities as part of his reflectionprocess on the future health strategy of theEU; a consultation which attracted a recordlevel of high quality responses. Many ofthese responses welcomed the renewedemphasis given to this topic, and have beentaken into account in the proposals for theHealth and Consumer ProtectionProgramme 2007–2013.6
Health Inequalities were one of the keythemes of the UK Presidency of the EU,from July to December 2005. ThePresidency Summit: Tackling HealthInequalities: Governing for Health pro-duced several proposals for action which
Action by the European Union onhealth inequalities
Michael Hübel is Head of Unit C4 Health Determinants and Charles Price aNational Expert at the European Commission, Directorate General Healthand Consumer Protection, L-2920 Luxembourg. E-mail [email protected] and [email protected]
Michael Hübel and Charles Price
“the Commission
recently established an
Expert Working Group
on Social Determinants
and Health
Inequalities”
were presented to the Health Council inDecember 2005. Furthermore theCommission recently established an ExpertWorking Group on Social Determinantsand Health Inequalities, to facilitate com-munication and sharing of best practice inthis area.
Developments of key EU policy areasAn inequalities dimension is an importantelement of specific EU public health policyactions in areas such as alcohol, drugs,mental health, sexual health, and tobacco.This includes for example advocacy for atotal ban on smoking in the workplace,which will contribute to narrowing gaps inmortality between low status and high sta-tus jobs.
Regional policy also plays a major role intackling health inequalities by helping tonarrow the gap in wealth between econom-ically deprived regions and the rest of theEU. Tackling health inequalities throughsupport for community wide health pro-motion initiatives is included within theguidance for the use of the main fundingvehicle for regional policy, the EU struc-tural funds, from 2007.
Another key policy area is that of agricul-ture and rural development. Poorer healthin rural areas is a feature in a number of thenewer Member States of the EU. Theincreasing emphasis on rural development
within the Common Agricultural Policywill help to narrow the health gap betweenrural and urban areas, particularly in newMember States.
Turning to social policy, employment andequal opportunities, EU legislation on dis-crimination and on the rights, health andsafety of workers is an essential underpin-ning of the protection of the health ofEuropeans. The programme on socialinclusion as part of the Open Method ofCoordination includes a specific elementrelating to health and access to health ser-vices.
There is a strong association between apoor environment and social disadvantage.EU environmental policy objectives of cre-ating higher environmental standardsthrough measures such as the setting oflimit values for key air pollutants and thelicensing and control of polluters are likelyto contribute to a reduction in healthinequalities by leading to bigger improve-ments in environmental quality in areaswith poorer health.
A final key area is research. A significantbody of research on health inequalities hasbeen funded by the EU framework pro-grammes. This includes work in the ECU-ITY project. Further funding opportunitieswill also be available as part of the 7thFramework Programme currently beingfinalised.
Next stepsThe UK Presidency priority on healthinequalities has given an important impetusto the further development of EU wideaction in this area. The EU is already mak-ing a significant contribution to reducinghealth inequalities through its equal rightslegislation, environmental, regional andsocial policies and specific public healthactivities. Further work will concentrate onsupporting Member States actions –through the Public Health Programme andthrough mechanisms to facilitate theexchange of good practice. The EU willalso continue to develop its capacity toassess key policies for their health impact,including impact on health inequalities, andthis additional transparency could help tofoster arguments for modification of bothexisting and new policies. An importantpart of future EU policy in this area will bethe link between action on health inequali-ties and overall economic development.Additional work is anticipated to assistunderstanding of the costs and benefits ofaction on social determinants and healthinequalities.
eurohealth Vol 11 No 45
HEALTH INEQUALITIES
REFERENCES
1. Decision No 1786/2002/EC of the European Parliament and of the Councilof 23 September 2002 adopting a programme of Community action in the fieldof public health (2003-2008). Official Journal L 271, 09/10/2002 pages 1-12.
2. Menke R, Streich W, Rössler G, Brand H (eds). Report on Socio-economicDifferences in Health Indicators in Europe: Health Inequalities in Europe andthe Situation of Disadvantaged Groups. Bielefeld: Institute of Public HealthNRW, 2003.
3. Mackenbach J, Bakker M (eds). Reducing Inequalities in Health: AEuropean Perspective. London: Routledge, 2002.
4. Closing the Gap: Strategies for Action to Tackle Health Inequalities inEurope. http://europa.eu.int/comm/health/ph_projects/2003/action3/action3_2003_15_en.htm
5. The Health Status of the European Union: Narrowing the Health Gap.Luxembourg: European Commission, Office for Official Publications of theEuropean Communities, 2003.
6. Communication from the Commission to the European Parliament, theCouncil, the European Economic and Social Committee and the Committeeof the Regions: Healthier, Safer, More Confident Citizens: a Health andConsumer Protection Strategy. Proposal for a Decision of the EuropeanParliament and of the Council Establishing a Programme of CommunityAction in the Field of Health and Consumer Protection 2007–2013. Brussels:Commission of the European Communities.COM(2005) 115, 2005.
“An important part of
future EU policy will
be the link between
action on health
inequalities and
overall economic
development”
eurohealth Vol 11 No 4 6
HEALTH INEQUALITIES
The UK Presidency, health andmental healthHealth and inequality issues have featuredstrongly during the UK’s Presidency, andwill continue to do so. I had the honour ofaddressing a recent European conferenceon Health Inequalities at Westminster andit is right, in this associated event, that wenow give prominence to mental health as akey component and determinant of thehealth and well-being of our countries andof citizens across Europe.
Indeed, we see an unprecedented interest inand commitment to mental health acrossEurope. First, with the WHO EuropeanMinisterial Conference on Mental Healthin Helsinki and the signing of the MentalHealth Declaration and Action Plan forEurope and second, with the launch lastmonth of the European Commission’sGreen Paper on Mental Health.
We need to build on these important devel-opments for Europe and today we can dothat by concentrating in detail on the issueof Mental Health Inequalities. This is avital area for European collaboration, shar-ing, learning and action, and I am confidentthat this event provides a good opportunityfor exploring the issues and challenges inmore depth, and for developing strongerEuropean networks and collaborations.
The conference programme looks atinequality issues head on. We will hearabout the causes and consequences of men-tal health inequalities, about the resourceand service inequalities that exist acrossEurope and about the contribution andcommitment that Governments can make.These presentations help stimulate discus-sions and debate and give an opportunityto consider the actions each of us needs totake, and what we can do together. First Iwould like to share with you some of theways that we in Scotland are trying to tack-le mental health inequalities in our country.
Work in Scotland Responsibility for tackling health and men-tal health issues in Scotland lies primarilynot with the UK government, but ScottishMinisters accountable to a ScottishParliament. Scotland, while an integral partof the United Kingdom, has alwaysretained distinct legal and administrativestructures, and there has been devolvedmanagement of the National Health Servicein Scotland from the beginnings of theNHS. Devolution of political responsibilityand policy making came with the establish-ment of a Scottish Parliament in 1999.
Our approach as a small country is to buildan integrated approach to address healthinequalities, both geographic and withinspecific social groups, as part of what weare trying to achieve in addressing socialinequalities. It is our firm belief thataddressing social inequalities is the key totackling health and mental health inequali-ties, social exclusion, discrimination, socialisolation, and risks for suicide; it is also keyto helping to achieve a more just and fairsociety, with better health and mentalhealth, and a country which takes positiveaction to achieve greater inclusion, restorehope, and build confidence for the future.
Health and mental health inequalitiesin ScotlandAs things currently stand, those living inthe most affluent areas of Scotland canexpect to live more than a decade longerthan those living in our most deprivedcommunities. Suicide rates are twice as highin our more deprived communities, andmen and women with low incomes aretwice as likely to develop a mental illness asthose on average incomes.
The children of families from the lowestsocioeconomic groups are three times morelikely to have a mental health problem thanthose in the highest socioeconomic group.These are gaps in life expectancy, in risk ofsuicide, and in the likelihood of mental ill-health which arise directly from social andeconomic advantage and disadvantage.
We are determined to tackle these inequali-
Government action to tackle mentalhealth inequalities in Scotland
Lewis Macdonald is Deputy Minister for Health and Community Care,Scottish Executive, Scotland, UK. More information on the ScottishExecutive’s approach to mental health can be found at www.wellscotland.info
Lewis Macdonald
“Suicide rates are twice
as high in our more
deprived communities”
ties, to close the opportunity gap andenable the poorest in our society to enjoypositive mental health and well-being on apar with the richest; and, where there areindicators by which we can measure mentalhealth and mental ill-health inequalities wehave set targets to reduce those by 15%.(This includes suicides in young people)
Health improvement and publichealthIn our health improvement and publichealth work we have an integratedapproach which covers physical, mentaland social health and well-being andincludes life stages, circumstances andopportunities such as employment andworking life, education, housing and com-munity regeneration. We also have a focuson the key health challenges in Scotland:coronary heart disease, cancer, suicide andmental illness.
We know that traditional health improve-ment and public health messages usuallyseem to have the greatest impact on themore affluent and socially advantaged, andthe least impact on those who need themmost. We need to step up our health andmental health improvement work toaddress these inequalities and ensure that aswell as universal messages and deliveryaction we also target those at most risk ofsocial, health and mental health inequalities.
And in that context, I would like to men-tion two key areas of action we are takingforward in Scotland. From March 2006,Scotland will have one of the most compre-hensive sets of restrictions on smoking inpublic places anywhere in the world. Weare convinced that the new arrangementswill bring substantial public health benefitsto Scotland, particularly in deprived com-munities, where smoking rates are highest,and where heavy smoking often goes hand-in-hand with mental ill-health.
On suicide prevention, we have a nationalstrategy and action plan in place called‘Choose Life’. Since its launch in 2002, wehave developed an infrastructure of localand national action. Each of our 32 LocalAuthority areas now has a suicide preven-tion action plan, supported by new invest-ment and backed up by a national imple-mentation support team, and a nationaltraining strategy on suicide preventiontraining, with over 4,000 people nowtrained in suicide prevention.
We have also set specific targets for reduc-ing the inequalities in rates of suicide acrossthe Scottish population; and, whilst a single
suicide is one too many, I am pleased toreport that the latest figures for suiciderates in Scotland show a reduction of near-ly 10% compared with three years ago.
Mental healthOn mental health, in general, we are settingin place a comprehensive policy encom-passing public mental health, promotionand prevention, improved care and treat-ment services with the prime objective ofpromoting and supporting recovery,backed up by modern legislation.
However, we also know that withoutimproving the public’s understanding andawareness of mental health and mental ill-ness and actively working to eliminate thestigma and discrimination that still existaround mental ill-health, we will notachieve all we can in breaking down mentalhealth inequalities and improving the quali-ty of life for those experiencing mental illness.
That is why, since 2002, we have supportedthe development and delivery of a nationalanti-stigma campaign in Scotland. Thecampaign is called ‘See Me’ and has beenactive nationally and locally in working tochange public attitudes towards peoplewith mental illness.
I am pleased to report that real improve-ments in public attitudes are already evi-dent. One of the most impressive statisticsfrom our bi-annual survey work of publicattitudes is that in 2002, 32% of people sur-veyed thought that people with mental ill-nesses were often dangerous. By 2004 thisfigure had dropped to 15%: the number ofpeople frightened by mental ill-health inothers, reduced by over half.
This national and local anti-stigma cam-paigning work needs to be sustained over along period of time to truly bring about theunderstanding and behavioural change weneed to see. In our experience, this workalso needs to be part of wider anti-discrimi-nation actions.
LegislationThe Scottish Parliament passed in 2003 theMental Health (Care and Treatment) Actthat came into force in October 2005. I amdelighted that this Act has received recog-nition across Europe as leading the way inmental health legislation. The Act has builtin safeguards to protect people’s rights.These include the right to independentadvocacy, the right to make advance state-ments, the right to appeal against detentionand the right to an individual care plan.
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HEALTH INEQUALITIES
“Each of our 32 Local
Authority areas now
has a suicide
prevention action plan”
The Act also places a duty on LocalAuthorities and their agency partners topromote the well-being and social develop-ment of people with a mental illness and tosupport their rights to access arts, cultureand recreational activities, to be able to takeeducation and training opportunities, andto be able to gain and sustain employment.We see this section of the Act as a veryeffective driver for greater social inclusion,improved educational, training andemployment opportunities for peopleexperiencing mental illness. This is also apositive action for promoting and support-ing people’s recovery.
Health care servicesOn health care in general, we recently pub-lished our strategy, ‘Delivering for Health’.This lays out the steps we will take over thenext few years to shift the focus of ourNational Health Service in Scotland froman emphasis on acute conditions, treated inhospital, to an emphasis on chronic condi-tions, cared for and treated in the commu-nity.
A significant part of that new emphasis willbe about anticipatory care in disadvantagedcommunities, bringing healthcare out ofhospitals to those who need it most. Thatshift in emphasis will have real benefits inidentifying and addressing disadvantageand inequalities in health and mental health.
EmploymentAnother key area in addressing inequalitiesin Scotland is employment. A job can makeall the difference in lifting people out ofpoverty and disadvantage and in providingthose with mental health problems with awider array of opportunities in their lives.
With estimates of 72% as the rate of unem-ployment for people with mental healthproblems and approximately 45% of allincapacity benefit claimants in Scotland cit-ing a mental illness as their main reason forbeing unable to work, there are some realgains to be made for people, their familiesand local communities if those individualscan be enabled and supported to enter thelabour market.
Work is progressing on an EmployabilityFramework for Scotland that will do muchmore to support people back to and stayingin work. This framework includes peoplewith mental health problems and combinesemployment support with health care sup-port. We have also set up a Scottish Centrefor Healthy Working Lives. A key part ofthe Centre’s work is in improving mental
health in the workplace, and improving jobretention for people who develop mentalhealth problems whilst at work.
Race and mental healthPart of the delivery agenda in health andmental health services is in improving theirresponse to the needs of people from blackand minority ethnic communities. With2% of our population now made up ofpeople from black and minority ethniccommunities and our ‘Fresh Talent’ initia-tive to attract people to live and work inScotland, this is an important issue for nowand the future. We have recently undertak-en a race equality assessment of servicesthrough our National Resource Centre forEthnic Minority Health and the recom-mendations for action are being taken for-ward in partnership with local services,backed up by support from the ScottishTranscultural Mental Health Network, tohelp support the development of culturallyappropriate and responsive services.
The Equal Minds reportRace and ethnicity are among a number of‘equalities’ groups which are examined indetail in a report ‘Equal Minds’ that hasjust been published (and available atwww.wellscotland.info). It provides anoverview of the policy and legislative con-text for mental health and inequalities inScotland. It gives an extensive array of factsand figures, and evidence for policy andpractice. This is an extremely useful andcomprehensive report and resource docu-ment for us. I would like to thank thereport’s principal author Fiona Myers forher hard work and dedication. I would alsolike to commend the report to you, and Iknow it will raise a number of issues.
In conclusionAs I have illustrated, we are committed tothe goals of social justice in Scotland and totackling health and mental health inequali-ties as one key part of what we are aimingto achieve in our work on addressing socialinequalities. This also involves improvingour health services, improving publichealth and public mental health, tacklingthe determinants of mental health and illhealth, and improving the quality of lifeand social inclusion of people experiencingmental health problems and illnesses inScotland. We are also hearing and learningabout what is happening across Europe, inorder to take important lessons back toScotland, and for us to continue to play arole and help in improving mental healthacross Europe.
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HEALTH INEQUALITIES
This article is based on aspeech delivered to a UKPresidency Associated Event:Mental Health Inequalities inEurope: Government Actionto Tackle Mental HealthInequalities held at theRadisson SAS Hotel, StanstedAirport, on 8 November 2005.
“Work is progressing
on an Employability
Framework that will
do much more to
support people back to
and staying in work”
In Europe more people die from suicidethan from traffic accidents, and one in fourof all of us will suffer from a mental healthproblem at least once during our lives. Thatmeans on average, one member of eachfamily. Four of the six leading causes ofyears lived with disability are due to mentalhealth problems: depression, schizophre-nia, bi-polar disorders and alcohol use dis-orders. Depression alone is the third lead-ing cause of disability in Europe account-ing for 6.1% of burden of disease.1
People with mental health problems aremore likely to have physical health prob-lems, and vice versa, for example those withcancer have up to a 30% increased risk ofsuffering from depression. There is a strongconnection between poor mental health andsocial deprivation, as well as a greater riskof becoming homeless or coming into con-tact with the criminal justice system. Thelong-term impacts on the children of peo-ple with mental ill health can also be signifi-cant: they may suffer from neglect andaremore likely to have problems at school,curtailing their long-term opportunities.
The economic impact of poor mentalhealth is also substantial and impedesprogress towards the achievement of thetwin goals of economic growth and socialinclusion set out in the EU’s Lisbonprocess. Numerous studies indicate that thesingle most substantial contributor to theeconomic costs of mental health problemsis lost productivity, far exceeding directhealth and social care costs, typicallyaccounting for between 60% and 80% ofall estimated costs of poor mental health.2
But the case for investment in mentalhealth is not only about reducing the sub-stantial burden of mental disorders. It isalso about realising the added value for per-
sonal, social and economic development ofpromoting and maintaining good mentalhealth. “There is no health without mentalhealth”, has been the rallying call of profes-sionals, NGOs, and other key stakeholdersfor over 20 years but it is only now thatmental health is finally on the politicalagenda
The WHO Declaration and ActionPlan on Mental HealthIn Europe, a key milestone for mentalhealth initiatives occurred just one yearago, when in January 2005, ministers ofhealth and high level political representa-tives of the 52 Member States of theEuropean Region of the World HealthOrganization met in Helsinki at the firstever WHO Ministerial Conference onMental Health, “Facing ChallengesBuilding Solutions”. At this conference,ministers signed the Mental HealthDeclaration for Europe3 and endorsed aEuropean Action Plan for Mental Health.4
With the Declaration, mental health andmental well-being were acknowledged asbeing fundamental both to quality of lifeand also to the productivity of individuals,families, communities and nations.
As a support to the call for action, theWHO programme for prevention and pro-motion, in strong collaboration with theEuropean Commission, is developing col-laborative projects across the importantareas of evidence development, programmeimplementation, policy support and capaci-ty building for prevention and promotionin mental health. This is also to varyingdegrees being mirrored by efforts undertak-en at the national level in many countries.
The European Commission GreenPaper on Mental Health The European Commission (EC) has longsupported mental health developmentthrough its public health programmes. Italso was a strong collaborative partner inthe WHO Ministerial Conference onMental Health, and is currently active insupporting the implementation of the proposed action. In this scope the EC
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GREEN PAPER ON MENTAL HEALTH
Promoting mental health in Europe: atimely opportunity
Eva Jané-Llopis is responsible for the programme for Mental HealthPromotion and Mental Disorder Prevention, Mental Health Programme,World Health Organization, Regional Office for Europe, Copenhagen.
David McDaid is Research Fellow LSE Health and Social Care and EuropeanObservatory on Health Systems and Policies, London School of Economicsand Political Science
Correspondence: [email protected]
Eva Jané-Llopisand David McDaid
“the Green Paper
stresses the need to
translate existing
political commitments
into action”
launched in October 2005 a Green Paperon Mental Health,5 outlining a frameworkfor cooperation between Member States,aiming to help increase the coherence ofactions in the health and non-health policysectors both within Member States and atCommunity level, and also stimulating theinvolvement of a broad range of relevantstakeholders into the process of buildingsolutions.
The Green Paper emphasises the conse-quences of poor mental health, stressingagain for example, that mental ill health hasconservatively been estimated to be at leastequivalent to a loss of 3–4% of the EU’sGross National Product, whereas goodmental health can impact positively on soli-darity, prosperity and social justice. In anattempt to propose potential solutions forconsideration, the Green Paper stresses theneed to translate existing political commit-ments into action. It underlines that pro-jects under the EU’s Public HealthProgrammes have shown that action topromote mental health, to address mentalill health through preventive action, and toprotect the rights and the dignity of bothpeople with mental health problems andthose with learning disabilities are possible;more so they can be successful and poten-tially cost-effective.
One recent report produced by theIMHPA (Implementing Mental HealthPromotion Action) network focusing onmental health promotion and mental disor-der prevention activities, provides a snap-shot of initiatives across the EU.6 Whilethis particular study did not seek to pro-vide a comprehensive mapping of the situa-tion in Europe, it has highlighted policydevelopments, challenges and areas forfuture development. One of these chal-lenges remains the need for greater intelli-gence not only on what is effective but onhow this may be implemented. The pace ofimplementation will also be dependent inpart on available infrastructures, both interms of personnel and capital resourceswithin countries. This report also flags upsome potential possibilities for capacitydevelopment but local context is impor-tant, for instance, policy makers might wishto consider whether the use of specialistprevention and promotion workers in thefield of mental health that can be foundin the Netherlands may be a viable optionelsewhere.
It is clear therefore that there is a need for acomparable system of information sharingacross the EU. One of the final steps pro-posed in the Green Paper is to develop
an interface between research and policystakeholders and the creation of aEuropean Platform for Mental Health thatwould have the involvement of key stake-holders in the field of mental health and therelated public policy arenas.
The consultation process on theGreen Paper: we are all involved In October 2005, the EC formerlylaunched a consultation process on thisGreen Paper to stimulate a debate betweenthe European institutions, governments,health professionals, stakeholders in othersectors, civil society, and the research com-munity about the relevance of mentalhealth for the European Union (EU), theneed for a mental health strategy at EU-level, and its possible priorities. All relevantand interested parties and stakeholdershave been called to contribute, engage inthe consultation process and provide com-ments on the Green Paper.* The consulta-tion closes in May 2006. In addition, toensure feedback during the consultationprocess, and taking a lead from proposalsin the Green Paper, the Commission hasindeed started to develop mechanisms forboth a research/policy interface andEuropean platform.
Towards an EU strategy for mentalhealthDuring late 2006, the EC intends to presentits analysis of the consultation process anda proposal for an EU strategy on mentalhealth. The expectations of those who havelong championed mental health areundoubtedly high. If the emergent out-comes do indeed encourage the develop-ment of a comprehensive EU strategy, thesubsequent steps to be taken after launchwill be even more important. The EU strat-egy per se may not not be binding for gov-ernments but their commitment and thesupport from key stakeholders and the sci-entific and practice communities in thefield will be crucial to foster much neededsupport for the implementation process.That is why this process of open consulta-tion providing an opportunity to involveall stakeholders and organisations in thefield, from civil society to internationalagencies, is essential and welcome in thisimportant initiative. Dialogue with stake-holders cannot of course be confined sim-ply to the current consultation process,continuing opportunities for discussionand input on the way forward will aid intaking truly significant and sustainablesteps towards the promotion of mentalhealth in Europe.
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GREEN PAPER ON MENTAL HEALTH
REFERENCES
1. Ustun T B, Ayuso-Mateos JL, Chatterji P, et al. Globalburden of depressive disordersin the year 2000. BritishJournal of Psychiatry2004;184:386–92.
2. McDaid D, Curran C,Knapp M. Promoting mentalwell-being in the workplace: aEuropean policy perspective.International Review ofPsychiatry 2005;17(5):365–73.
3. World Health Organization.Mental Health Declaration forEurope. Facing the Challenges,Building Solutions.Copenhagen: World HealthOrganization, 2005.
4. World Health Organization.Mental Health Action Plan forEurope. Facing the Challenges,Building Solutions.Copenhagen: World HealthOrganization, 2005.
5. Commission of theEuropean Communities.Improving the Mental Healthof the Population: Towards aStrategy on Mental Health forthe European Union. GreenPaper. Brussels: Health andConsumer ProtectionDirectorate, EuropeanCommission, 2005.
6. E Jane-Llopis and PAnderson (eds). MentalHealth Promotion and MentalDisorder Prevention AcrossEuropean Member States: ACollection of Country Stories.Luxembourg: EuropeanCommunities, 2006.
* To take part in the consultation process see:http://europa.eu.int/comm/health/ph_determinants/life_style/mental/green_paper/consultation_en.htm
The EU now has more platforms than thecentral station in Brussels. So how does theinauguration of a newcomer addressingmental health offer extra value?
PurposeThe mental health platform is an artificialrather than organic body, created by theEuropean Commission to contribute to thecurrent consultation on the Green Paperlaunched in October 2005 in response togrowing calls for an EU mental healthstrategy to be brought forward.
That it has taken until the fiftieth year ofEuropean political and economic collabo-ration to do this is cause enough for shamegiven the welter of regulations politicalleaders have found time for, some of themarguably contributing to the burden ofmental disorders and linked economic coststhat are outlined in the Green Paper. Socredit is due to those making it happennow.
I include myself in that criticism, inciden-tally: I did not give sufficient emphasis tomental health in my 1999 parliamentaryreport on public health strategies. Nowchampions such as parliament’s currentGreen Paper Rapporteur John Bowis MEPare helping to make up for lost time, andhaving been asked to chair the platform Ihope to ensure its impact is considerableand complementary.
ParticipantsThe twenty core member bodies are drawnfrom interested stakeholders who partici-pated in consultative steps leading to theGreen Paper or related strategies. Whyshould they have a say when nationalhealth policies have hitherto been regardedas paramount? Because if the scale of theneed is to be tackled, it will not be by top-down imposition but by all relevant sectorsand actors working in new partnerships.
Crucially members represent not only lead-ing mental health non governmental organ-isations such as Mental Health Europe, butalso wider public health groups and othersfrom education, employment, industry, andeconomic, social and cultural perspectives.
This reflects the fundamental need for theoutcomes to have widespread support andownership. The direct competences of theEU to act in support of the ministerialHelsinki commitments are limited, but thewider consequences are significant.
Therefore the core platform will not onlyconsider evidence from the three thematicmeetings and early public inputs to theoverall consultation, but welcomes relevantcontributions from all interested parties.An informal consultation meeting inBrussels in March will provide wideropportunities, and while the remit is finiteto produce a report and recommendationsby 31 May there is already support for asustainable, enlarged platform to be consid-ered to help take the strategy forward.
Be that as it may, the partnership approachcertainly extends to the other groups ofexperts and member state authorities, withwhom platform members engage in usefulplenary debates and liaison. We have deter-mined already that implementation is whatmatters, so wish lists should be avoided infavour of achievable priorities; assessmentof short and long-term goals; realistic callson capacity and resources; and integrationwith other EU policy objectives.
PrioritiesThe Commission has defined the parame-ters of the consultation in the Green Paper.We test every submission against the threekey questions:
1. How relevant is the mental health of thepopulation for the EU’s strategic policyobjectives?
2. How would the development of a com-prehensive EU strategy on mental healthadd value to the existing and envisagedactions and does the Green paper proposeadequate priorities?
3. Are the initiatives proposed appropriateto support the coordination between mem-ber states, to promote the integration ofmental health into health and non-healthpolicies and stakeholder action, and to bet-ter liaise research and policy on mentalhealth aspects?
To complete the matrix, the given thematicapproaches around promotion and preven-tion; rights and social context; information
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GREEN PAPER ON MENTAL HEALTH
The EU Mental Health Platform
Clive Needle is Director of EuroHealthNet and Chair of the EU MentalHealth Platform.
Clive Needle
“The Platform
welcomes relevant
contributions from all
interested parties”
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GREEN PAPER ON MENTAL HEALTH
and data will clearly frame our detailedresponses. But while we are working in adisciplined way to provide specific stake-holder perspectives on all that, the platformadded value is also to include broader con-siderations in the context of mental health.
For example, the overarching theme for thenext period at EU level is economicgrowth, exemplified in the Lisbon strategy.The Green Paper estimates that 3-4% ofGDP in economic cost alone is attributableto mental ill health; there are also substan-tial social consequences. Consider theimpact of such conditions across youngpeople, a third of working age adults andtheir families as set out in the accompany-ing statistics, and clearly the core priorityof the whole EU project needs mentalhealth improvement if it is to succeed.
So while the internal market implicationsare unspecified in the Green Paper, we willwelcome views on that, including the cul-tural impact of multinational media on stig-ma, discrimination and mental well being.There may be more examples: within ourcapacity we will attempt to draw on anysound evidence for how the EU might pro-vide additional value to what is beingachieved by other actors.
ProgressAlready concepts are being developed: weunanimously feel the EC does and shouldhave a strategic and active role; we preferwork in “settings” rather than stark identi-fication of “vulnerable groups”; education,training and capacity building will be vital;a proactive public health approach isfavoured. However the debate is very muchopen and will not conclude until May onthese and the many other sensitive issuesthat demand careful and responsible con-sideration.
Already the difficult-to-quantify value oflearning from other viewpoints is bringingdividends. In welcoming views to be swift-ly channelled to the official address in theGreen Paper and also, if you wish, to mycolleague, Kasia Jurczak, who is thePlatform Rapporteur at [email protected], I urge responses to help us tomaintain the cooperative, constructiveapproach that has been a hallmark so far.
Whatever shape the European mentalhealth train is in when it leaves thisPlatform, the passengers are determined itscarriage will be as express as possible, butthat it will reach its destination as an inte-grated, interoperable and integral part ofthe EU strategic network.
Cambridge University Press have launched a newjournal, Health Economics, Policy and Law (HEPL).The first issue is now available freely online athttp://journals.cambridge.org/jid_HEP
International trends highlight the confluence ofeconomics, politics and legal considerations in thehealth policy process. Health Economics, Policyand Law serves as a forum for scholarship onhealth policy issues from these perspectives, and isof use to academics, policy makers and health caremanagers and professionals.
HEPL is international in scope, and publishes both theoretical and applied work.Considerable emphasis is placed on rigorous conceptual development and analysis, and on the presentation of empirical evidence that is relevant to the policy process.
The definition of health policy is broad, and includes factors that affect health butthat transcend health care, and factors that only indirectly affect health, such aslegal and economic considerations in medical research. Articles on social careissues are also considered.
The most important output of HEPL are original research articles, although readers are also encouraged to propose subjects for editorials, review articlesand debate essays.
HEPL invites high quality contributionsin health economics, political scienceand/or law, within its general aims andscope. The recommended text-lengthof articles is 6–8,000 words for originalresearch articles, 2,000 words forguest editorials, 5,000 words forreview articles, and 3,000 words fordebate essays.
All articles should be written in English,and should follow the instructions forcontributors, which can be found at:www.cambridge.org/journals/hep/ifc
All contributions and general correspondence should be sent to:
Anna Maresso, Managing EditorLSE Health and Social CareLondon School of Economics andPolitical ScienceHoughton StreetLondon WC2A 2AEUK
Email [email protected]
New Journal Launched – Health Economics, Policy and Law
Policy makers increasingly talk about theneed for ‘evidence-based policy’. Theyrequire rapid and concise information onpotential policy options. It is thus impor-tant not only to understand whether or notsomething works, but also what resourcesthis will require and what positive, as wellas adverse, wider consequences it mayentail.
The demands for an evidence basedapproach within the health sector seemparticularly strong. Much has been madefor instance of the work of the CochraneCollaboration in systematically synthesis-ing robust evidence on the effectiveness ofinterventions, while Cochrane’s sisterorganisation, the Campbell Collaboration,has begun synthesising evidence on theeffectiveness of interventions in the educa-tion, social welfare and criminal justicefields. In all countries we now hear muchdiscussion of the need for interventions notonly to be proven as effective but also costeffective. Indeed, strict cost effectivenesshurdles governing both access to and reim-bursement of new drugs and technologieshave been introduced in a number of coun-tries across Europe and elsewhere.
For instance, much evidence points towardthe superiority of balanced mental healthservices, relying predominantly on a vari-ety of community-based mental health sup-port, backed up by specialist inpatientcare.1 Moreover evidence on economicimpact suggests that not only does a greaterreliance on community based services havea positive impact on quality of life butoften this is cost neutral not leading to anincrease in costs to the health care system.
Towards evidence based mentalhealth policyYet despite all of this substantial invest-ment in developing an infrastructure to
produce evidence based information toinform the health policy making process, itis perhaps remarkable that mental healthpolicy and practice in many Europeancountries remains far from evidence-based.While it is true that substantial progress hasbeen made in making the mental health sys-tem more community orientated in manycountries, this process has often been tooslow, in some cases being achieved overseveral decades, while in other countries,most notably in central and eastern Europe,large psychiatric asylums continue to formthe backbone of the mental health care sys-tem and consume most of the resourcesallocated to the mental health sector.2
What still of public mental health and thepromotion of mental well-being, areas thatin comparison to treatment remain theCinderella sectors of the mental health sys-tem? Here as well recent research has alsoindicated that a number of promotion andprevention approaches for mental healthare highly effective,3 but again few coun-tries systematically employ these strategiesto improve their population’s mental health.If major improvements may be achievablethrough rather inexpensive interventions,this is likely to be preferable to incurringsubstantial and long term costs arising frommental health disorders. This is to saynothing of the benefits of avoiding the stig-ma and discrimination often associatedwith poor mental health.
So we actually know quite a lot, not onlyabout drugs and psycho-social therapies,but also about approaches to the preven-tion of mental health disorders and the pro-motion of mental well-being. Does thisthen mean that the apparent lack of invest-ment and a more evidence-based approachon mental health in a number of Europeancountries is simply due to policy makersignoring what is becoming an ever morecompelling case for investment in mentalhealth?
Of course the situation is far more complexthan this – too often researchers and othersstakeholders are failing connect with thepolicy making community to get across
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GREEN PAPER ON MENTAL HEALTH
Enhancing the policy relevance ofmental health related research inEurope
Kristian Wahlbeck is Research Professor, Mental Health Group, STAKES,Helsinki, Finland. David McDaid is Research Fellow LSE Health and SocialCare and European Observatory on Health Systems and Policies, LondonSchool of Economics and Political Science. Correspondence: [email protected]
Kristian Wahlbeckand David McDaid
“it is perhaps
remarkable that
mental health policy
and practice in many
European countries
remains far from
evidence-based”
their messages on the potential benefits ofgreater investment in mental health.Reports are often very long, highly techni-cal and not focused on policy. Moreoverresearchers may not be prepared (or havethe right incentives) to participate in thenecessary long term iterative dialoguerequired to genuinely have an opportunityto influence policy and practice.
Plugging the gapThis gap between what we know aboutmental health and current policies has beenhighlighted by the European Commission’sGreen Paper on Mental Health currentlyout for consultation.4 The paper points to aneed not only to improve still further ourknowledge base on mental health in theEU, but also recognises that there is a needfor improved monitoring of mental healthand effective dissemination of informationnot only on what works, but in what set-tings and at what cost.
The Green Paper underlines that mentalhealth is poorly covered by existing healthmonitoring systems. This is also recognisedby the WHO European Region MemberStates who have already committed them-selves ”to develop surveillance of positivemental well-being and mental health prob-lems, including risk factors and help-seek-ing behaviour” at the Helsinki WHOEuropean Ministerial Conference onMental Health in January 2005.5 TheHelsinki Action Plan outlined the follow-ing tasks:
– Internationally standardised, compara-ble indicators and data collection sys-tems.
– Periodic population-based mentalhealth surveys.
– Measurement of base rates of incidenceand prevalence of key conditions,including risk factors.
– Development of an integrated set ofdatabases on mental health policies,strategies, implementation and deliveryof evidence-based promotion and pre-vention.
– Dissemination of information on theimpact of good policy and practicenationally and internationally.
Interface between research and policyAs one element of the ongoing consultationprocess on the Green Paper, theCommission services have called upon agroup of researchers, policy makers andother stakeholders to form an interface
between the mental health policy andresearch communities. The aim of thisinterface is to stimulate a dialogue aroundmental health information, including bothpopulation mental health surveillance andthe exchange of information on evidence-based best practice in mental health. It isalso importantly considering such funda-mental issues as how to ensure that policymakers seek responses to questions that canbe answered, or that researchers do indeedproduce findings that take account of theeveryday context and challenges that policymakers face.
This interface group will debate theseissues during three thematic meetingsorganised as part of the Green Paper con-sultation process. Contributions can alsobe provided via the SINAPSE (ScientificInformation for Policy Support in Europe)web site. The interface will also explore theneed for more sustainable infrastructuresfor any mental health information andknowledge system. For instance whatadded value might there be, if any, in thecreation of a European Observatory onMental Health or a EuropeanClearinghouse for Best Practice in MentalHealth?
At the end of the consultation process acollated report will be produced includingrecommendations on research priorities aswell as suggested actions to bridge the gapbetween research and policy and thusenhance policy relevance. It may also con-sider the infrastructure required to supportany enhanced information systems. Theseoutputs will then have an opportunity to beconsidered by the Commission in thepreparation of a future European mentalhealth strategy emerging after the consulta-tion process.
The European Commission faces the chal-lenge of developing a mental health infor-mation and knowledge system, both for thesurveillance of population mental healthand for the exchange of information onbest practices in the field of mental health.The work can build on several successfulmental health information projects, co-funded by the European Commission.However such information will ultimatelybe of little value, and indeed perhaps is awaste of scarce resources if it does not havean opportunity to influence both policyand practice. The Green Paper consultationprocess thus provides a timely opportunityto devise a long term strategy to indeedfacilitate the greater use of robust evidenceon what works in the policy makingprocess.
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GREEN PAPER ON MENTAL HEALTH
REFERENCES
1. Thornicroft G, Tansella M.What Are the Arguments forCommunity Based MentalHealth Care? Copenhagen:World Health Organization,Health Evidence Network,August 2003. Available atwww.who.dk/document/E82976.pdf
2. Thornicroft G, McDaid D.Policy Brief: BalancingInstitutional and Community-based Mental Health Care.Copenhagen: EuropeanObservatory on HealthSystems and Policies, 2005
3. Doughty C. The effective-ness of mental health promo-tion, prevention and earlyintervention in children, ado-lescents and adults. NZHTAReport 2005;8(2).
4. Commission of theEuropean Communities.Green Paper. Improving theMental Health of thePopulation: Towards aStrategy on Mental Health forthe European Union.Luxembourg: Commission ofthe European Communities,2005.
5. World Health Organization.Mental Health Declaration forEurope. Facing the Challenges,Building Solutions.Copenhagen: World HealthOrganization, 2005.
Focal points for contact withthe “Interface betweenmental health research andpolicy” are:
Interface Leader: ProfessorKristian Wahlbeck, e-mail:[email protected]
Interface Rapporteur: Dr Jordi Alonso, e-mail: [email protected]
IntroductionThe population of Europe is ageing:1 thissituation presents one of the great publichealth challenges of certainly the first halfof the 21st century. In 1960 there werearound 34 million people over 65 years liv-ing in the pre-expansion European Union(EU) 15 countries. By 2001, that figure hadnearly doubled to 62 million, with project-ed increases of a further 25 million between2010 and 2030.2 In 2000, 16% of the popu-lation was over 65 years, a level expected toreach 22% by 2025 and 27.5% by 2050.3 Insome European countries, the situation iseven more striking, with growth in thepopulation aged over 65 expected to beover 30% over the next 15 years in Ireland,Luxembourg, the Netherlands andFinland.3 The situation is similar for thevery elderly, with a projected increase of44% in the number of people over 80 yearsold between 2010 and 2030.2 In Germanyand Italy, the European countries with theoldest populations, an estimated 33.2% and34% respectively of citizens are expected tobe over 60 years by 2025.4
Properly analysed, this trend towardsincreased longevity should be regarded as acause for celebration, and partially reflectsthe improvements in sanitation, nutritionand medical technology that have led tosignificant reductions in infant mortalitythroughout the last century. Other factors,such as better education, improved medical,surgical and diagnostic techniques, greaterhealth and safety at work, social advancesand economic growth have increased lifeexpectancy to 78 years in pre-expansionEU 15 countries.2 Any problems and chal-lenges associated with this ageing popula-
tion stem not from an increase in lifeexpectancy per se, but rather from anincrease in the ratio of older to youngerpeople. Birth rates in many parts of Europeare now well below replacement levels,with a trough of under four million birthsin 1999,2 increasing the upward pressure onaverage ages. The most recent fertility data,from 2001, shows a European average of1.47 births per woman, with the ratedeclining fastest in countries such asGreece, Spain, Ireland and Portugal, wherethe birth rate has historically been high.2
All of these factors have contributed toEurope’s demographic change; the conse-quences of which are impossible to deter-mine, but will be influenced by current andfuture public health policy, and by an ever-changing external environment. For exam-ple, migration and changes in attitude toworking and retirement may mitigate muchof what can be presented as a potentialsocial and economic imbalance betweenyoung and old (the ‘ageing time-bomb’). Atthe same time, smaller and less stable fami-ly structures, the migration of the young tocities, and increased employment amongwomen may reduce the willingness andcapacity of family networks to provideinformal care for older people, transferringresponsibility, and cost, to the formal statehealth care system.3
In the UK, for example, dramatic reduc-tions in the availability of informal carethroughout the last century can be partiallyexplained by comparison of the 1911National Census with that of 1991. In 1911,90% of the population lived within a 15mile radius of where they were born.However, the resulting close-family networks, which often crossed three gener-ations and were a basis for mutual supportwithin the family circle, had all but disap-peared by 1991 when only 10% of the pop-ulation lived close to where they wereborn. The reduction in informal care islikely to be compounded by a reduction informal care, as increased competition with-in the labour market reduces the attractionsof care work, with its unsocial hours andlow pay.
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HEALTHY AGEING
A long life – and all of it healthy: theideal of healthy ageing in Europe
Rodney Elgie is President of The European Patients' Forum, Bruxelles,Belgium, Vice President of The European Men's Health Forum, Bruxelles,Belgium & Immediate past President of GAMIAN-Europe (Global Allianceof Mental Illness Advocacy Networks).
June Crown is Vice President, Age Concern England.
Mike Tremblay is Partner, Tremblay Consulting, Kent, UK.
Correspondence to Rodney Elgie, Riverside Business Centre, River LawnRoad, Tonbridge, Kent TN9 1EP, UK; Telephone & Fax no: ++ 44 (0) 1732367 926; E-mail: [email protected]
Rodney Elgie, June Crown andMichael Tremblay
The aim of this paper is to exploreEurope’s response to its ageing population;in particular, to draw attention to the largedifferences in health outcomes that current-ly exist between countries, and to speculateon their causes. These differences in healthoutcomes are exaggerated in older people,suggesting that the EU is not tackling theproblem of chronic disease in a compre-hensive and coordinated way, and thereforeneeds to rise further to the challenge of itsageing population. Finally, some possiblemechanisms by which standardised carecan be offered across Europe are explored.
How has the ageing populationimpacted European public health?One consequence of Europe’s ageing popu-lation is a marked increase in chronic dis-eases linked to older age, including cardio-vascular disease, stroke, hypertension, dia-betes, cancer, chronic obstructive pul-monary disease and other respiratory dis-eases, mental health conditions includingdepression and dementia, and muscu-loskeletal conditions such as arthritis andosteoporosis. Chronic diseases are alreadythe largest cause of death in Europeans.1
Cancer, for example, kills about 800,000EU-15 citizens a year, and is the main causeof death in people aged 40–69 years.2
Respiratory diseases kill around 300,000 ayear, although this is predicted to rise inolder people as the long-term effects ofsmoking emerge.2 The biggest killer ofEuropeans, however, is cardiovascular dis-ease and related conditions such as stroke.Around 1.5 million deaths per year in theEU-15 are caused by heart disease orstrokes; 42% of the total number ofdeaths.2
Anxieties associated with the ageing popu-lation tend to centre on the burden ofchronic diseases towards the end of life.The vision that exercises some commenta-tors is that of a mass of older, ill peoplesurviving on tiny pensions, whilst plunginghealth care systems into penury with con-stant demands on resources, all supportedby a diminishing pool of economicallyactive younger people. However, this sce-nario will only occur if disease and disabili-ty increase at a faster rate than longevity.Despite a strong relationship between ageand chronic disease, extensions to lifeexpectancy do not necessarily result inmore years of ill health. In a second possi-ble scenario, increases in longevity andthose in morbidity and disability are bal-anced, resulting in something like the statusquo – people live longer, but with the same
number of years of ill-health as before. Athird scenario is that people live a longeractive life, but have less ill health and disability in their later years. In this ‘com-pressed morbidity’ scenario, illness and dis-ability follow a long healthy life and aresqueezed into a short period before death.5
In other words, life expectancy would con-tinue to climb, but the total amount of timespent in ill health would fall, yielding atotal increase in the number of healthyyears lived.
Emerging epidemiological evidence sug-gests that populations in developed coun-tries often resemble the second or third sce-narios. Research in the United States (US)has shown that individuals who are healthyat 70 years have total medical expensesuntil death of no more than for those inpoor health at 70 years – despite the factthat the first group are more likely to livefor longer.6 Put simply, the onset of poorhealth in the years prior to death appears tobe cost-constant, regardless of longevity.Therefore, encouraging health promotionand disease prevention does not appear toincrease the health cost burden of the elder-ly, and nor will doing nothing decrease thatcost.
There is further evidence to suggest thatolder people are not just maintaining theirindependence, but increasing it, as positedby the third scenario of an ageing popula-tion. For example, the proportion of yearsin which UK women over the age of 85 liveindependently rose from 64% to 79%, andfrom 69% to 80% for UK men, from 1980to 1991. Although the proportion of peoplein this age group living in institutions rosethroughout the 1980s, the increase is notsufficient to account for all of this improve-ment.7 In the US, there does appear to be atrue compression of morbidity. Physicaldisability or other morbidity is falling by2% a year compared to a 1% fall in mortal-ity in the US, and the onset of disability isbeing postponed by 7–12 years – longerthan the increase in longevity. 8,9
Longitudinal studies in the US have alsosuggested that the prevalence of disabilityhas reduced at all ages, and that the trend iscontinuing.10 Based on these and othertrends, US analysts have estimated that adecline in disability could lower medicalspending by as much as 20% over the next50 years.11 Such reduced levels of disabilityallow people to spend a longer time livinghealthily, and less time battling physicaldecline and morbidity in the latter stages oflife.
Most ill health and consequent use of
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HEALTHY AGEING
“Increased longevity
should be a cause for
celebration”
health services occurs in the last few yearsof life; particularly the last year, whateverthe age at death. In one CambridgeUniversity study there was little differencein total time spent as hospital inpatientsbetween those who died in their 70s andthose who died in their 90s;12 the use ofresource intensive secondary care does notincrease disproportionately with age. Inanother study men aged 90–94 years atdeath spent 26 days as an inpatient in theirlifetime compared to 11 days for men aged45–59 at death. Women who died at age90–94 had spent 32 days in hospital in theirlifetime compared to 18 days if they died at45–59.12 For men and women, the numberof days spent in hospital per year of lifewas similar if death occurred at a relativelyyoung or relatively old age.
It seems clear that old age need not neces-sarily be associated with a high burden ofdisease and accompanying high health carecosts, and that health care systems thatproperly cater for older people are effectiveat reducing disability and dependence.Europe’s health outcomes, however, sug-gest that European health systems do notcater equally for the health problems of theageing population. An examination of theburden of ill health at a national leveldemonstrates that there are large between-country differences in the effects of chronicdiseases, which suggests that Europeancountries are not responding in a consistentmanner to the continent’s ageing popula-tion; in particular, the data show large dis-crepancies in Life Expectancy (LE). Acrossthe pre-expansion EU-15 countries, aver-age LE is around 78.2 years, with a high of82.3 years in Spain compared to 77.6 yearsin the UK.4 Among the countries that haverecently joined the EU, LE is generallymuch lower: in Poland it is 73.1 years, 74.8years in the Czech Republic and just 70.654
in Hungary, nearly 12 years less than Spain.
Healthy Life Expectancy acrossEuropeUsing a well defined and consistent mea-sure of LE allows relevant comparisons tobe drawn and reveals where actions shouldbe taken. Life Expectancy is such a usefulmeasure of health in a population, but bysubtracting from total LE the average num-ber of years a person in a given countrywill spend throughout their lives in illhealth, it is possible to arrive at anotheruseful measure of health for comparingpopulations – Healthy Life Expectancy(HALE). HALE is most easily understoodas the number of years a newborn can
expect to live in good health, based on thecurrent local rates of ill-health and mortali-ty, and therefore has the advantage of mea-suring what is important – not just the rawyears of extra life, but measure of the quali-ty of those years. Just as with LE, HALEdiffers substantially from country to coun-try. Italy has the highest HALE figure inEurope, at 71.20 years compared to a LE of79.12 years. In Hungary, HALE is morethan 11 years lower than in Italy, at 59.90years.4 Citizens of the UK spend the fewestnumber of years in ill-health in Europe,with a difference between LE and HALEof 7.71 years. In Spain, however, the aver-age person spends 11.67 years of their lifein ill-health, despite Spain’s high LE, andacross the EU-15 countries, the averageperson spends the best part of a decade oftheir life (8.37 years) in ill-health.
The startling differences in LE and HALEreflect health outcome differences betweencountries for many of the chronic diseasespreviously mentioned. The burden of car-diovascular disease, measured in terms ofthe Standardised Death Rate (SDR) per100,000 of population, is far higher inHungary (SDR 586.48) or the CzechRepublic (SDR 495.75) than it is in France(SDR 178.17), Spain (SDR 228.90) or Italy(SDR 256.76). Germany and the UK lieroughly in the middle (SDR 316.90 and285.97 respectively). Examining the datafor respiratory diseases reveals furtherbetween-country differences, with the bur-den ranging from highs in Denmark (SDR66.7) and Spain (SDR 60.8) to lows in Italy(SDR 35.9) and Sweden (SDR 36.2). Similardiscrepancies are found across a wide spec-trum of disease areas, and in particular thechronic diseases that affect older people.4
The emerging picture is not one of coher-ence at the European level, and reflectsnational policy and practice differences.The expansion of the EU adds additionaldimensions to an already complex situa-tion.
Access to European health systemsThe large gap across Europe between LEand HALE is not the only evidence to sug-gest that the correct mix of factors requiredto deliver the ‘compressed morbidity’model of ageing has not yet been found. Asin the past, this mix is likely to include afocus on health promotion activities thatare environmental (for example improvedhousing), social (an emphasis on socialinclusion), economic (reducing poverty)and personal (lifestyle issues such as smok-ing, exercise and diet). In addition, the mix
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“encouraging health
promotion and disease
prevention does not
appear to increase the
health cost burden of
the elderly”
will also include universal access to effec-tive health care, in terms of screening andsurveillance, disease management, prophy-laxis, timely referral, effective treatment,adequate rehabilitation and up-to-datemedical technology.
The positive effects of modern health careon older people can only be realised ifolder people have full access to such treat-ments. In some countries there are bothformal and informal barriers to health care,and occasionally explicit rationing based onchronological age rather than clinicalneed.13,14 Within the UK, for example, dis-crimination on the basis of age occurs informal policies, informal and unwrittenpolicies, and through behaviours and atti-tudes.13 Examples include provision ofpsychiatric and stroke services only tothose under-65, and more subtle indirectdiscrimination such as restricting palliativecare to cancer patients, but not those withother terminal conditions like heart failurethat largely affect older people.13 Limitedphysical access to buildings and poor pub-lic transport are more likely to be a prob-lem for older than younger people. In addi-tion, older people may be less frequentlyreferred for investigations and treatmentsthan younger people, even in the absence ofany clear clinical evidence to support suchan approach.13
Other limits to access have occurred fornew advances in treatment of conditionssuch as Alzheimer’s Disease, where in someareas insufficient funding has been madeavailable to meet demand for treatmentsrecommended by evidence-based clinicalguidelines.15 Greater choice by individualsin how they access health care serviceswould help to expose systemic discrimina-tion against older people, and the problemsassociated with the proper channelling ofresources to where they are most needed.The central planning of some health sys-tems creates a mismatch between plannedservice levels and what the public wouldactually choose if they could, and demon-strates a structural failure of health systemsin adapting to the needs of the populationsthey support.
Beliefs and attitudes within health systemsalso discriminate, by valuing older peopleless and by offering them fewer choices.These attitudes include assumptions thatolder people do not need to be fit andphysically active because they are not inpaid employment. There may be assump-tions that all older people are confused, orthat the views of those who are confused orhave dementia may be ignored.
A European standard?The evidence presented in this article sug-gests that health care across Europe hasscope for improvement. Despite this, theWorld Health Organization ratings showthat some of the best health care systems inthe world are found here in Europe.Indeed, France topped the rankings, whichwere based on a combination of the grossdomestic product (GDP) spent per capitaand the health outcomes achieved.16 Itwould be comforting, therefore, to thinkthat European health systems are capableof adjusting and responding to the chang-ing demographic situation. However, theobserved heterogeneity of health outcomesacross countries points to a lack of engage-ment in the issue at a centralised Europeanpolicy level. Undoubtedly, some of thisvariance is due to cultural factors; forexample, comparatively low rates of car-diovascular disease in France are oftenattributed to the health properties of wineconsumption – the so-called ‘FrenchParadox’,17 and those countries with higherrates of respiratory disease correlate withcountries afflicted by high rates of smok-ing.4
Cultural differences, however, are not theonly factors behind Europe’s heterogeneityof health outcomes. The resources allocatedto health care (for both young and old) alsoplay a part in determining health outcomes.European countries, although politicallyaligned to a certain degree by shared EUmembership, have markedly differentapproaches to health provision and levelsof access to health care resources. In spiteof cost differentials, those countries with alower GDP per capita, such as Portugal,Greece and many of the ten new EU mem-bers, inevitably need to spend a higher per-centage of GDP on health care to rival theservice offered by countries with higherGDP per capita, and this is not always eco-nomically possible.18 These national differ-ences in health provision and access toresources in turn lead to national differ-ences in disease burden, health perceptions,and other measures of health such as LEand HALE.17
Despite the variance in spending levels,organisation and management, there ismuch good practice within Europe thatcould be more widely applied to maintainand improve the health of Europe’s oldercitizens.16 It is a fact that there is no basisin EU law for a united front on ageing orthe management of chronic disease, andconsequently health systems and outcomesare not held accountable to a European
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HEALTHY AGEING
“healthy life
expectancy differs
substantially across
countries”
standard, although standardisation hasoccurred in other equally or less importantareas, such as agriculture, fishing, environ-ment and trade policy, or the distributionof EU subsidies.
ConclusionEurope’s population is ageing, and willcontinue to do so.1 It is wrong to think ofthe health challenges associated with thistrend purely in terms of health care systemperformance. There are many other factorsthat determine an individual’s health status,whatever their age, and any populationhealth model must include these within itsstructure along with an understanding ofthe role that health systems play. However,there is a known association between ageand the burden of chronic disease, and alsothe cost of that burden. Despite this associ-ation, evidence exists to show that if peopleage healthily, with the support of andaccess to satisfactory health care, the bur-den of chronic disease need not increasewith increased longevity. In the UK, forexample, deaths from cardiovascular dis-ease have fallen by 23% between 1995/1997and 2000/2002,19 largely due to a commit-ment by physicians to adhere to guidelinesregarding preventive treatments and assess-ment of cardiac risk.20
The Assessing Care of the VulnerableElders (ACOVE) project, which wasdesigned to assess the quality of careoffered to the over 65s, and to recommendhow to improve that care, has suggestedthat one reason for apparent discriminationagainst older people may simply be igno-rance among health professionals of thecomplicated health needs of the older pop-ulation.21 Evidence-based guidelines forphysicians are often conceived from the tri-als of relatively young sample populations,and do not necessarily take into accountother geriatric co-morbidities. The physi-cian, if following the guidelines, may optfor treating the primary condition withoutnecessarily taking into account the holisticneeds of the older patient. ACOVE hasproposed simple guidelines on commonconditions specifically for older people,which represent a minimum standard ofcare.
The challenge for health care systems is toensure that resources are used as effectivelyas possible to achieve good health out-comes. Evidence is accruing that older peo-ple largely benefit from the same medical,surgical and other interventions as youngerpeople. What is needed is health care that isas accessible to older as younger patients,
and delivers age-neutral services. One sug-gestion has been that more of the healthcare of older people should be carried outby specialists such as cardiologists, neurol-ogists and psychiatrists, drawing on theexpertise of specialist geriatricians as neces-sary.22
An understanding is needed at Europeanpolicy-maker level that older patients are tobe valued as much as younger patients.Spending on health care, particularly pre-ventive health care, for older people shouldbe seen as an investment in longer-termhealth, delaying morbidity and disability,rather than as a cost burden of a group whohave already used up an entitlement tohealth care.23 Adopting a coherentapproach to measuring life expectancy aswe suggest will move European policymakers closer to understanding that olderpatients are as equally deserving of treat-ment and care as younger patients.Compatible with proposals that emergedunder the Dutch Presidency of the EU ,spending on health care is really an invest-ment in longer-term health by delayingmorbidity and disability. Older personscannot be removed from this analysis asthough they had already used up their enti-tlement, since HALE data show that olderpeople will enjoy considerable years ofpost-retirement activity and hence willcontinue to be a source for health serviceinvestment to avoid the disability tradition-ally associated with the ageing process.
Crucially, this change in perspective mustnot just resonate across Europe, but betranslated into action by policy makers andhealth system stakeholders. The ageingprocess is not the problem, but the respon-siveness of health systems to how wechange as we age – it is the health systemsthat must adapt and ensure that those whowill need care the most are not excluded.We must be vigilant to ensure that this doesnot happen through design of discriminato-ry health systems, or through careless plan-ning and design.
But as we have shown here, measurementsacross Europe suggest that despite theexpenditure of vast resources on health ser-vices, and supportive social welfare pro-grammes, variances exist and persist,despite high rankings on the World HealthOrganization ranking of health systems.Clearly expenditure and excellence in theseareas are not translating into improved per-formance for older persons. One can onlyconclude that greater effort is needed toaddress the whole spectrum of determi-nants of improved well-being, which begin
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“there is much good
practice within Europe
that could be more
widely applied”
with ensuring appropriate and responsivehealth service support to older people. It isalso a sober reminder that the health needsof older people will not be met just byfocusing on the performance of the healthservice system, but will require policies andactions which address a wider mix of deter-minants.
In this way, appropriate and personalhealth services to meet the needs of popula-tions as they age will ensure that we realisethe European ideal of a long life – all of ithealthy.
REFERENCES
1. World Health Organization. ActiveAgeing: A Policy Framework. Geneva:World Health Organization, 2002.
2. European Commission Directorate-General for Employment and Social Affairs.The Social Situation in the European Union.Brussels: Commission of the EuropeanCommunities, 2003.
3. Communication from the Commission tothe Council, the European Parliament, theEconomic and Social Committee and theCommittee of the Regions. The Future ofHealth Care and Care for the Elderly:Guaranteeing Accessibility, Quality andFinancial Viability. Brussels: Commission ofthe European Communities, 2001.
4. Pfizer Outcome Research Group. The‘Ageing Population’ Health OutcomesReport, 2003.
5. Tallis R. Medical advances and the futureof old age. In: Marinker M, (ed).Controversies in Health Care Policies:Challenges to Practice. London: BritishMedical Journal Publishing, 1994.
6. Lubitz J, Cai L, Kramarow E, LentznerH. Health, life expectancy, and health carespending among the elderly. New EnglandJournal of Medicine 2003;349(11):1048–55.
7. Grundy E M. Population Review: (5). ThePopulation aged 60 and over. PopulationTrends 1996;84:14-20.
8. Fries JF. Measuring and monitoring suc-cess in compressing morbidity. Annals ofInternal Medicine 2003;139(5 Pt 2):455–59.
9. Kirkwood TB. The most pressing prob-lem of our age. British Medical Journal 2003;326:1297–99.
10. Manton KG, Corder L, Stallard E.Chronic disability trends in elderly UnitedStates populations: 1982–1994. Proc NatlAcad Sci 1997;94(6):2593–98.
11. Cutler DM. Declining disability among
the elderly. Health Affairs 2001;20(6):11–27.
12. Himsworth R L, Goldacre M J. Doestime spent in hospital in the final 15 years oflife increase with age at death? A populationbased study. British Medical Journal1999;319:1338–39.
13. Levenson R. Auditing AgeDiscrimination: A Practical Approach toPromoting Age Equality in Health andSocial Care. London: King’s Fund, 2003.
14. Kmietowicz Z. Elderly women are beingdenied treatments for breast cancer. BritishMedical Journal 2003;327:1069.
15. Roberts E, Robinson J, Seymour L. OldHabits Die Hard: Tackling AgeDiscrimination in Health and Social Care.London: King’s Fund, 2002.
16. World Health Organization. The WorldHealth Report 2000. Health Systems:Improving Performance. Geneva: WorldHealth Organization, 2000.
17. Health For All Database. Copenhagen:World Health Organization Regional Officefor Europe.
18. Eurostat: the Statistical Office of theEuropean Communities. Health Statistics:Key Data on Health 2002. Luxembourg:Office for Official Publications of theEuropean Communities, 2002.
19. UK Department of Health. The NationalService Framework for Coronary HeartDisease: Winning the War on Heart Disease– Progress Report. London: Department ofHealth, 2004.
20. European Society of Cardiology. EuroHeart Survey. 2003.
21. Westropp JC. ACOVE. New toolsaddress unmet need in quality assessmentfor older patients. Geriatrics2002;57(2):44–51.
22. European Commission Economic PolicyCommittee. Budgetary Challenges Posed byAgeing Populations: The Impact on PublicSpending on Pensions, Health and Long-term Care for the Elderly and PossibleIndicators of the Long-term Sustainability ofPublic Finances. EPC/ECFIN/655/01-ENfinal. Brussels: Economic Policy Committee,2001.
23. Hall B. Immigration in the EuropeanUnion: problem or solution? OECDObserver 2000; Summer No. 221/222.
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ACKNOWLEDGMENTS
This paper has arisen as a result of discussions held at the launch of the PfizerHealth Outcomes report on Europe’s Ageing Population (2003). Editorialsupport was provided by Toby Minton.
“spending on health
care is really an
investment in
longer-term health by
delaying morbidity
and disability”
Numerous authoritative reports on passivesmoking have concluded that environmen-tal tobacco smoke (ETS) causes or exacer-bates a range of important health condi-tions among adults and children.1-3 There isbroad consensus that protection from ETSexposure is an important public health con-cern. So why has the Tobacco AdvisoryGroup of the Royal College of Physicians(RCP) published yet another report onpassive smoking?
Going Smoke-free: The Medical Case forClean Air in the Home, at Work and inPublic Places4 is the latest in a series ofRCP reports addressing the biggest singlecause of preventable death and ill-health inmost developed and, increasingly, mostdeveloping countries.* In 1962, the firstreport, Smoking and Health, 5 recommend-ed government action to ensure widerrestrictions on smoking in public places, arecommendation repeated subsequently.6,7
For many years there was only limitedprogress within the UK, and most othercountries, on this aspect of tobacco control.However, recently several US states such asNew York and California, and countriesincluding New Zealand, Norway, andIreland, have introduced comprehensivelegislation to make enclosed public placesand workplaces smoke-free.
This new document does not simply coverthe well-trodden ground of previousreports which largely outlined the healtheffects of ETS exposure. Instead GoingSmoke-free provides a succinct and com-prehensible summary of the evidence, argu-ments and issues concerning the introduc-tion of smoke-free policies and legislation(i.e. banning smoking from all enclosedpublic places and workplaces.
The report is particularly timely for theUK where Scotland, and (probably) Wales,will soon introduce smoke-free legislation,whereas in England the situation is uncer-tain. The English public health WhitePaper, Choosing Health,8 proposed a par-tial ban on smoking in public places, withexemptions for private members’ clubs andpubs or bars which do not prepare andserve food.
The UK government recently completed aconsultation exercise9 on the ChoosingHealth proposals and subsequently decidedto stick with its proposed partial ban,although it subsequently allowed LabourMPs a free vote in Parliament on whetherto accept this proposal or alternativeamendments including a complete ban. InFebruary 2006 MPs endorsed a total ban inmost public places and the bill now is beingconsidered by the upper chamber of theParliament, the House of Lords. The finaldecision therefore is still in the balance andcontinued informed advocacy in favour ofcomprehensive smoke-free legislation iscrucial. However, since ETS exposure is aglobal problem and few countries havecomprehensive smoke-free legislation, theissues outlined in Going Smoke-free are ofwider relevance.
The problem of passive smokingClear evidence that ETS exposure harmsindividual and public health is crucial tosupport the case for the introduction ofsmoke-free policies. The report describesthe composition of ETS, how exposure ismeasured, and summarises the evidence forthe many adverse health effects of ETS onadults, children and the unborn child.Evidence cited is strong, and although theincreased risks from ETS exposure at an
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GOING SMOKE FREE
Going smoke-free: The medical case for clean air in the home,at work and in public places
Richard Edwards is SeniorLecturer in Epidemiology,Department of Public Health,Wellington School of Medicineand Health Sciences,University of Otago,Wellington, New Zealand. E-mail:[email protected]
Tim Coleman is SeniorLecturer in General Practice,School of Community HealthSciences, Queen’s MedicalCentre, Nottingham, UK.E-mail: [email protected]
Richard Edwardsand Tim Coleman
* This report was written by Richard Edwards and Tim Coleman and published by the RoyalCollege of Physicians of London in July 2005. The Royal College of Physicians of Londonretains copyright. It is available for £16.00 (UK) £18.00 (overseas) ISBN 1 86016 246 0 Softcover, 198 pages. To order your copy call 020 7935 1174 ext 358 or visitwww.rcplondon.ac.uk/pubs/brochures/pub_print_GSF.htm
individual level are modest compared toactive smoking, they are important in pub-lic health terms because of the ubiquity ofexposure. Thus, ETS exposure is estimatedto cause 12,200 deaths annually in the UK,including 500 from occupational exposures,with 50 in the hospitality industry alone.These are conservative estimates due to theassumptions of the model. Also, morbidityattributable to ETS exposure, which willundoubtedly be substantial, was not esti-mated.
The considerable burden of ill healthattributable to ETS contrasts markedlywith the far lower and often unsubstantiat-ed risks which have been evident in manyrecent, well-publicised, but transient healthscares. The clarity about the magnitude ofharm caused by ETS documented in GoingSmoke-free4 contrasts sharply with the lan-guage used by the UK government inChoosing Health,8 suggesting that strongadvocacy is still required. For example, thelatter states weakly that: “The evidence ofrisk to health from exposure to second-hand smoke points towards an excess num-ber of deaths, although the debate on theprecise scale of the impact continues”.8
Solutions and non-solutionsThe two main proposed solutions to theproblem of ETS in public places and work-places discussed are partial and comprehen-sive smoke-free policies. Whilst compre-hensive smoke-free policies prevent smok-ing throughout enclosed workplaces andpublic places, partial policies seek to min-imise harm from ETS by using designatedsmoke-free or smoking areas with or with-out additional atmospheric ventilation/fil-tration.
Evidence cited demonstrates that workersin the hospitality sector, particularly inbars, pubs and clubs, are the most heavilyexposed occupational groups. Perverselythese venues are often excluded wholly orpartially from smoke-free policies, as wasthe case with the Choosing Health propos-als. The report cites international evidenceshowing that smoke-free areas with orwithout additional ventilation offer, at best,limited improvements in air quality forworkers in the hospitality trade and else-where. There is absolutely no evidence thatthese minimal changes in air quality willimprove health outcomes and protect thehealth of exposed staff.
In contrast, there is unequivocal evidencethat comprehensive smoke-free policiesmassively improve air quality, and there issome evidence of direct improvements in
workers’ health following their introduc-tion. Therefore, proposals to introduce par-tial smoke-free measures (including the‘smoke-free zones’ around the bar area pro-posed for pubs in England) will be whollyineffective for protecting workers’ health.The case for excluding these workplacesfrom complete smoking bans is impossibleto justify, particularly as hospitality work-ers are the most heavily ETS-exposed occu-pational group. Going Smoke-free illus-trates that such proposed exemptions areillogical, unethical and unreasonable.
Ethical and economic argumentsNot only do comprehensive smoke-freepolicies offer the greatest potential forhealth gain amongst the population, butthere are strong ethical and economic argu-ments for their adoption.
Choosing Health describes the ethicalissues as “hotly debated ... involving as(they do) a conflict between individualrights, and between rights and responsibili-ties in society”.8 It argues, with littleattempt at justification, that the partialsmoke-free proposals represent the ‘rightbalance between freedoms and responsibili-ties’. The rigorous exploration of the ethi-cal case for smoke-free policies in GoingSmoke-free, however, clearly demonstratesthat this view is impossible to sustain.
Ethically, the argument for comprehensivesmoke-free policies is an almost whollyone-sided debate with the ethical balancebeing clearly tipped in favour of the indi-vidual rights of non-smokers. Put simply,non-smokers deserve protection from theharm caused by ETS released wittingly orunwittingly by smokers. These and a rangeof other ethical arguments presented inGoing Smoke-free in favour of smoke-freelegislation far outweigh the relativelyminor restriction that such legislationimposes on smokers as to where, notwhether, they can smoke.
The economic arguments presented forintroducing comprehensive smoke-freepolicies are compelling. The report indi-cates that from the societal perspective,smoke-free legislation is highly cost-effective, providing substantial benefits tocountries’ economies. These are estimatedat £4,000 million per year in the UK.
However, arguments about the economiceffects of smoke-free policies tend to focuson the hospitality sector. Experience fromaround the world is that in debates aboutthe introduction of restrictions on smok-ing, the hospitality industry usually sides
eurohealth Vol 11 No 4 22
GOING SMOKE FREE
“Environmental
tobacco smoke is
estimated to cause
12,200 deaths annually
in the UK”
with the tobacco industry, aiming to prevent or delay smoke-free legislation, byarguing that implementation would be eco-nomically ruinous. The chapter on thepotential economic impact of legislationdispels the myth that smoke-free policieswould harm the hospitality industry. Hardeconomic data from many countries showthat after adjustment for trends and otherkey factors, the overall effect of compre-hensive smoke-free policies on the hospi-tality industry is broadly neutral or weaklypositive. Judging by the following quotefrom a tobacco company marketing andsales director in 1994, the tobacco industryhas long been aware of this:
Economic arguments often used by theindustry to scare off smoking ban activitywere no longer working, if indeed they everdid. These arguments simply had no credi-bility with the public, which isn’t surprisingwhen you consider our dire predictions inthe past rarely came true.10
Public opinionThe remaining argument advanced inChoosing Health and subsequently by UKGovernment Ministers against comprehen-sive smoke-free legislation is that publicopinion does not support legislation for allpubs and bars to be smoke-free. This isbased on the findings from a single nationalsurvey.11
Politicians often seem to delight in ignoringmanifest public opinion, generally withbrazen declarations of the need to take ‘dif-ficult’ or ‘unpopular’ decisions.Introducing comprehensive smoke-freelegislation would demand just such politi-cal machismo, if public opinion wereindeed strongly against it. The evidencesuggests this is not the case.
Going Smoke-free reviews rigorously theevidence about public opinion on smoke-free areas. This reveals that public opinionis more complex than the simplistic analy-sis suggested by the UK government, and isnot a substantial barrier to implementingcomprehensive smoke-free policies. Areview of a range of independent surveysand polls from the UK in the reportdemonstrates that there is overwhelmingsupport for the principle of the right towork in a smoke-free environment. Thereis also majority support for legislation tomake public places and workplaces smoke-free, and for smoke-free legislation formost specified public places and work-places. The exception to the latter are bars,pubs and nightclubs, although there ismajority support among non-smokers for
these venues to be smoke-free.
These somewhat contradictory findingssuggest that pubs and bars are not alwaysperceived as workplaces and that once thisis explained support will increase further.This is supported by the finding that wheresmoke-free legislation has been introduced,public support increased steadily duringthe run up to implementation as the issueswere debated, and increased further after itsintroduction.
Smoke-free legislation and ETS expo-sure in homes The main source of ETS exposure in theUK, particularly for children, is in thehome. The previous UK Health Ministerclaimed that making all pubs and barssmoke-free would increase smoking in thehome and children’s exposure to ETS.12
Going Smoke-free demonstrates clearlythat this assertion was based on belief notevidence, and that introducing smoke-freelegislation is likely to reduce domestic ETSexposure.
The report firstly summarises the over-whelming evidence that smoke-free policiesdiscourage people from starting smokingand encourage smokers to quit or cutdown, thereby reducing smoking preva-lence and tobacco consumption. This is anextremely welcome side-effect of such poli-cies, though not as the report makes clearthe mainstay of the ethical case for intro-ducing smoke-free legislation. Reducingsmoking prevalence and consumptionshould by itself reduce ETS exposure in thehome. This is supported by evidence thatdeclines in children’s ETS exposure in theUK (as indicated by their cotinine levels)have mirrored declines in populationsmoking prevalence.
Furthermore, after restrictions on work-place and public place smoking were intro-duced in the USA, Australia and Ireland,the proportion of smoke-free homes amonghomes with one or more smokers increased.This suggests that introducing comprehen-sive smoke-free policies, often with sup-porting health education campaigns, result-ed in smokers implementing their own vol-untary, domestic smoke-free policies.Presumably the new legislation helped tochange social norms, a possibility that wassuggested in justifying the recommenda-tions within the first RCP tobacco report.5
Tackling domestic ETS exposure raisescomplex issues of ethics and civil liberties.However, the evidence suggests that com-prehensive smoke-free legislation is likely
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GOING SMOKE FREE
“the overall economic
effect of comprehensive
smoke-free policies on
the hospitality industry
is broadly neutral”
to be an effective intervention to reduceETS exposure in the home. This is animportant finding given evidence thatbehaviour-change interventions to promotesmoke-free homes have only a limitedimpact.13
The tobacco industry Finally, doctors who are unfamiliar withthe strategies of the tobacco industry sim-ply must read about the shoddy, self-inter-ested tactics of this discredited industry inrelation to passive smoking and smoke-freepolicies. A key point is that the tactics arerepeated in every setting and hence areentirely predictable. These tactics include:disputing and attempting to undermine thescientific evidence; championing coexis-tence of smokers and non-smokers in thesame environment through smoke-freeareas and ventilation; predicting economicmeltdown for the hospitality industry; andportraying smoke-free legislation as‘nanny-statism’ advocated by health fanat-ics. The report indicates the motivations ofthe tobacco industry’s stance, revealing thatit has long understood the threat whichsmoke-free legislation poses to its sales andprofits – another good reason to support it.
Summing upGoing Smoke-free details exhaustively howETS exposure contributes to the enormousburden of ill health and premature deathcaused by tobacco smoking. This alonemakes it compelling reading and a formida-ble reference text for all physicians. Bydetailing the issues and arguments for com-prehensive smoke-free legislation it isinvaluable to those who want greaterinvolvement in tobacco control advocacy.We urge that all doctors and other healthprofessionals stand up and are counted onthis issue.
What the UK and other non-smoke-freecountries urgently need is to repeat theIrish experience of going smoke-free asdescribed in the final chapter of the report.This relates how Micheál Martin, the thenIrish Health Minister, demonstrated princi-pled political leadership to achieve a keypublic health measure in the face of deter-mined resistance from the tobacco and hos-pitality industries. This section of thereport should be compulsory reading forhealth ministers globally. Introducing com-prehensive smoke-free legislation as advo-cated in Going smoke-free requires similarbold political action. Physicians need toplay their part to ensure that this happens.
REFERENCES
1. California Environmental ProtectionAgency. Health Effects of Exposure toEnvironmental Tobacco Smoke. The Reportof the California Environmental ProtectionAgency. Bethseda: National Institute forHealth, National Cancer Institute, 1999.
2 . International Agency on Research onCancer. Tobacco Smoke and InvoluntarySmoking. Lyon: International Agency onResearch on Cancer, 2004.
3 . Scientific Committee on Tobacco andHealth. Report of the Scientific Committeeon Tobacco and Health. London: StationeryOffice, 1998.
4 . Tobacco Advisory Group of the RoyalCollege of Physicians. Going Smoke-Free:The Medical Case for Clean Air in theHome, at Work and in Public Places.London: Royal College of Physicians ofLondon, 2005.
5 . Royal College of Physicians. Smokingand Health. London: Pitman, 1962.
6 . Royal College of Physicians. Smokingand Health Now, 2nd report. London:Pitman, 1971.
7 . Royal College of Physicians. Health orSmoking? Follow-up report of the RoyalCollege of Physicians. London: Pitman,1983.
8 . Department of Health. Choosing Health:Making Healthier Choices Easier. London:Stationery Office, 2004.
9 . Department of Health. Consultation onthe Smoke-free Elements of the HealthImprovement and Protection Bill. London:Department of Health, 2005.
10. Walls T. CAC Presentation Number 4, 8July 1994. Bates Number 2041183751–90.http://legacy.library.ucsf.edu/tid/vnf77e00.
11 Lader D, Goddard E. Smoking-relatedBehaviour and Attitudes. London: Officefor National Statistics, 2003.
12 Evidence to the Health Select CommitteeEnquiry into the Government’s PublicHealth White Paper, 23 February 2005.www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/ 358/5022301.htm.Accessed 30/09/2005.
13 Roseby R, Waters E, Polnay A, CampbellR, Webster P, Spencer N. Family and CarerSmoking Control Programmes for ReducingChildren’s Exposure to EnvironmentalTobacco Smoke. The Cochrane Database ofSystematic Reviews 2002 (Issue 3).DOI:10.10002/14651858. CD001746.
eurohealth Vol 11 No 4 24
GOING SMOKE FREE
ACKNOWLEDGEMENT
This article is reproducedwith permission and firstappeared in ClinicalMedicine 2005;5:548–50.
“comprehensive
smoke-free legislation
is likely to be an
effective in reducing
smoking exposure at
home”
Mythbusters
Serious illness takes a heavy toll on individ-uals, their families, and society. So it makessense to invest in stopping illness before ithappens, with strategies from public healthprogrammes that ensure we have safe foodand clean water to direct disease-preven-tion efforts such as mass vaccination pro-grammes. In addition, programmes thateducate people on how lifestyle affectshealth and what they can do to keep them-selves healthy provide important benefitsto Canadians.
Penny-wise and pound-foolish?While the over-arching goal of any healthpromotion or disease prevention measure isimproved health, supporters say thatinvesting money in these programmes isalso old-fashioned fiscal common sense.They argue that failing to invest in theseprogrammes now is penny-wise butpound-foolish, that spending less nowmeans we will spend more in the future.2
After all, mass vaccination of infants savesmoney by reducing the number of cases ofmeasles and mumps – not to mention theclassic example of smallpox, which waseradicated in 1980 and has incurred no pre-vention or treatment costs in more than 20years. And helping pregnant women stopsmoking also saves money, because they
give birth to stronger, healthier babies thatincur fewer healthcare costs.3,4
Unfortunately, this evidence does not sup-port the broader argument that preventionand promotion will always save money.Few diseases can be eradicated like small-pox, and postponing a chronic illness is notthe same as eliminating it. The so-called‘Iron Law of Epidemiology’ – that one outof one die – will always apply.
Getting in the actionGiven the current epidemic of obesity inCanada, many experts are working toencourage physical activity. And studies inthe United States and Canada also suggestmillions of dollars in direct medical costscould be saved every year if people were asactive as each country’s federal guidelinessuggest.5,6 After all, shouldn’t a populationthat is less obese require less healthcare?
However, these studies often fail toaccount for implementation costs, the costof treating injuries associated with exercise,such as broken bones and muscle strains, 7
the cost of treating people for any condi-tion as they live longer, or the fact thatmany programmes promoting healthybehaviour just end up preaching to the con-verted.8
In fact, demonstrating the economic impactof physical fitness may always be an elusivegoal. Properly conducted randomised con-trolled trials of exercise are difficultbecause it’s hard to ensure the controlgroup doesn’t change. ParticipAction, theclassic Canadian health promotion pro-gramme, was never rigorously evaluated,and it would have actually been very diffi-cult — with national programmes wherethere can be no control group, there is noway to properly determine if they causeCanadians to exercise more, and if this pre-vents illness and saves healthcare costs.Without these experiments, the health andcost benefits of these programmes remainlargely anecdotal.9
eurohealth Vol 11 No425
Myth: An ounce of prevention buys a poundof cure
Mythbusters are prepared by Knowledge Transfer and Exchange staff at theCanadian Health Services Research Foundation and published only afterreview by a researcher expert on the topic.
The full series is available at www.chsrf.ca/mythbusters/index_e.php. This paper was first published in 2003. © CHSRF, 2003.
“There are enormous potential benefits to be derived from health and wellness promotion, disease and injury prevention, public health and healthprotection and population health strategies, measured primarily in terms ofimproving the health of Canadians, but also in terms of their positive long-term financial impact on the health care system.”
Senator Michael Kirby, Senate Standing Committee on Social Affairs, Science and Technology 1
eurohealth Vol 11 No 4 26
Easing the PressureIt’s easier to test clinically delivered diseaseprevention programmes for their healthbenefits, but the cost benefits are still elu-sive. One example is hypertension, or highblood pressure. Heart disease is the singlegreatest cause of death in Canada, account-ing for 37% of all deaths,1 so it is impor-tant to identify warning signs, such ashypertension, and treat them before theylead to heart attacks and strokes.
Unfortunately, treatment for hypertensionis complex and expensive – right from theinitial testing. Many people become so ner-vous at the thought of seeing the doctorthat their blood pressure goes up whenthey’re at the doctor’s office, only to dropback to normal once they get home. Thismeans people must be re-tested at leasttwice more to ensure they are not ‘falsepositives.’7 Not only have they cost thesystem for the extra tests, but they experi-ence unnecessary stress as well. (The num-bers can be significant for other diseases aswell; for screening mammography, it isestimated that between 80 and 93% of sus-picious or positive results are false posi-tives.10
Furthermore, treatment for hypertensionusually involves many doctors’ visits, labtests, and medication that patients musttake for the rest of their lives. This can costthe system a lot – one provincial drug planspent more than $127 million on cardiovas-cular drugs alone in 1999,11 and one reviewshows hypertension drugs can cost any-where from $3,800 to $93,000 per life-yearsaved.3 And while this is certainly cost-effective for older patients, it is a bit morequestionable for a forty-year-old with onlymild hypertension, as the cost of 10, 20,even 30 years of preventive treatment goesfar beyond the one-time cost of treating aheart attack.12 Finally, not all people withhypertension will follow their treatmentregimens, leaving them at high risk whileincurring costs to the system.7
In general, preventing fatal diseases meansthe healthcare system can end up spendingmore, because people live longer andbecome vulnerable to conditions such asmental illness, respiratory disease, and jointand bone problems. These diseases accountfor about the same proportion of health-
care budgets as cancer and heart disease.1
However, because they are less fatal, theymay cost more in the long term.13
Penny foolish?Leading longer, healthier lives is in itselfjustification for disease prevention andhealth promotion. And it is important toremember that just because somethingcosts money doesn’t mean it isn’t costeffective. Thus, supporters of health pro-motion and illness prevention don’t need todepend on cost-saving rhetoric to maketheir arguments, and they probablyshouldn’t, because the evidence is simplynot there.
REFERENCES
1. Kirby M (Chair) The Health of Canadians – The Federal Role: InterimReport: Volume Six: Recommendations for Reform. Ottawa: Senate of Canada.The Standing Senate Committee on Social Affairs, Science and Technology,2002.
2. Fries JF, Koop CE, Beadle CE et al. Reducing health care costs by reducingthe need and demand for medical services. New England Journal of Medicine1993;329:321–25.
3. Tengs TO, Adams ME, Pliskin JS et al. Five-hundred life-saving interven-tions and their cost-effectiveness. Risk Analysis 1995;15(3):369–90.
4. Partnership for Prevention. Guide to Smart Prevention Investments.Washington, DC: Partnership for Prevention, 2001.
5. Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physi-cal inactivity in Canada. Canadian Medical Association Journal2000;163(11):1435–40.
6. Pratt M, Macera CA, Wang G. Higher direct medical costs associated withphysical inactivity. The Physician and Sportsmedicine 2000;28(10):63–70.
7.Russell LB. Is Prevention Better Than Cure? The Brookings Institution,Washington, DC: The Brookings Institution, 1986.
8. Harvey K. Health promotion is a waste of time and money. British MedicalJournal 1998;317(7162):887.
9. World Health Organization. The World Health Report 2002 – PreventingRisks, Promoting Healthy Life. Geneva: World Health Organization, 2002.
10. Wright CJ, Mueller CB. Screening mammography and public health poli-cy: the need for perspective. Lancet 1995;346:29–32.
11. British Columbia Ministry of Health Services. Pharmacare Trends.Victoria: British Columbia Ministry of Health Services, 2000.
12. Russell, LB. The role of prevention in health reform. New EnglandJournal of Medicine 1993;329(5):352–54.
13. Bonneux L, Barendregt JJ, Nusselder WJ, Van der Maas PJ. Preventingfatal diseases increases healthcare costs: cause elimination life table approach.British Medical Journal 1998;316(7124):26–29.
eurohealth Vol 11 No 427
NEW PUBLICATIONSEurohealth aims to provide information on new publications that may be ofinterest to readers. Contact David McDaid [email protected] if you wish tosubmit a publication for potential inclusion in a future issue.
The Public HealthObservatory Handbookof Health InequalitiesMeasurement
Roy Carr-Hill and PaulChalmers-Dixon.
Edited by Jennifer Lin
Oxford: South East PublicHealth Observatory, 2005
Freely available on line atwww.sepho.org.uk/extras/rch_handbook.aspx
This new handbook primarily focuses on the measurement and interpretation of health inequali-ties. Written by Roy Carr-Hill and Paul Chalmers-Dixon from the University of York, it pro-vides a comprehensive collection of material for those concerned to document and understandhealth inequalities.
Speaking on the publication of the book Sir Donald Acheson said “…Resources are going intoresearch and development to advance our knowledge and understanding of what works. In paral-lel with that we need to be able to measure inequalities, in order to plan, set targets, monitor andevaluate. I recommended in my report the need to establish mechanisms to monitor inequalitiesin health and to evaluate the effectiveness of measures taken to reduce them.
This book therefore is a welcome contribution to the resources available to people working toreduce inequalities in health in their communities. I commend it to anyone involved in address-ing health inequalities. The measurement of inequalities is a complicated and convoluted science,but this book brings together much of that science in a rigorous but accessible way. It is a richsource of information and will contribute to advancing our knowledge and practice, with theultimate aim to reduce inequalities and to make this country a more equitable society…”
Contents: Introduction; Measuring inequality by social categories; Measuring inequality byhealth and disease categories (using data from administrative sources); Measuring inequality byhealth and disease categories (using data from surveys); An introduction to the use of indexes tomeasure deprivation; A selection of indexes of multiple deprivation; Indexes: properties andproblems; Data sources: availability and problems; Designing surveys to measure inequality;Inequalities and methods of measurement; Context, history and theory; Index
Decent Work – SafeWork
J Takala
Geneva: InternationalLabour Organization, 2005
ISBN 92-2-117750-5(print)
ISBN 92-2-117751-3 (web pdf)
Freely available atwww.ilo.org/publns
Written by J Takala, Director of Safework at the ILO in Geneva, this report provides anoverview of the most recent estimates of occupational and work-related accidents and diseases,world-wide, some of the causes for recent changes and what the ILO and its member states aredoing to improve conditions in the workplace for the millions who are at risk from injury.
Throughout the world, there is growing acceptance that accidents and ill-health at work impactnot only on the lives of individual workers, their families and their potential for future work,but also the productivity and profitability of their enterprises and ultimately the welfare of thesociety in which they live. In short, safety and health at work makes good business sense, andmaintaining acceptable standards is seen as an integral and key component of societal develop-ment, poverty alleviation and of ‘decent work’.
Globally, the statistics appear to show an increasing trend in occupational accidents and dis-eases. Many Conventions, Recommendations and other instruments on occupational safety andhealth (OSH) have been adopted over the years, and these have helped to improve workingconditions throughout the world. This impetus has been maintained, and recent years have seenthe adoption of a Global Strategy for OSH.
The report concludes that this Global Strategy has already had a profound impact on OSHpolicies and programmes at both international and national levels. The systems approach andnational programming for OSH are also gaining momentum at the national level, and nationalprofiles including a set of indicators of progress are being progressively developed. Continuousand stepwise improvement of both national OSH systems and national OSH programmes,which have measurable targets and are governed by tripartite dialogue, will also help to achievebetter OSH outcomes in reality.
Contents: Part I – Estimates of occupational accidents and work-related diseases; Costs of occu-pational injuries and diseases; Productivity and competitiveness; Employability; Genderaspects; Age-related aspects; Absenteeism; Workers’ health promotion and well-being at work;Part II – A global occupational safety and health strategy; Promotion, awareness raising andadvocacy; Development of new instruments and related guidance; Technical assistance andcooperation; Knowledge development, management and dissemination; International collabora-tion; Conclusions; Statistical annexes.
eurohealth Vol 11 No 4 28
E-mail [email protected] to suggest websites for inclusion in future issues.
Belgium Scientific Instituteof Public Health
www.iph.fgov.be
The International SocietyforPharmacoepidemiology(ISPE)
www.pharmacoepi.org
Royal College ofPhysicians
www.rcplondon.ac.uk
ISPE is an international organisation dedicated to advancing the health of the public by pro-viding a forum for the open exchange of scientific information and for the development ofpolicy, education and advocacy for the fields of therapeutic risk management and pharma-coepidemiology. Pharmacoepidemiology is the science that applies epidemiologic approachesto studying the use, effectiveness, value and safety of pharmaceuticals. The web site containsnewsletters and journals, lists of conferences and courses, a career centre and links to relatedweb sites.
Norwegian KnowledgeCentre for the HealthServices
www.kunnskapssenteret.no
Based in Oslo, the Centre was founded in 2004 from the merger of the Norwegian Centre forHealth Technology Assessment (SMM), parts of the Division for Knowledge Management inthe Directorate for Health and Social Affairs, and the Foundation for Health ServicesResearch (HELTEF). The Norwegian Knowledge Centre for the Health Services gathers anddisseminates evidence about the effect and quality of methods and interventions within allparts of the health services, and works towards the uptake of evidence by the health services.They produce HTA reports, systematic reviews, overviews and early warnings, and surveysfor patients and employees. Available for download from the web site are published articles,presentations and strategic reports. The web site is available in both English and Norwegian.
Health Council of theNetherlands
www.gr.nl
The Health Council of the Netherlands is an independent advisory body in charge of provid-ing Ministers and parliament with scientific advice on public health matters. The Council pro-duces advisory reports in response to requests from ministers as well as unsolicited advisoryreports, which have an alerting function. There are three main themes, including generalissues (i.e. population screening, blood safety), effectiveness and efficiency of diagnosis andtreatment (i.e. cholesterol lowering therapy), and the prevention and treatment of infectiousdiseases. The web site has news items, a newsletter for subscription, and reports and publica-tions for download. Both the web site and newsletter are available in English and Dutch.
Austrian Presidency of theEU
www.eu2006.at/info/de
News and information on the Austrian Presidency of the European Union.
The Royal College of Physicians, based in London sets standards for clinical practice, con-ducts examinations, defines and monitors education and training programmes for physicians,supports doctors in their practice of medicine, and advises the government, public and medicalprofessions on health care issues. The College has 21,000 fellows and members worldwide.Information is available on publications, organised events, clinical guidelines, continuing pro-fessional development, and online learning. The ‘hot topics’ section draws attention to perti-nent health issues, such as alcohol, medical professionalism, the new consultant contract andwomen in medicine. The web site also includes press releases, an international component andsections for specialists, patients and carers.
The Belgium Scientific Institute of Public Health conducts scientific research in view of sup-porting health policy. Based in Brussels, it also provides expertise in public health, includingthe surveillance of communicable and non-communicable diseases, verification of federalproduct standards, risk assessment, environmental health, and the management of biologicalresources. Reports and publications are available for download and topics can be searched bykeyword. The web site is available in English, French and Dutch.
World HealthOrganization – EssentialHealth Technologies (EHT)
www.who.int/eht/en
This web site provides information on essential health technologies, which are evidence-basedtechnologies that provide cost-effective solutions to health problems. The department’s aimsare to develop and maintain basic operational frameworks for safe and reliable health servicesand technologies; help WHO Member States complete the basic operational frameworksthrough project proposals; develop norms and standards, guidelines, training materials, refer-ence materials and estimation of burden of disease; and focus on diseases of the poor. Thereare links to WHO and other publications and information about relevant events.
WEBwatch
NEWS FROM EUROPEANINSTITUTIONS
EU budget for 2007–2013agreed by Member StatesEuropean Heads of States andGovernments reached an agreementon the EU budget for 2007–2013 inthe early hours of the morning on 16December in Brussels.
They agreed on a budget of €862.36billion, corresponding to 1.045% ofthe gross national income of the EU.Although this amount was less thanthat hoped for by some govern-ments, the reaction to the final bud-get across Europe has generally beenpositive. The UK gave up €10.5 bil-lion of its rebate, about 20% in totaland in return secured agreement on awide-ranging review of EU spendingin 2008–9, which could theoreticallylead to cuts in farm spending.
Development aid for poorer EUcountries will be set at €157 billion.This is €7 billion more than the UKenvisaged in its first proposal on 5December, but less thanLuxembourg proposed at the lastsummit in June. The rules for access-ing funds are also relaxed.
UK Prime Minister Tony Blair commenting on the deal said “Wehave delivered an EU budget dealwhich is €160 billion cheaper thanthe original Commission proposals,which provides for a huge transfer ofspending from the original 15 to thenew member states of easternEurope.”
€3.64 billion (€520 per annum) havebeen allocated to ‘internal policies’in particular culture, youth, audio-visual matters and health and consumer protection. The Councilproposal is now being discussed inthe European Parliament.
For more information on the budget:http://ue.eu.int/ueDocs/cms_Data/docs/pressData/en/misc/87677.pdf
MEPs reject proposed healthbudgetMembers of the EuropeanParliament’s Environment andHealth Committee, meeting on 31January voted to allocate €1,500 million over seven years to the newCommunity action programme onhealth. The European Parliament hasalready expressed opposition to thefigures proposed by the DecemberEuropean Council for the 2007–2013financial period, which MEPsregarded as too low. They rejectedby a high majority the budget pro-posed by the Council on the basisthat it “did not guarantee prosperity,solidarity and security for thefuture”. They have rarely used suchpowers to block any deal previously.
The Environment and HealthCommittee has now signalled itsintention to continue to supportgreater funding for health.According to Antonios Trakatellis,rapporteur for the Committee, theobjectives of the Community actionprogramme, “must always bematched by the resources availableto achieve them.” He also stated that“there is no guaranteed matchbetween these two in the proposedprogramme. I therefore propose thatthe funding be increased, in the cer-tainty that the Council and theCommission will realise that thisproposal is perfectly reasonable.”The rapporteur received overwhelm-ing backing from the committee andhis report was adopted by 54 votesto 1.
The European Commission original-ly suggested a single action pro-gramme for health and consumerprotection, with an overall budget of€1,203 million with €969 million ear-marked for health. The Commissionhoped to achieve more efficiency bycombining the two areas butParliament, while in favour of pool-ing administrative resources, decidedthat the areas, which come underdifferent legal bases (Articles 152and 153 of the EC Treaty) in which
the EU has different powers, shouldbe split into separate programmes.Parliament’s Committee on theInternal Market and ConsumerProtection will adopt what is now aseparate programme on 20 February,probably without modifying the initial budget of €233 million.
The Environment and HealthCommittee chaired by Karl-HeinzFlorenz believe that MEPs want ahigher standard of health protectionto be a goal of all EU policies andhave called for greater transparencybetween national healthcare systems.MEPs also want to see greater cross-border cooperation, in particular forthe treatment of rare diseases, plusexchange of information on the services and treatments available andon reimbursements. The newCommunity action programme alsoincludes special measures on riskprevention, information for practi-tioners and the public and theexchange of best practice. Talks on the budget will continue in a trialogue between the EuropeanParliament (President Borrell),European Commission (PresidentBarroso) and Council PresidentChancellor Schüssel (Austria).
Open consultation on nutritionand physical activityOn 8 December 2005 theCommission adopted a Green Paperon the promotion of healthy dietsand physical activity to begin anextensive public consultation onhow to reduce obesity levels and theprevalence of associated chronic diseases in the EU. The Green Paperinvites contributions on a broadrange of issues related to obesity,with a view to gathering informationfor a European dimension to reduc-ing obesity levels which could com-plement, support and coordinateexisting national measures. Around14 million EU children are currentlyoverweight or obese, of which morethan 3 million are obese. This figure
eurohealth Vol 11 No 429
EU newsCOMPILED BY EUROHEALTH WITH ADDITIONAL INPUT FROM EUROHEALTHNET
Press releases and other suggested informationfor future inclusion can be e-mailed to the editorDavid McDaid [email protected]
eurohealth Vol 11 No 4 30
is expected to continue to rise for theforeseeable future. The Green Papercalls for concrete suggestions andideas on action that can be taken inall sectors and at every level of society to address this serious prob-lem and to encourage Europeanstowards healthier lifestyles.
Health and Consumer ProtectionCommissioner Markos Kyprianousaid: “The rise in obesity is aEurope-wide problem whichrequires a coordinated Europe-wideapproach if we are to contain andreverse this trend. More than400,000 children are estimated tobecome overweight every year, andtoday’s overweight teenagers aretomorrow’s heart attack or diabetesvictims. The Commission’s GreenPaper aims to stimulate discussionabout effective initiatives to promotehealthy diets and physical activity,so best practice can be replicatedacross Europe. Apart from thehealth benefits and cost savings to bemade from tackling obesity, a coordinated European approach willalso ensure that the single market isnot undermined by the emergence ofa patchwork of uncoordinatednational measures.”
Contributions are invited on a rangeof specific questions in the GreenPaper, including:
– Which kind of Community ornational measures could con-tribute towards improving theavailability, accessibility andaffordability of fruits and vegetables?
– What contribution canCommunity policies maketowards enabling and encourag-ing consumers to shift towardsdiets lower in fat, sugar and salt?
– Are voluntary codes (‘self-regulation’) an adequate tool forlimiting the advertising and marketing of energy-dense andmicronutrient poor foods? Whatwould be the alternatives to beconsidered if self-regulation fails?
– How can consumers best beenabled to make informed choicesand take effective action? Whichshould be the key messages togive to consumers, how and bywhom should they be delivered?
– What is good practice for improv-ing the nutritional value of schoolmeals and for fostering healthydietary choices at schools, especially as regards the excessiveintake of energy-dense snacks andsugar-sweetened soft drinks?
– In which ways can public policiescontribute to ensure that physicalactivity be ‘built into’ daily routines?
– How can dietary guidelines becommunicated to consumers andin which ways could nutrientprofile scoring systems contributeto such developments?
The public consultation will rununtil 15 March 2006, and a reportsummarising the contributions willbe published on the Commission’swebsite by June 2006.
For more information, see:http://europa.eu.int/comm/health/ph_determinants/life_style/nutrition/nutrition_en.htm
EC commits funds to preventavian influenza Health officials and disease expertsfrom 90 countries gathered inBeijing in a bid to raise €1.9 billionat an international donors confer-ence on human and avian influenza.For its part, the EuropeanCommission pledged €80 million inaid grants from the Commission'sExternal Relations budget and theEuropean Development Fund, andcommitted €20 million to researchfunds for avian influenza from the6th Research FrameworkProgramme, bringing the totalEuropean Commission contributionto €100 million. European govern-ments have until 7 February to sendtheir national surveillance plans tothe Commission.
Speaking at the conference on theamount of money raisedCommissioner Kyprianou said:“This is a significant achievement weall can be proud of. We have sur-passed expectations by considerablyexceeding the estimated overallfinancing gap of around $1.2 billion,1 billion of which is in grants. For itspart, the European Commission hasplayed a central role both as a co-
host of this conference, and with atotal pledge of €100 million ($122million). Taken together with the€114 million ($140 m) pledged bythe EU Member States, the EU hasin total pledged around €214 million($260 m).”
Of the €80 million pledged by theEuropean Commission to thirdcountries, €30 million is destined forAsia, €5 million for Central Asia, €5million for the EU’s EasternEuropean neighbouring countries,€10 million for North Africa and theMiddle East, and €30 million is ear-marked for the African, Caribbeanand Pacific Countries, subject toapproval by the ACP countries.With the €20 million of researchfunds earmarked from the 6thResearch Framework Programme,this brings the total EuropeanCommission pledge to €100 million.Separately, the EuropeanCommission is preparing to bringforward urgently €4 million in pre-accession aid to Turkey foreseen for2007 to tackle avian influenza.
More information on the EU’sresponse to avian flu is available athttp://europa.eu.int/comm/world/avian_influenza/index.htm
Seventh FrameworkProgrammeThe European Commission has setout the details of its proposal for anew Seventh FrameworkProgramme to fund research anddevelopment from 2007 to 2013.Four specific programmes have beenproposed by the Commission:
Cooperation programme – designedto gain leadership in key scientificand technological areas by support-ing cooperation between universi-ties, industry, research centres andpublic authorities across theEuropean Union as well as the restof the world.
Ideas programme – to establish aEuropean Research Council, a pan-European mechanism to support thetruly creative scientists, engineersand scholars.
People programme – to strengthenhuman resources available to scienceand research across Europe, both
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qualitatively and quantitatively.
Capacities programme – to enhanceresearch and innovation capacitythroughout Europe.
These themes will be discussed withthe European Parliament, with a firstreading anticipated in March 2006,before being decided by the Council.Commenting on the SeventhFramework Programme, JanezPotoãnik, European Commissionerfor Science and Research said “Whatis important now is to allocate suffi-cient funds to allow this project toachieve its objective of greater com-petitiveness for Europe and a betterquality of life for its citizens.”
Rules for participation in the variousschemes have now been published.These are aimed at making the pro-gramme more accessible andstraightforward for their users.
Further information on the FP7Programme can be foundhttp://europa.eu.int/comm/research/future/index_en.cfm
The health programme of theAustrian presidency The Austrian Minister for Healthand Women, Maria-Rauch Kallatpresented the health programme ofthe Austrian presidency to theEuropean Parliament Committee onEnvironment, Public Health andFood Safety. Mrs Kallat presented along list of work areas including:
– Finding agreement on the jointHealth and Consumer ProtectionProgramme.
– Health threats (such as bird fluand HIV/Aids in neighbouringcountries).
– Working towards the adoption ofthe proposed directive on paedi-atric medicine.
– Working towards the adoption ofthe food additive and nutritionalclaim on food products directives.
– Reviewing legislation on medicineand exploring alternative medi-cines.
– Working on a EU alcohol strate-gy.
– Working on a EU strategy for
sustainable development and itsmainstreaming in all policies.
– Injuries and infection prevention.
– Promoting e-health for patientsand health care structures.
The two thematic priorities of theAustrian Presidency will bewomen’s health and diabetes type II.In the field of women’s health,Austria will focus primarily on cardiovascular diseases, lung cancer,osteoporosis, endometriosis anddepression and will ask theCommission to present a report onthe health status of women in theenlarged EU Community by June2006.
In the field of Diabetes type II, thepresidency will organise a confer-ence in Vienna on 15–16 Februaryand the Council will make conclu-sions on the issue of obesity inMarch. At a conference on e-healthin Malaga on 10–12 May, thePresidency will present a charter onhealth. This charter has been pre-sented by Minister Rauch Kallat asprogressive and innovative. The firstEU conference on injury preventionand safety promotion will also beheld in Vienna 25–27 June 2006.
Further information is available onthe Austrian Presidency’s websitewww.eu2006.at/en/index.html
Commission launches revisionto the Medical Device Directives Medical devices have become anincreasingly important health carearea in relation to their impact onhealth and health care expenditure.The sector covers some 10,000 typesof products, ranging from simplebandages and spectacles, through lifemaintaining implantable devices,equipment to screen and diagnosedisease and health conditions, to themost sophisticated diagnostic imag-ing and minimal invasive surgeryequipment. The public expects thatthese devises meet the highest safetystandards.
On 22 December 2005, theEuropean Commission proposedamendments to the current legisla-tive framework. The proposal hasbeen developed involving extensive
stakeholder consultation and hasalso been subject to public consulta-tion. The most significant proposalsconcern conformity assessment,including design documentation anddesign review, clarification of theclinical evaluation requirements,post market surveillance, complianceof custom-made device manufactur-ers and the alignment of the originalmedical device directive90/385/EEC.
Commission Vice President GünterVerheugen stated: “This is a goodexample of better regulation in thiscomplex and highly diversified sec-tor. We have listened to stakeholdersand have clarified and simplified thecurrent rules. At the same time webring improved requirements forsafety for the patients whilst contin-uing to provide a coherent legislativeframework that fosters competitive-ness.”
The proposal also brings increasedtransparency to the general public inrelation to the approval of devices. Itintroduces the necessary regulatoryclarification in order to continue thehigh level of protection of humanhealth and support better implemen-tation. It also foresees provisionsnecessary to regulate medical deviceswith an ancillary human tissue engineered product. This mirrors the proposed EU legislation onadvanced therapies and fills a potential regulatory gap.
The proposal enjoys widespreadsupport and it is anticipated, byauthorities and industry alike, thatits eventual adoption will see resur-gence in this sector, both in terms ofcompetitiveness and safety.
Moreover, the proposal fits neatlyinto the European Commission’spolicy to maintain the high competi-tiveness of this sector. Indeed, arecent study commissioned by theEuropean Commission has under-lined again the importance of thissector which consists of some 7,000business entities in Europe, employ-ing upwards of 350,000 Europeansand which regularly records thehighest production growth ratesamongst all industry sectors in theEU.
The Commission proposal will nowbe forwarded to the European
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Parliament and Council for co-decision.
Additional information, includingthe text of the study and theCommission proposal, can be foundat: http://europa.eu.int/comm/enterprise/medical_devices/revision_mdd_en.htm
Information on the proposal onAdvanced Therapies can be found at:http://pharmacos.eudra.org/F2/advtherapies/index.htm
NEWS FROM THE EUROPEANCOURT OF JUSTICE
ECJ rules on professionalrecognition of dentists inAustriaThe European Court of Justice hasruled that individuals with non-university dental training of threeyears’ duration are not entitled toengage in their occupation under thename of dental practitioner or den-tist. The judgement (Case C-437/03)comes following an enforcementaction brought by the Commissionagainst Austria, for failure to complywith two Community Directivesrelating to the dental profession onthe mutual recognition of diplomas(Recognition Directive) and thecoordination of training required bythe various Member States(Coordination Directive) TheDirectives were adopted with a viewto facilitating the free movement ofworkers as well as freedom of estab-lishment and freedom to provideservices.
The European Commission claimedthat Austria had infringed the provi-sions of the Directives on twogrounds, firstly the ‘CoordinationDirective’ (Council Directive78/687/EEC) provides that dentistsmust complete a five-year full timedentistry course at university.However, the ‘RecognitionDirective’ (Council Directive78/686/EEC) provides for an excep-tion (in order to take into accountthe situation in Italy, Spain andAustria) whereby those havingundertaken medical training in a uni-versity can also avail themselves ofthe title of dentist. Austria’s national
legislation still allowed for individu-als with non-university training topresent themselves as dentists. TheCourt therefore concluded thatAustria had failed to fulfil its obliga-tions under Community law.
The European Commission had alsoclaimed that Austria had failed tocomply with the Directives by notrequiring doctors specialising indental, oral and facial surgery to usethe title ‘Dental practitioner’.However, the Court rejected thiscomplaint on the grounds that theCommission had failed to show thatthis might lead to a genuine risk ofconfusion between specialists indental surgery and other doctors;moreover a requirement for doctorsto give up their professional title infavour of the title of ‘Dental practi-tioner’ would effectively oblige themto hold themselves out to patients asdentists without indicating theirskills as a physician, which would beharmful to the pursuit of their pro-fession; finally the possibility forthem to continue to use the title‘Doctor specialising in dental, oraland facial surgery’ appeared to bejustified on the grounds of trans-parency, enabling patients to distin-guish between the two professions.
ECJ rules on the protection ofworkers from exposure to carcinogens The European Court of Justice hasstated that Austria failed to protectworkers by not adopting the neces-sary legislation to fully implementthe Council Directive on the protec-tion of workers from the risks relat-ed to exposure to carcinogens atwork and extending it to mutagens(1999/38/EC).The action (Case C-378/04) was brought before theCourt by the EuropeanCommission.
The Austrian government arguedthat the Directive had been sub-sumed into national law at federallevel within the time limit prescribed. However, since theDirective had not been subsumed byall of the Länder, the Court foundthat the measures required to ensurethe incorporation of the Directiveinto national law had not beenadopted.
NEWS FROM AROUND EUROPE
Climate change and humanhealthGrowing evidence shows that climate change and variability isaffecting health now. The 890 million inhabitants of the EuropeanRegion are exposed to rising temper-atures, changes in precipitation pattern and increases in the severityand frequency of extreme weatherevents, particularly heatwaves,droughts and intense rainfall.Southern Europe is likely to becomedrier in the future, while the climatein northern Europe is expected to bewarmer and wetter. Climate changeand variability are affecting health ina variety of ways. Some of thesechanges find countries unprepared.Weak health system preparednesscontributed to the more than 35,000excess deaths in western Europealone in the 2003 heat-wave. Thismeans that climate change affects allcountries, irrespective of their socio-economic development.
At the United Nations summit onclimate change that took place inMontreal in December, the WHORegional Office for Europelaunched a new report, ClimateChange and Adaptation Strategiesfor Human Health (cCASHh). Thereport illustrates how across Europepeople and systems can adapt to newclimate-related threats and how pub-lic health interventions can best curbthe negative effects on health now. Itidentifies concrete action that thehealth sector can take, in collabora-tion with other sectors, as a pre-requisite for effective policy-makingon health and the climate. Thisincludes creating early warning systems for heat-waves and floods,strengthening disease surveillanceand systematically collecting health,meteorological, environmental andsocioeconomic data at the local,regional and national levels, andwith adequate time scales.
“If the health sector is to exercise itsstewardship,” suggests Dr RobertoBertollini, Director of the SpecialProgramme on Health andEnvironment of the WHO RegionalOffice for Europe, “it will have towork with other sectors, such asenergy, transport, industry and
agriculture, to advocate ‘healthy’mitigation measures. It will have toinform the public and keep peopleaware of how to avoid the risks offood-, vector- and rodent-borne diseases and allergic disorders. It willhave to learn to collaborate with cli-matologists and land-use and urbanplanners, to prepare communitiesand cities for the growing risksposed by climate change.”
The UN conference in Montrealadopted more than 40 decisions atwhat the acting head of the UNClimate Change Secretariat RichardKinley described as “one of the mostproductive UN Climate ChangeConferences ever”.
Information on the conclusions of theUN conference is available atwww.montreal2005.gc.ca whileinformation on the WHO RegionalOffice for Europe’s work on climatechange and health is available atwww.euro.who.int/globalchange
New health insurance systemcomes into effect in theNetherlandsFrom January 2006, a new insurancesystem for curative healthcare cameinto force in the Netherlands. Underthe new Health Insurance Act(Zorgverzekeringswet), all residentsof the Netherlands are obliged totake out health insurance.
The new system is a private healthinsurance subject to social condi-tions. The system is operated by pri-vate health insurance companies; theinsurers are obliged to accept everyresident in their area of activity. Asystem of risk equalisation enablesthe acceptance obligation and pre-vents direct or indirect risk selection.The insured pay a nominal premiumto the health insurer. Everyone withthe same policy pays the same insurance premium. The HealthInsurance Act also provides for anincome-related contribution to bepaid by the insured. Employers contribute by making a compulsorypayment towards the income-relatedinsurance contribution of theiremployees.
The new health insurance covers astandard package of essential health-
care. The package provides essentialcurative care tested against the crite-ria of demonstrable efficacy, costeffectiveness and the need for collec-tive financing. Prior to 2006, therewere two types of health insurance:obligatory and voluntary.Employees, people entitled to asocial benefit and the self-employedpeople with incomes up to a maxi-mum level were compulsorilyinsured under the Social HealthInsurance Act (Ziekenfondswet).Individuals with higher incomescould choose to opt out of this system and either take out privatehealth insurance or even remainuninsured.
More information on the new systemis available atwww.minvws.nl/en/themes/health-insurance-system/default.asp
Belgium: national health surveyresults publishedBelgium has carried out its thirdnational health survey since 1997covering almost 12,500 respondents.The survey indicates that the overallhealth status of the population hasbeen relatively stable since 1997.23% of respondents complain abouttheir health while 13% report suffer-ing from mental health problems.Smoking is on the decrease, especial-ly among the young, but on theother hand it appears that peopleabove 65 consume too many medica-tions. One worrying result of thesurvey is the emergence of a trendsince 2001 suggesting that the lesswell-off tend to postpone medicalvisits because of cost, with morethan 15% of those interviewed inWallonia and Brussels delaying contact with the health system.
The report is available in French andDutch at www.iph.fgov.be/epidemio/epien/index.htm
Latest Nordic social welfareand health statistics focus onchildrenThe annual publication of the twoNordic committees dealing with sta-tistics on health and social welfare,Nomesko and Nososko, in 2005focused on children and young
people. Few of the overall trends areencouraging, but they help socialpolicy makers better target child andyouth welfare needs.
Overall trends show that in Finlandfewer underweight infants are borneach year compared to other Nordiccountries, Finnish children smokethe most but Danish children use themost drugs and alcohol. The num-bers of children in care haveincreased. Sweden has the lowestmortality rate among 1–17 year olds,13 per 100,000, while in Finland thefigure is 18 per 100,000. Traffic acci-dent deaths and suicides are highestin Finland. Diabetes has increasedamong the young everywhere, withFinland facing the most cases.Asthma and allergies have alsobecome more common in each coun-try, and more 15–19 year olds thanearlier require treatment for mentalhealth problems.
Further information atwww.stm.fi/Resource.phx/publish-ing/documents/5493/index.htx
The Netherlands: report on thestate of health in 2005This report published by theHealthcare Inspectorate (IGZ)assesses the health care system'seffectiveness in addressing popula-tion health issues. It concludes thatboth the health system and the qual-ity of services provided at themunicipal level (which has gainedincreasing responsibility for health)have improved considerably over thepast ten years. The report also concludes, however, that there is stilltoo little focus on preventative careand on tackling emerging healthproblems. These problems includethe growing number of overweightpeople, the increasing risk of largescale epidemics, psychosocial prob-lems amongst the young and theneed to provide basic care to unin-sured and undocumented migrants.The report does however suggestthat the current structure of thehealth care system should be capableof tackling such problems.
Dutch Minister of Public Health,Well-being and Sport, HansHoogervorst, noted that futurehealth policy will focus on stimulat-
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ing further implementation andimproving effectiveness at themunicipal level, while strengtheningthe national level's ability to provideguidance and play a coordinatingrole. An emphasis will also be placedon addressing the weaknesses high-lighted by the report and on improv-ing the quality of municipal healthpolicy.
More information in English can befounds at www.minvws.nl/en
Ireland: Report of the expertgroup on mental health policy Mary Harney, Tánaiste (DeputyPrime Minister) and Minister forHealth and Children and TimO’Malley, Minister of State at theDepartment of Health and Children,on 24 January 2006 launched ‘AVision for Change’, a new nationalpolicy framework for mental healthservices.
The report, which was developed bythe Expert Group on Mental HealthPolicy, is the first comprehensivereview of mental health policy sincePlanning for the Future was pub-lished in 1984. The Expert Group,appointed by Minister O’Malley inAugust 2003, was chaired byProfessor Joyce O’Connor,President of the National College ofIreland, and consisted of 18 widelyexperienced people drawn from arange of backgrounds within themental health services. The reportoutlines an exciting vision of thefuture for mental health services inIreland and sets out a framework foraction to achieve it over the next7–10 years.
It proposes a holistic view of mentalillness and recommends an integrat-ed multidisciplinary approach toaddressing the biological, psycho-logical and social factors that con-tribute to mental health problems. Aperson-centred treatment approachwhich addresses each of these ele-ments through an integrated careplan, reflecting best practice, andmost importantly evolved andagreed with both service users andtheir carers is recommended. “Thiscomprehensive mental health policyframework outlines a set of valuesand principles that will guide both
Government and service providersas we proceed to develop and put inplace a modern high- quality mentalhealth service for our citizens” theTánaiste said.
Substantial additional funding willbe required to finance the implemen-tation of this policy document. Thereport estimates that an additional€21m per annum is needed over thenext seven to ten years for additional1,800 staff. The Tánaiste has confirmed an additional allocation of €25m in the 2006 budget to theHealth Service Executive for mentalhealth services. The report also estimates that nearly €800 million in capital expenditure is required.
The report was preceded by anationwide consultation processdrawing on the experience, perspec-tives and ideas of key stakeholders,interested agencies and concernedindividuals. “The necessity ofinvolving service users and their car-ers in all aspects of service deliverywas a key message and this is thefoundation on which ‘A Vision forChange’ was built” said Minister O’Malley.
‘A Vision for Change’ makes clearrecommendations on how the men-tal health services should be man-aged and organised in the future.These recommendations include theestablishment of a National MentalHealth Service Directorate and thereorganisation of the current MentalHealth Catchment Areas. It also recommends the closure of all theremaining mental hospitals and there-investment of resources realisedas a consequence in the mentalhealth services.
The closure of large mental hospitalsand the move to modern unitsattached to general hospitals, togeth-er with the expansion of communityservices, has been Government poli-cy since the publication of Planningfor the Future in 1984. A number of the large mental hospitals aroundthe country have already closedcompletely.The re-organisation ofservices which these closuresentailed resulted in more communityfacilities, new acute psychiatric unitsin some cases and an overallimprovement for service users, theirfamilies and carers. The remaining
hospitals, of which there are 15 inall, cater in the main for long-staypatients, many of whom are over 65years of age.
The report can be viewed atwww.dohc.ie/publications/pdf/vision_for_change.pdf
Finland: Finnish EU presidencywill seek closer cooperation ondrugsA main theme Finland intends topursue during its stint in the EUpresidency, in the second half of2006, is to intensify cooperationwith the Union’s eastern neighbours– Russia, Belarus, Ukraine andMoldova. This will focus especiallyon drug prevention, tighter borderpolicing to stop drug trafficking andcooperation between police andsocial and health authorities on drugproblems. A specific goal during thepresidency will be to get acceptanceof the EU Council’s resolution onpolice and social and healthcare col-laboration on the treatment of drugusers. During the Finnish presidencyan ‘expert conference’ will be held inTurku on disease prevention inintravenous drug use. Towards theend of the year the EU Commissionwill also hold a conference on drugsfor non-governmental organisations.The basis for the conference will bethe Green Paper handled in the EU’sHorizontal Drugs Group during theFinnish presidency.
UK: Meeting on attractinginvestment to develop newmedicinesOn 9 February 2006 a high levelgroup bringing together governmentministers and top-level representa-tives of the pharmaceutical industry,met in London to discuss how theUK can continue to be a leader inattracting investment to develop newmedicines. The Ministerial IndustryStrategy Group (MISG) discussedthe progress made by the LongTerm Leadership Strategy, whichaims to ensure that the UK remainsan attractive option for the pharma-ceutical industry, and agree howthey might build on progress so far.
The meeting coincides with the publication of The Department of
Health and Association of BritishPharmaceutical Industry (ABPI)Pharmaceutical IndustryCompetitiveness Task Force(PICTF) Competitiveness &Performance Indicators for 2005,which help in monitoring the com-petitiveness of the UK relative to 12other countries as a location for thepharmaceutical industry.
Jane Kennedy, Minister for Healthand co-chair of MISG said “theGovernment wants the UK to main-tain its position as a leading countryfor the pharmaceutical industry todevelop medicines. We see from theTaskforce indicators that the UKattracts 9% of world pharmaceuticalindustry research and developmentexpenditure while it has less than4% of the global market for medi-cines. We want to improve even fur-ther on this. The Strategy has deliv-ered real improvements to date, but Iwould now want it to increase thismomentum so that when MISG nextmeet in November we have concreteproposals that will maintain theUK’s leading position as leaders indeveloping new medicine.”
John Patterson, of AstraZeneca, said:“Historically the industry hasinvested strongly in the UK, and aquarter of the world’s top 100 medi-cines were developed in British labo-ratories. This joint initiative is verytimely, since global competition forresearch, development and manufac-turing are all intensifying and theUK needs to continue to developpositive reasons to do business here.We are therefore very committed tothe success of this exercise, for thebenefit of UK patients and of theeconomy.”
The MISG welcomed the achieve-ments of the Strategy and endorsedthe recommendations for the nextstage of the work that look at:
– Improving the rate at which effective new treatments are madeavailable to NHS patients.
– Facilitating joint workingbetween the NHS and the pharmaceutical industry for thebenefit of patients.
– Building on the high level pharmaceutical meeting heldunder the UK Presidency of the
EU in December 2005, and devel-oping proposals to assist the aimsof the European Commission’sPharmaceutical Forum to makeEurope a more attractive locationfor pharmaceutical companies toinvest.
– Considering new methods forsafe introduction of medicinesand ensuring the safety of medi-cines that are already licensed,whilst maintaining patient accessto innovative medicines.
More information on the MinisterialIndustry Strategy Group can befound atwww.dh.gov.uk/PolicyAndGuidance/MedicinesPharmacyAndIndustry/IndustryBranch/fs/en
Keynote speech on health policy and health economics inGermanyGerman Health Minister UllaSchmidt delivered a keynote speechat the conference, ‘The AmericanModel and Europe: Past–Present–Future’, organised by the FriedrichEbert Foundation, Washington, DC,on 27 January 2006. In a wide rang-ing speech the Minister stated herdesire to see Germany move towardsa mandatory system of health insur-ance. One first step towards this isthe decision of the new FederalGovernment that no one may losetheir insurance coverage. Individualswho have lost their coverage becausethey were unable to pay their premi-ums, are to be given a right to rein-statement.
She also discussed the challenge ofcontaining the rising costs of healthcare expenditure and the futurefunding of the system, believing that“it is indeed, possible to managetrends in health care expenditure andto guarantee high quality health carefor all at affordable prices. The prerequisite, however, is that policy-makers do not allow their goodintentions to be co-opted by lobby-ists”
She touched on current discussionson how insurance contributionsshould be funded in future. At pre-sent health insurance contributionsare charged solely on earned income(or replacement such as pensions),other sources of income are not
taken into account. She noted a difference in perspective between thetwo partners in the coalition govern-ment on this issue, “while theChristian Democrats wish to replacethe income-dependent contributionwith a standard premium (supple-mented by state subsidies for low-wage earners), at least for those per-sons covered by the statutory healthinsurance, we Social Democratswant to maintain income-relatedcontributions. But we want all citizens to pay contributions andcontributions to be paid from allkinds of income.” Both major par-ties agree that reforms are necessaryto stabilise health care financing,ensure that burdens are shared andreduce labour costs to boost thecompetitiveness of the economy.
The minister also spoke of cuttingedge development of the infrastruc-ture “for an electronic health cardthat is to be provided to all people inGermany as early as possible. Thissystem will link 82 million insured,more than 100,000 office-basedphysicians, 22,000 pharmacies, 2,200hospitals and roughly 300 privateand statutory health insurers.Thanks to this card, every physician– anywhere in Germany – will haveeasy access to the health details oftheir patients and be able to avoidtreatment errors.”
The Minister discussed reimburse-ment and coverage issues and high-lighted the participation of patientand consumer organisations in thedecision-making process. She statedthat “this has considerably improvedthe transparency of and the culturesurrounding the decision-makingprocess. Informed patients whomanage their own health are indis-pensable partners in a modern healthcare system.” She concluded byannouncing that new proposals thatwill contribute to a more economicalprovision of drugs, liberalisation ofmedical professional activity and theorganisation of the health care sys-tem, and a reorganisation of financ-ing would be brought forward in thecoming weeks and months.
The full text of the Minister’s speechcan be accessed atwww.bmg.bund.de/cln_041/nn_617014/EN/Health/health-policy,param=.html
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2006: European Year ofWorker’s Mobility 2006 is ‘European Year of Workers'Mobility’. Two key objectives are toraise awareness and exchange goodpractice on mobility and its benefits.
http://europa.eu.int/comm/employment_social/workersmobility2006/index_en.htm
New work for EU bodyThe European Foundation for theImprovement of Living andWorking Conditions has announcedits work programme for 2006. Thisfocuses on job creation, mobility,better working conditions andwork–life balance
More information at www.eurofound.ie/press/releases/2006/060118.htm
EU Environment Agency reporton Environment and Health The European Environment Agencyhas recently published a new reportenvironment and health.
http://reports.eea.eu.int/eea_report_2005_10/en
Our health, our care, our say:A new direction for communityservicesA new White Paper published onJanuary 30 2006 proposes to makeNHS care in England more accessi-ble by shifting services from hospi-tals into the community. The WhitePaper could see specialisms such asear, nose and throat and dermatol-ogy carried out in new communityhospitals and GP surgeries. The GPmarket could also be opened to theprivate and voluntary sector to helpfill gaps in under-doctored areas. Intotal medical work worth £4billion ayear could be diverted from hospitaloutpatient departments in Englandinto NHS and private units closer topeople's homes.
The paper can be accessed atwww.dh.gov.uk/assetRoot/04/12/74/59/04127459.pdf
What is the evidence on effec-tiveness of empowerment toimprove health?A new report from the HealthEvidence Network authored byNina Wallerstein from theUniversity of New Mexico showsthat empowering socially excludedpopulations is a viable strategy forimproving health. While participato-ry processes make up the base ofempowerment, strategies must alsobuild community organisations’ andindividuals’ capacity to participate indecision making and advocacy.
More information atwww.who.dk/eprise/main/WHO/Progs/HEN/Syntheses/empowerment/20060119_10
New EC Roma websiteThe European Commission haslaunched a new website dedicated tothe Roma. It aims to provide infor-mation on the EU's activities in sup-port of the Roma, gypsy and trav-eller communities across Europe.The site does not contain informa-tion on health but contains a sectionon how the EU intends to promotethe social inclusion of the Romapopulation (via the European SocialFund, Equal Initiative, theCommunity Programme for SocialInclusion).
http://europa.eu.int/comm/employment_social/fundamental_rights/roma/rfund/rempl_en.htm
A new framework for coordina-tion of social protection andinclusion policies The EC has launched a communica-tion setting new objectives to theOpen Method of Coordination onsocial protection and social inclu-sion. These new common objectivesreflect the lesson from the analysis ofthe 2005 implementation NationalAction Plans (NAPs) for inclusionthat inclusion objectives need to bemainstreamed into relevant publicpolicies, including structural fundprogrammes and education andtraining policies. Specific objectivesinclude provision of sustainable pen-
sions and ensuring access to highquality and sustainable health andlong term care.
More information athttp://europa.eu.int/comm/employment_social/emplweb/news/news_en.cfm?id=110
Global plan to stop TB 2006 –2015The Global Plan to Stop TB 2006-2015, Actions for Life was launchedat the World Economic Forum inDavos, Switzerland, on 27 January.“The burden of suffering and eco-nomic loss caused by tuberculosis isan affront to our conscience. TB is acurable and preventable disease.Urgent action is necessary to scaleup our efforts to Stop TB”, theGlobal Plan states. WHO Europehas declared a TB emergency in theEastern part of the Region. Action isunderway with discussion amongMember States, donors and counter-parts to set up resources and a timelyintervention.
More information atwww.who.int/tb/en
European Health InsuranceCard now in force Since 1 January 2006, the old E111forms have been replaced by the newcredit-card sized European HealthInsurance Card. The card containsno medical information on the indi-vidual covered but will entitle theholder to free or reduced cost healthtreatment as if they were a residentof the country they are visiting. Itdoes not apply if the main purposeof any trip is to seek medical atten-tion.
http://europa.eu.int/comm/employment_social/healthcard/index_en.htm
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EuroHealthNet6 Philippe Le Bon, Brussels.Tel: + 32 2 235 03 20.Fax: + 32 2 235 03 39Email: [email protected]
News in Brief
ISSN 1356-1030
Rt Hon Patricia Hewitt, Secretary of State Department of Health, UKMr Markos Kyprianou, EU Commissioner for Health and Consumer ProtectionMs Rosie Winterton, Minister of State for Health Services, UKMrs Maria Rauch-Kallat, Minister of Health, AustriaMr Hans Hoogervorst, Minister of Health, Welfare and Sport, NetherlandsMrs Ylva Johansson, Minister for Health and Elderly Care, SwedenDr Pawel Sztwiertnia, Under Secretary of State, Ministry of Health, PolandMs Liisa Hyss�l�, Minister of Health and Social Services, FinlandDr Radoslav Gaydarski, Minister of Health, BulgariaProf Ant�nio Correia de Campos, Minister of Health, PortugalMr Neven Ljubicic, Minister of Health and Social Welfare, CroatiaMr Rudy De Motte, Minister of Social Affairs, Public Health and the Environment, BelgiumMr Xavier Bertrand, Minister for Health and Solidarity, FranceMr George Konstantopoulos, Deputy Minister, Health and Social Solidarity, GreeceDr Vlad Anton Iliescu, Secretary of State for European Integration, RomaniaMr Andreas Gavrielides, Minister of Health, CyprusMr Peeter Laasik, Deputy Minister, EstoniaMr Andrej Bru�an, Minister of Health, SloveniaDr Klaus Theo Schr�der, State Secretary Federal Ministry of Health andSocial Security, GermanyMrs Katerina Ciharov�, Czech RepublicDr Alexandra Novotna, State Secretary of Health, SlovakiaMr G�bor Kap�cs, Deputy State Secretary for Health Policy, HungaryDr Sabhattin Aydin, Deputy Under Secretary, TurkeyMrs Mary Harney, Minister for Health and Children, IrelandMr Gundars B�rzins, Minister for Health, LatviaProfessor Zilvinas Padaiga, Minister of Health, LithuaniaMr Mars di Bartolomeo, Minister of Health and Social Security, LuxembourgHon Francesco Storace, Minister of Health, ItalyMr Lars L¿kke Rasmussen, Minister for the Interior and for Health, DenmarkMs Elena Salgado, Minister of Health and Consumer Affairs, SpainThe Hon Dr Louis Deguara, Minister of Health and Elderly Care, Malta
