13.5. Demands on healthcare services

Population ageing is an aggregate mark of human success in improving living conditions and curbing risks of death through innovations in public health and medicine as well as through the adoption of more effective policies. However, an increased longevity leads to changing patterns of mortality, morbidity and disability. The elderly suffer more often from chronic and degenerative illnesses and are at a higher risk of suffering from multiple co-morbidities and experiencing limitations in performing daily life activities compared to the younger population. Chronic diseases may contribute to the gradual loss of senses such as sight and hearing, to impaired mobility, increased risks of falls and fractures and disability in performing daily life activities. Quantitative research on the determinants of healthy ageing is needed to understand the mechanisms through which factors that may increase the quality of life in the elderly operate and to plan and evaluate interventions aimed at preventing the avoidable decline in quality of life as well as to cure and rehabilitate unhealthy old individuals. This field of research remains underdeveloped and the available investigations suffer from methodological limitations, namely lack of data comparability. Age-related mental illnesses, especially dementia, are particularly difficult to cope with. Dementia is a condition of irreversible decline in cognition, functioning and behaviour. Alzheimer’s disease accounts for approximately 60-70% of dementia cases. The primary risk factor for dementia is age, with the prevalence doubling for every 5-year age group after the age of 65 and reaching up to 39 percent after age 90. Chronic diseases are a heavy burden on older adults due to associated long-term illness, diminished quality of life and increased health care costs. Although the risk of disease and disability clearly increases with advancing age, poor health is not an inevitable consequence of ageing. Despite the overall progress in life expectancy, new and re-emerging health threats may potentially reverse this progress. Mortality reversals have e.g. occurred in Eastern Europe. A deteriorating health system combined with the hardships of the transition to a market economy has hampered the fight against adult cardiovascular disease, alcohol and tobacco related mortality, and drug resistant tuberculosis. The rapid spread of obesity and diabetes may also potentially reduce life expectancy gains. Care-giving responsibilities put a heavy burden on societies. Patterns of care-giving have been changing as the numbers of younger family members available to provide care has been shrinking and women, who traditionally are the main family caregivers, increasingly participate in the labour force. Spouses are still the main caregivers for both men and women. Because of the sex differential in longevity, however, women are more likely than men to find themselves without a spouse and to be living alone when they need care.

Insufficient preparedness for the needs of an ageing population on the part of health and social service providers is the major challenge confronting societies at all levels of development. European countries intensively debate how to fund generous pensions and health programs as there are fewer working-age adults to support the elderly. Additional concerns about the quality and cost of institutional care are garnering attention in many countries. However, while it is true that disability rates are higher among the elderly, population ageing is not necessarily associated with peaks in demand for health care services. As the recent generations of elderly are, on average, better educated and have a better track record in terms of regular employment, higher income levels and, consequently, access to national health care systems much more sensitive to their needs than in the past, it is reasonable to assume that demand for health care services will rise at a slower pace than the population ageing rate. The findings of an OECD survey in a group of countries point to a decline in disability rates especially in the 65-80 age bracket, with a more sustained decline for men than for women (Jacobzone, 1999).

EU Member States have realised the need to look at long term care as a new social risk to be covered by social protection and are committed to ensuring near universal access. While some differences in provision are inevitable, the individuals’ ability to pay or the share of private sources of financing must not hinder accessibility to high quality services. Despite the recognised need, current supply does not necessarily translate into a comprehensive and universal framework for long term care provision. Member States are striving to ensure a sustainable mix between public and private sources of finance. Measures include changes in the financing mechanisms, but secure financing of long-term care is yet to be achieved in many countries. A preventative approach to the health status of the elderly could help alleviate the burden. The same applies to long term care. Policy measures that can reduce disability and favour home care rather than in institutions, can have a large impact on public spending. While age itself is not the causal factor of health care spending (but rather the health condition of a person), the existing projections illustrate that the pure effect of an ageing population would put heavy pressure for increased public spending unless the above-mentioned initiatives are adopted in due time and in a successful manner (EPC, 2006).

Provision tailored to the dependent person in a residential or community setting is the preferred alternative to institutional care. Support for informal carers and exploiting new technology can help people to stay as long as possible in their own homes. The ESFs will be used to promote de-institutionalisation and reinforce community-based services. Stronger coordination between healthcare and social services is seen as crucial for achieving an adequate continuum of care, enabling a high level of quality and efficient use of resources in the provision of long-term care services in an institutional or community setting. To ensure a high level of quality, measures include uniform standards and quality accreditation mechanism coupled with legally enforced evaluation methods.

An increased demand on health care services will derive from the need for overcoming current inequalities in access to high quality care reflecting recent technological progress. This is considered as one of the main cause for significant differences in life expectancy observed among groups with different socio-economic status. Member States should be strengthening policies to reduce these inequalities, e.g. by: addressing risk factors through health promotion; reducing the prevalence and incidence of certain diseases; and ensuring more effective prevention activities in various settings (at home, school, work). Also important are steps to increase population coverage, address financial barriers to care, emphasize promotion and prevention activities over curative care and address cultural barriers to the use of services. The structural funds should be used to support reform and capacity building mainly, to improve access and develop human resources. A combination of general policies and those tailored to lower socio-economic groups is needed. Virtually, all Member States have implemented universal or almost universal rights to care and have adapted services to reach those who have difficulty in accessing conventional services due to physical or mental disability or to linguistic or cultural differences. However, only a few countries have begun to address health inequalities systematically and comprehensively by reducing social differences, preventing the ensuing health differences or addressing the resulting poor health. This would ensure in practice equal access for equal needs.

Moreover, adequacy of current health services in Member States for coping with different diseases is uneven. The data reported in this Report provide a help in identifying sectors in which significant improvements would be needed (e.g. schizophrenia and transplants).

The importance of well-performing health systems in a context of demographic and epidemiological change, widening socio-economic inequalities, limited resources, technological developments and increasing demands for health and healthcare has been reaffirmed by the WHO European Ministerial Conference on Health Systems “Health Systems. Health and Wealth” held in Tallinn (Estonia) on 25-27 June 2008. With the Tallinn Charter (http://www.euro.who.int/document/E91438.pdf), the Member States of the WHO European Region commit themselves to promote shared values of solidarity, equity and participation; invest in health systems and foster investment across sectors that influence health; promote transparency and be accountable; make health systems more responsive; engage stakeholders; foster cross-country learning and cooperation; ensure that health systems are prepared and able to respond to crises.

Although the fundamental responsibility for ensuring universal access to high-quality care, funded through solidarity, lies with the Member States, there is a European dimension to these issues. Successive rulings from the European Court of Justice established the rights of patients to seek healthcare in other countries and be reimbursed under certain conditions, in line with their national health insurance coverage. Prior authorisation can only be required for hospital treatment abroad and must be given and, if not motivated, within a reasonable time frame. In 2003, the Commission invited all EU Health Ministers, a representative of the European Parliament and 6 European NGOs representing civil society, including European doctors and patients, to engage in a high level reflection process on patient mobility and healthcare developments in the European Union. Their report made nineteen recommendations across five main areas and represented a political milestone by recognising the potential value of European cooperation in helping Member States to achieve their healthcare objectives. In April 2004, the Commission set out its response to the report of the reflection process in two communications, making proposals for European co-operation and extending the open method of coordination on healthcare and long-term care. These activities have been taken forward through the new High Level Group on Health Services and Medical Care established in July 2004, with regular reports to the Council, in several areas:

·         cross-border healthcare purchasing and provision and patients’ rights and responsibilities;

·         health professionals (continuing development and migration within the EU);

·         centres of reference, that could pool resources, for example on tackling rare diseases;

·         health technology assessment, with a network supported by the public health programme;

·         e-health, and information strategies for health services;

·         hospital performances (waiting time and nosocomial diseases); and

·         patient safety.

An improved co-operation at EU level among national health services could provide a tremendous benefit to improve their ability to meet healthcare demands of citizens. Therefore, the results of on-going attempts to this end are of paramount importance.