Sociedades científicas publicam guidelines éticas, face a pandemia COVID-19 – Itália e Espanha

O Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) publicou guidelines dos critérios que devem ser seguidos em circunstâncias extraordinárias.

Decisioni eticamente fondate per il trattamento dei pazienti affetti da insufficienza respiratoria grave secondaria a infezione da COVID-19

Il Documento in questione – Decisioni eticamente fondate per il trattamento dei pazienti affetti da insufficienza respiratoria grave secondaria a infezione da Covid-19 – riprende, conferma e divulga le nostre Raccomandazioni di etica clinica per l’ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili.

 The document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.” The principle they settle upon is utilitarian. “Informed by the principle of maximizing benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.” The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: “It may become necessary to establish an age limit for access to intensive care.” Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.” In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.” (The Atlantic)

Em Espanha, a Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) publicou recomendações

RECOMENDACIONES ÉTICAS PARA LA TOMADE DECISIONES EN LA SITUACIÓN EXCEPCIONAL DE CRISIS POR PANDEMIA COVID-19 EN LAS UNIDADES DECUIDADOS INTENSIVOS.(SEMICYUC)

Los objetivos principales de estas recomendaciones, en conclusión, son: 1-Apoyar a los profesionales en la toma de decisiones difíciles, facilitando criterios colegiados que permitan compartir la responsabilidad en situaciones que implican una gran carga emocional. 2-. Explicitar unos criterios de idoneidad de asignación de recursosen una situación de excepcionalidad y escasez.

Ante situaciones de crisis como la que vive España con la enfermedad Covid-19 y en un contexto de recursos limitados, las personas con más posibilidades de sobrevivir deben tener prioridad para ser ingresadas en las unidades de cuidados intensivos (UCI). «Admitir un ingreso puede implicar denegar otro a otra persona que puede beneficiarse más, de forma que hay que evitar el criterio primero en llegar, primero en ingresar».

Así reza literalmente el documento de recomendaciones UCI y Covid-19 que ha elaborado el Grupo de Trabajo de Bioética de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (Semicyuc) y cuyo contenido han consensuado con la Sociedad Española de Medicina Interna (SEMI). En suma, las sociedades médicas que representan a internistas e intensivistas, dos de los especialistas que están en primera línea de combate en la lucha contra la infección.

La limitación de recursos en una situación de pandemia como la actual obliga, según intensivistas e internistas, a «consensuar una serie de criterios técnicos y éticos comunes», y el primero que plantean es que el ingreso en UCI se base en «maximizar el beneficio común. Ante pacientes críticos con patologías críticas diferentes de la infección por Covid-19, se debe valorar ingresar prioritariamente al que más se beneficie». (El Mundo)

#FicaEmCasa – STOP COVID-19

13 de março. Aprovadas medidas extraordinárias e de caráter urgente de resposta à situação epidemiológica do novo Coronavírus.

“O novo coronavírus, designado SARS-CoV-2, foi identificado pela primeira vez em dezembro de 2019 na China, na cidade de Wuhan. Este novo agente nunca tinha sido identificado anteriormente em seres humanos. A fonte da infeção é ainda desconhecida.”

A COVID-19 transmite-se por contacto próximo com pessoas infetadas pelo vírus, ou superfícies e objetos contaminados.

Estima-se que o período de incubação da doença (tempo decorrido desde a exposição ao vírus até ao aparecimento de sintomas) seja entre 2 e 14 dias. A transmissão por pessoas assintomáticas ainda está a ser investigada.

A Organização Mundial da Saúde recomenda medidas de higiene e etiqueta respiratória para reduzir a exposição e transmissão da doença:
• Medidas de etiqueta respiratória: tapar o nariz e a boca quando espirrar ou tossir, com um lenço de papel ou com o antebraço, nunca com as mãos, e deitar sempre o lenço de papel no lixo;
• Lavar as mãos frequentemente. Deve lavá-las sempre que se assoar, espirrar, tossir ou após contacto direto com pessoas doentes. Deve lavá-las durante 20 segundos (o tempo que demora a cantar os “Parabéns”) com água e sabão ou com solução à base de álcool a 70%;
• Evitar contacto próximo com pessoas com infeção respiratória;
• Evitar tocar na cara com as mãos;
• Evitar partilhar objetos pessoais ou comida em que tenha tocado.

As pessoas que correm maior risco de doença grave por COVID-19 são os idosos e pessoas com doenças crónicas (ex: doenças cardíacas, diabetes e doenças pulmonares). A maioria das pessoas infetadas apresentam sintomas de infeção respiratória aguda ligeiros a moderados:
• Febre (T>37,5ºC)
• Tosse
• Dificuldade respiratória (Falta de ar)

Portanto, façam o favor de ficar em casa, lavar as mãos, cumprir as regras de distanciamento social e da etiqueta respiratória. Escolhas de consciência cívica.

 

Tools and methodologies to assess efficiency of health care services in Europe, 2019

“In a context of rising health care costs driven principally by the increasing prevalence of chronic conditions, ageing populations and the high costs associated with technological advances in medicine, health care systems in Europe are nowadays facing the intricate challenge of delivering accessible, equitable and high-quality care while ensuring the sustainability of public finances.
At the same time, there is emerging consensus among policymakers and researchers that a significant share of current health care spending in modern health systems could be reallocated to better use
without undermining access and quality of care. As a result, European governments are increasingly interested in capturing opportunities to extract additional value from available resources, and increase the efficiency of their health care systems to tackle this twofold challenge.
Yet while the idea of efficiency in this context – that is, how well a health care system uses its resources (input) to improve population health (outcome) – is simple to understand, several methodological questions remain on how to correctly identify inefficiencies within health care systems and devise corrective interventions without unintended consequences on access or quality of care.
The relationship between health system inputs and health outcomes is complex and influenced by several factors that are typically outside of the control of the health system, which makes it difficult to measure the effect of specific care interventions on health outcomes and perform fair comparative
assessments across entities. Together with considerable data limitations affecting analysts’ capacity to capture the performance of different segments of the ‘health production process’, assessing health care efficiency becomes a very complex endeavour in practice.
In light of these difficulties, specifying a set of appropriate instruments to analyse, measure
and assess efficiency of care (as well as spelling out their limitations) is a precondition for policymakers to design and implement interventions that can effectively make use of the ample potential to increase
efficiency mentioned above.
In support of this undertaking, among its activities over the course of 2018 the Expert Group on Health Systems Performance Assessment (HSPA) produced this report on tools and methodologies to assess efficiency of care. The report sets out to explore the most recent theory and observed practice of
health care efficiency measurement and assessment across European countries, in view of discovering what opportunities exist for European countries to improve their tools and methods to measure and assess efficiency of care, and to make better use of efficiency information for policy formation.”

executive summary

 

Relatório da Primavera, OPSS, 2019

O Observatório dos Sistemas de Saúde destacou assimetrias nos cuidados de saúde primários, falta de planeamento no combate à SIDA e falta de investimento na saúde mental.”O que ficou para memória futura é manifestamente pouco, face às expectativas geradas“, conclui-se. “As preocupações e orientações políticas resultaram numa ação dominada pela procura da sustentação financeira do SNS no imediato, sem se poder centrar na sustentabilidade técnica, estrutural, humana e financeira do SNS, a longo prazo.”

O Relatório de Primavera 2019, cujo “papel é sobretudo pedagógico”, vem demonstrar que, apesar de existir uma visível evolução dos indicadores de saúde do país, existem ainda algumas interrogações sobre a capacidade de resposta aos desafios presentes e futuros na área da saúde em Portugal. “Existem aspetos positivos e negativos. Nós fizemos a apresentação com o cuidado de qualquer que fosse o tópico, apresentar os resultados de forma neutra. O Observatório não tem opinião. Quisemos marcar um conjunto de aspetos positivos, que devem ser marcados, e aspetos nega que devem ser combatidos”.

Relatório da Primavera, OPSS, 2019

Começando por formular o direito humano,

explicitam-se as componentes – “sempre que falamos em universalidade em saúde, estamos a referir três componentes inter-relacionadas: 1. A cobertura da população;  2. O leque de serviços disponíveis; 3. A extensão da proteção financeira relativamente aos custos dos serviços de saúde.É intuitivo deduzir-se que a universalidade melhora os resultados em saúde, pois assim as pessoas têm mais acesso aos cuidados quando deles necessitam.Este conceito inclui aspetos como o acesso aos serviços de saúde e aos medicamentos, à informação necessária, à manutenção de um equilíbrio físico e mental saudável, a ações de promoção em saúde individuais ou coletivas, e outras políticas públicas que lidam com os determinantes em saúde. O financiamento é vital pois todas as outras funções do sistema de saú-de dependem de um financiamento adequado e sustentável. As restantes componentes relevantes são: a) a formação, o desenvolvimento e a retenção dos recursos humanos e o reconhecimento das novas categorias profissionais; b) as estratégias para um acesso universal dos medicamentos, vacinas e tecnologias; c) um sistema de informação efetivo; d) mecanismos para a governança, prestação de contas e liderança.

Sendo os sistemas de saúde muito complexos em termos demográficos, económicos, legais e regulatórios, epidemiológicos, tecnológicos, socioculturais e políticos, uma melhoria no sentido de uma destas áreas reflete-se necessariamente numa melhoria global da universalidade da cobertura. Espera-se, assim, que os governos reforcem estas componentes do sistema de saúde para tornarem possível atingirem os seus objetivos e proporcionarem uma prestação de alta qualidade. Em termos económicos, não defender a universalidade do acesso, mais que um ato ideológico, seria um grave erro económico” (p. 15)

os capítulos debruçam-se sobre

a governação em saúde,

a reforma dos Cuidados de Saúde Primários,

Infeção VIH: o que estará para mudar,

Saúde Mental em Portugal,

e despesas com o medicamento.

Das conclusões, transcrevemos uns excertos:

Este ano mais uma vez o RP coincide com o fim de um ciclo legislativo. Um balanço sobre a atividade governativa do setor impôs-se desde logo. Foi realizado por três visões politica-mente engajadas e assumidas. Delas, ressalta o tempo perdido em reformas que se impunham e ficaram mais uma vez por concretizar.

Sobre a Lei de Bases da Saúde, os constantes avanços e recuos estratégicos traduziram-se na aparente incapacidade de promover consensos para a sua aprovação nesta legislatura. Salientou-se que as preocupações e orientações políticas resultaram numa ação dominada pela procura da sustentação financeira do SNS no imediato, sem se poder centrar na sustentabilidade técnica, estrutural, humana e financeira do SNS, a longo prazo.

Repensar o SNS é defendido como uma obrigação e defende-se que o seu principal problema e o seu desafio primordial, são os profissionais de saúde. Afirma-se a necessidade de remunerar a qualidade, recompensar as boas práticas e valorizar e reconhecer o trabalho diferenciado. A qualificação dos recursos humanos, a sua satisfação, a clara definição das carreiras profissionais e remunerações adequadas, a par do trabalho de equipa, da skill mix da força de trabalho, da regulação do pluriemprego, de ambientes de trabalho saudável e do planeamento e informação sobre RHS, são fatores essenciais para a boa governação em saúde.

Partindo dessa análise minuciosa, os autores apelam à necessidade de um novo impulso na reforma dos Cuidados de Saúde Primários dirigido essencialmente para um novo modelo de contratualização assente nas seguintes recomendações:

• Garantir que todas unidades funcionais usufruam de condições de trabalho essenciais de qualidade (estruturais, meios humanos, autonomia de gestão dum orçamento local base), de segurança e justas, de forma a responder às necessidades da população pela qual são responsáveis.

• Manter o foco sobre a melhoria continua de qualidade, com construção de indicadores complexos, num processo de revisão dinâmico para incluir novos indicadores, apoiando estratégias e políticas que respondam às necessidades reais (grande impacto sobre a qualidade de vida das pessoas e das suas famílias), embora menos mediatizadas.

• Tornar as unidades mais eficientes na utilização dos recursos, através de medidas de fomento à cooperação e inclusão de outras profissões de saúde, em complementaridade de funções.

• Refletir as especificidades organizacionais de cada unidade (e.g., conferir grau de auto-nomia que permita adequar-se às necessidades da população que servem).

• Repensar os cuidados aos utentes sem equipa de saúde, para não agravar as desigualdades em saúde desta população, nem prejudicar o desempenho das unidades funcionais afetas.

O capítulo dedicado ao HIV: O que estará para mudara prevenção permanece um desafio fundamental e que é reduzida a cobertura de prevenção no território nacional, quer no que concerne às populações-chave quer a que se dirige à população geral. Também se desconhece quanto se investe no país em promoção da saúde e prevenção dirigida à infeção VIH. Em termos de diagnóstico, estima-se que em Portugal existam mais de 3000 casos por diagnosticar, o que pode representar um dos números de casos por diagnosticar por 100 000 habitantes mais elevado entre os países da Europa Ocidental.

No capítulo sobre as Políticas de Saúde Mental, o parente pobre da saúde em Portugal, apresentou-se o traçado histórico da sua evolução e da produção legislativa associada e destacou-se o facto de o sistema de saúde mental em Portugal sempre ter permanecido atrasado em comparação com a evolução da psiquiatria europeia, no que diz respeito ao diagnóstico, tratamento e acompanhamento da doença mental. O mesmo tem acontecido com a aplicação das recomendações internacionais (nomeadamente o modelo da comunidade) que nunca foram conseguidas de forma rápida e completa, fruto da uma orientação  política sempre sustentada em preocupações de cariz economicista, que não confere dignidade a estes cidadãos. Salientou-se nunca ter existido um compromisso político em investir nesta área, com recursos que permitam melhorar a qualidade de vida do portador de perturbação mental. Da mesma forma, a importante função de cuidadores, que normalmente recai sobre as famílias, não é devidamente reconhecida, exigindo-lhes esforços suplementares económicos, físicos e mentais apesar de, para o Estado, as famílias representam um importante recurso económico.

A análise realizada deu origem às seguintes recomendações:

• Priorizar as questões organizacionais e políticas, que têm sido o maior entrave no desenvolvimento deste plano;

• Criar uma equipa de coordenação para a efetiva implementação do PNSM;

• Alterar o modelo de gestão e organizacional dos atuais serviços de saúde mental;

• Desenvolver/repensar um novo modelo de pagamento destes serviços;

• Criar uma carteira de serviços mínimos de prestação de cuidados, para diminuir as assimetrias territoriais a nível nacional.

No capítulo do Medicamento recomenda-se:

• A prossecução de uma política sustentável que concilie rigor orçamental e inovação e que reforce o papel central dos processos de avaliação e de decisão de financiamento público das tecnologias da saúde em Portugal, que não só o medicamento;

• Perspetivar uma regulação mais eficiente, com instrumentos e incentivos apropriados aos agentes, bem como sistemas de informação eficazes, que potenciem o combate ao desperdício e à fraude, e que promovam a monitorização de resultados em saúde;

• Reforçar a equidade no acesso e a qualidade dos serviços prestados, numa perspetiva de proximidade aos cidadãos e coesão territorial, reconhecendo as sinergias necessárias entre os diversos níveis de cuidados e agentes do sistema.

Considera-se ainda que os cidadãos portugueses têm direito a obter maior transparência nestes processos, com aumento de eficiência dos procedimentos de decisão, disponibilização de um leque alargado de instrumentos de análise, previsão e construção de um sistema jus-to, sustentável e capaz de dar resposta a necessidades terapêuticas, face a avanços tecnológicos significativos e a custos associados que colocam em questão modelos tradicionais de decisão.Perante o quadro de análise realizado e no âmbito das decisões a implementar nesta área devem-se considerar três determinantes major: o quadro europeu, o quadro institucional por-tuguês (incluindo a sustentabilidade financeira do SNS) e a transparência e eficiência dos procedimentos.

Ao longo dos 19 anos da sua existência o RP enumerou anualmente um conjunto de recomendações à tutela sobre cada um dos temas analisados. A realização do follow-up dessas recomendações é uma medida simples e que se impõe. Este ano, por constrangimentos internos ao próprio OPSS não foi possível concretizar este acompanhamento. Nos próximos anos o RP passará a contar na sua edição com o follow-up das recomendações efetuadas à tutela no ano anterior. Este devia ser um trabalho do interesse do próprio MS, mas claramente já se percebeu o desinteresse dos decisores que parecem não olhar sequer para propostas/recomendações concretas que anualmente são enunciadas pelos diferentes colaboradores do RP.

França: reembolso da homeopatia 126,8 milhões de euros em 2018

O debate em França já ia longo, pelo menos com polémica pública desde 2018, com a posição da Ordem dos Médicos e, já este ano, da Academia nacional de Medicina e Academia nacional de Farmácia assim como as posições públicas e a questão da comparticipação pelo Estado.

L’an dernier, le remboursement de l’homéopathie a représenté 126,8 millions d’euros sur un total d’environ 20 milliards pour l’ensemble des médicaments remboursés, selon l’Assurance maladie – afirmou o Parismatch

La Haute Autorité de Santé (HAS) a été saisie par le ministère des Solidarités et de la Santé pour évaluer le bien-fondé du remboursement des médicaments homéopathiques.

França deixa de comparticipar medicamentos homeopáticos. Razão: falta-lhes “eficácia”. Não demonstram “eficácia científica suficiente para justificarem comparticipação”. Corte será faseado e terá início em Janeiro de 2020.

Lida a notícia do Público e do Independent, – France to abolish state funding for homeopathic medicines, saying they are no better than ‘placebo’ – France will end funding for homeopathic remedies through its state health system from 2021 after the government acknowledged the remedies are no better than a placebo. It could be a serious blow for the alternative remedies in the country, which are often sold in pharmacists alongside evidence-backed medicine and prescribed by doctors. French social security payments for homeopathic remedies topped €126.8m in 2018, according to official figures, despite most being almost entirely water.

fui à procura do comunicado conjunto “L’homéopathie en France : position de l’Académie nationale de médecine et de l’Académie nationale de pharmacie” datado de março de 2019.

L’Académie nationale de médecine et l’Académie nationale de pharmacie

• estiment dans ces conditions :

* qu’il n’est pas contraire à l’éthique ni aux bonnes pratiques d’user de préparations homéopathiques, dans les situations où l’emploi d’une thérapie complémentaire est souhaitée, à condition que celle-ci n’induise pas une perte de chance en retardant la procédure diagnostique et/ou l’établissement d’un traitement reconnu efficace, sous condition que le médecin soit conscient qu’il use d’un placebo avec attente ;

* qu’il n’est pas acceptable d’user de l’homéopathie comme une “médecine alternative” dans les autres situations.

• confirment oqu’aucun diplôme universitaire d’homéopathie ne doit être délivré par les facultés de médecine ni par les facultés de pharmacie ;”

Será gradual, de acordo com a ministra francesa,dos 30% atuais para 15% em 2020 e 0% em 2021.

Buzyn said she took full responsibility for a measure that might prove unpopular, and denied that the primary aim of the plan was to save €127 million in social security payouts. She estimated that some 7 million French people, or just over 1% of the population, had used homeopathic drugs in 2018.

(imagem d’aqui)

“A false economy” – Council of Deans of Health, UK

É muito interessante que o «Council of Deans of Health» (“the voice of UK university  faculties for nursing, midwifery and the allied health professions“) tenha tomado uma posição sobre os cortes de financiamento na formação de enfermeiros, parteiras e outros profissionais de saúde. É de 2016 e ainda vale a pena ler. Porque em matéria de formação de profissionais de saúde cortar financiamento e embaretecer custam caro (ou como diz o adágio, «o barato sai caro»).

A false economy.  Cuts to Continuing Professional Development funding for nursing, midwifery and the Allied Professions in England

This report focuses on the impact of funding cuts across England to ongoing education and training for nurses, midwives and allied health professionals (AHPs) and the risks this poses to the NHS.

The scale of the cuts
For 2016/17 this funding in England has been the subject of deep cuts, often without much warning and with little evidence of strategic planning at national level. These cuts will have a material impact both on universities and on the NHS and its workforce. There is little in the public domain that sets out the extent of the cuts and almost no policy discussion of the potential consequences, either for the NHS or the higher education sector. However, these cuts could undermine the NHS in achieving its own strategic objectives, as set out in the Five Year Forward View (NHS, October 2014) and the General Practice Forward View (NHS, April 2016) because CPD is vital to equip staff with the knowledge, skills and values required by the huge transformation programmes currently taking place in the NHS.
The cuts are also already damaging mentorship preparation for NHS staff in some areas, courses which are crucial to delivering the pre-registration programmes for nursing, midwifery and AHPs that the Government wants to expand in England. Every student spends a substantial part of their course in practice placements, so mentors and practice educators are essential to support students during their practice placements.
These reductions in mentorship training for qualified staff put at risk the Government’s ambition to increase nursing, midwifery and allied health pre-registration places during the current Parliament due to the possibility that there will be too few mentors available to support practice placements in pre-registration education.” (p. 7)

“Impact on NHS staff and service delivery
Although these cuts impact on universities, the most significant impact is on the NHS workforce and the NHS’s ability to meet its own objectives.
Nurses, midwives and AHPs make up around 75% of the NHS clinical workforce. Although policy attention is often focused on the future workforce, most of the health professionals that will be in the workforce in 20 years are already there. Given this, and the profound changes that are expected to nursing, midwifery and AHP roles as demand for services grows and patient needs and service configurations change, CPD is vital. CPD is equally important for sustaining services that are core to the NHS, such as accident and emergency and intensive care, where specialist training is required for staff to be able to deliver the care that patients require.” (p12)

General impact on the HE sector
In the regions where LETBs have cut their CPD budgets for 2016-2017, the likely short term and medium term impact of the cuts on the higher education sector vary. In some cases the immediate impact on universities will be relatively minor because they either have comparatively small CPD contracts or have gained new commissions from trusts which balance out the impact of the cuts to their LBR budgets.
However, a number of the institutions with large CPD offers report that the cuts are going to have a substantial impact on their staffing and the scale and scope of their CPD provision.
Downsizing also remains a possibility in institutions operating in regions where trusts have yet to complete their commissioning of CPD. All of the institutions that participated in this study indicated that they had been told there were further plans for additional significant cuts to follow in 2017-2018 and beyond that would have a significant impact on their ability to deliver CPD.
The situation is made worse in some cases by the reluctance of some trusts to release staff for CPD. Some institutions are considering the possibility of pulling out of CPD altogether (apart from mentorship courses) and concentrating on pre-registration education and, in one case, focusing more on private and business and enterprise led CPD.” (p. 15)

6. What to do next
6.1. Recognise the current gap between national strategic priorities and funding decisions
The first step is for Government to acknowledge that national strategic priorities and funding decisions on CPD are at odds with each other. A clear message from universities is that if Government does not recognise and deal with the stark disparity between what is expected of the workforce in the Five Year Forward View (NHS, October 2014) and the General Practice Forward View (NHS April 2016) and decisions about CPD funding, it is highly unlikely that these strategies will be delivered. There is also likely to be a negative impact on the Government’s plans to expand pre-registration education for the future workforce.

6.2. Convene a national strategic discussion to address the disconnect
Universities recognise the pressures on NHS funding and the need to find new and creative ways to meet education and training needs. Short-term budget cuts with little or no strategic direction are probably the worst way of addressing difficult questions about funding for education and training. It is essential that changes are planned strategically and from a genuinely multiprofessional perspective. If new models involve more students self-funding, this will take time to embed and the NHS could be left with significant skills shortages. As one interviewee dean observed, it is likely that any plans to reduce funding for nurses, midwives and AHPs will be a particular bone of contention given the widening gap between the education and training opportunities for doctors and other health professionals.
To navigate these issues, there is an urgent need for discussion at national level to align strategies and funding. This must involve NHS England and NHS Improvement, as the bodies leading STPs, HEE and should be led by DH, as the system steward. There is no evidence that current national fora, such as the Workforce Advisory Board are effective in convening these discussions and DH should consider reconfiguring advisory structures to ensure that strategy and funding align.” (p. 21)

 

“Health at a Glance: Europe 2018” – Sumário Executivo

Health at a Glance: Europe 2018
STATE OF HEALTH IN THE EU CYCLE
Health at a Glance: Europe 2018,  lançado a 22 de novembro, apresenta dados de saúde da União Europeia [28 países].
Sumário Executivo

Health at a Glance: Europe 2018 presents comparative analyses of the health status of EU citizens and the performance of the health systems of the 28 EU Member States, 5 candidate countries and 3 EFTA countries. It is the first step in the State of Health in the EU cycle of knowledge brokering.

This publication has two parts. Part I comprises two thematic chapters, the first focusing on the need for concerted efforts to promote better mental health, the second outlining possible strategies for reducing wasteful spending in health. In Part II, the most recent trends in key indicators of health status, risk factors and health spending are presented, together with a discussion of progress in improving the effectiveness, accessibility and resilience of European health systems.

Ideias-chave destacadas no sumário executivo

Making the case for greater priority to improving mental health

  • Mental health is critical to individual well-being, as well as for social and economic participation. Yet, according to recent estimates, more than one in six people across EU countries had a mental health issue in 2016, equivalent to about 84 million people. Moreover, in 2015 the deaths of more than 84 000 people in EU countries were attributed to mental illness or suicide.

The total costs of mental ill-health are estimated at more than 4% of GDP – or over EUR 600 billion – across the 28 EU countries

  • The economic and social costs of mental illness are substantial.The total costs of mental ill-health are estimated at more than 4% of GDP – or over EUR 600 billion – across the 28 EU countries. EUR 190 billion (or 1.3% of GDP) reflects direct spending on health care, another EUR 170 billion (1.2% of GDP) is spent on social security programmes, while a further EUR 240 billion (1.6% of GDP) represents indirect costs to the labour market due to lower employment and productivity.
  • The heavy individual, economic and social burdens of mental illness are not inevitable. Many European countries have in place policies and programmes to address mental illness at different ages. However, much more can be done to manage and promote mental health.

Reducing wasteful spending to make health systems more effective and resilient

“Evidence from various countries suggests that up to one-fifth of health spending is wasteful and could be reallocated to better use”

  • Wasteful spending occurs when patients receive unnecessary tests or treatments or when care could have been provided with fewer and less costly resources. Evidence from various countries suggests that as much as one-fifth of health spending is wasteful and could be reduced or eliminated without undermining quality of care. Reducing wasteful spending not only contributes to health system resilience, but helps achieve and maintain universal access to effective care.
  • When it comes to hospitals, many admissions could be avoided with better management of chronic conditions in the community. Potentially avoidable admissions for conditions such as asthma and diabetes consume over 37 million bed days each year across the EU. Unnecessarily delayed discharges are also costly for hospitals, and many discharge-ready patients occupy beds that could be used for patients with greater needs.
  • When it comes to pharmaceuticals, minimising waste and optimising the value derived from medicine spending are also critical to achieving efficient and sustainable health systems. A mix of policy levers can support this goal, including: 1) ensuring value for money in the selection and coverage, procurement and pricing of pharmaceuticals through Health Technology Assessment; 2) exploiting the potential savings from generics and biosimilars; 3) encouraging rational prescribing; and 4) improving patient adherence.

Gains in life expectancy have slowed in many EU countries, and large  inequalities persist

  • While life expectancy increased by at least 2 to 3 years over the decade from 2001 to 2011 in all EU countries, the gains have slowed down markedly since 2011 in many countries particularly in Western Europe, increasing by less than half a year between 2011 and This slowdown appears to have been driven by a slowdown in the rate of reduction of deaths from circulatory diseases and periodical increases in mortality rates among elderly people due partly to bad flu seasons in some years.

“People with a low level of education can expect to live six years less than those with a high level of education”

  • Large disparities in life expectancy persist not only by gender, but also by socioeconomic status. On average across the EU, 30-year-old men with a low level of education can expect to live about 8 years less than those with a university degree (or the equivalent), while the “education gap” among women is narrower, at about 4 years. These gaps largely reflect differences in exposure to risk factors, but also indicate disparities in access to care.

Putting a greater focus on preventing risk factors

  • While smoking rates in both children and adults have declined in most EU countries, about one-fifth of adults still smoke every day, and as many as one in four in countries with less advanced tobacco control policies.
  • Alcohol control policies have reduced overall alcohol consumption in several countries, but heavy alcohol consumption among adolescents and adults remains an important public health issue. In EU countries, nearly 40% of adolescents report at least one “binge drinking” event in the preceding month, and more than 40% of young men aged 20-29 also report heavy episodic drinking.

At least one in six adults are obese across EU countries, with wide disparities by socioeconomic status”

  • The prevalence of obesity continues to increase among adults in most EU countries, with at least one in six defined as obese. Inequality in obesity remains marked: 20% of adults with a lower education level are obese compared with 12% of those with a higher education.

Strengthening the effectiveness of health systems can reduce premature mortality

More than 1.2 million deaths could have been avoided in EU countries in 2015 through better public health policies or more effective and timely health care

  • More than 1.2 million people in EU countries died in 2015 from diseases and injuries that could have been avoided either through stronger public health policies or more effective and timely health care.
  • Vaccine-preventable diseases have resurged in some parts of Europe in recent years, pointing to the importance of promoting effective vaccination coverage for all children across all EU countries.
  • It is estimated that 790 000 people in EU countries died prematurely in 2016 due to tobacco smoking, harmful consumption of alcohol, unhealthy diets and lack of physical activity.
  • The quality of acute care for life-threatening conditions has improved in most countries over the past decade. Fewer people die following a hospital admission for acute myocardial infarction (a 30% reduction on average between 2005 and 2015) or stroke (a reduction of over 20% during this same period). However, wide disparities in the quality of acute care persist not only between countries but also between hospitals within each country.
  • Remarkable progress has also been achieved in cancer management through the implementation of population-based screening programmes and the provision of more effective and timely care. Survival rates for various cancers have never been higher, yet there is still considerable room for further improvement in cancer management in many countries.

Ensuring universal access to care is critical to reducing health inequalities

“Unmet health care needs are generally low in EU countries, but low-income households are five times more likely to report unmet needs than high-income households

  • Unmet health care needs are an important measure of accessibility. Recent survey data show that in most EU countries the share of the population reporting unmet care needs is generally low and has declined over the past ten years. Yet, low-income households are still five times more likely to report unmet care needs than high-income households, mainly for financial reasons.
  • In addition to being affordable, health services must also be accessible when and where people need them. While the numbers of doctors and nurses in nearly all EU countries have increased over the past decade, shortages of general practitioners are common, particularly in rural and remote areas.
  • Long waiting times for elective surgery is an important policy issue in many EU countries as it impedes timely access to care. In many of these countries, waiting times have worsened in recent years as the demand for surgery has increased more rapidly than the supply.

Strengthening the resilience of health systems

  • Health systems need to respond more efficiently to changing health care needs driven by demographic changes and exploit more fully the potential of new digital technologies to strengthen prevention and care.
  • In 2017, health spending accounted for 9.6% of GDP in the EU as a whole, up from 8.8% in Population ageing means not only that health care needs will increase in the future, but also that there will be increasing demand for long-term care. Indeed, spending on long-term care is expected to grow faster than spending on health care. “New digital technologies have the potential to promote more healthy ageing and more people-centred care”
  • New digital technologies offer great opportunities to promote healthy ageing and achieve more efficient and people-centred care. The use of Electronic Medical Records and ePrescribing is growing across EU countries, and growing numbers of EU residents use the internet to obtain health information and access health services, although there are disparities by age and socioeconomic groups.
  • Population ageing requires profound transformations in health systems, from a focus on acute care in hospitals to more integrated and people-centred care in the community. Many EU countries began this transformation over a decade ago – for example by reducing hospital capacity and average length of stay, and strengthening community care – but the process still requires ongoing, long-term effort.

Monitoring and improving the State of Health in the EU

Health at a Glance: Europe 2018 is the result of ongoing and close collaboration between the OECD and the European Commission to improve country-specific and EU-wide knowledge on health issues as part of the Commission’s State of Health in the EU cycle.

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The State of Health in the EU is a two-year initiative undertaken by the European Commission that provides policy makers, interest groups, and health practitioners with factual, comparative data and insights into health and health systems in EU countries. The cycle is developed in cooperation with the Organisation for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and Policies.

The two year State of Health in the EU cycle consists of four main stages:

  • The Health at a Glance: Europe, prepared by the OECD, gives a horizontal starting point.
  • 28 Country Health Profiles, adapted to the individual context and specificities of each EU country, assess the strengths and challenges in their respective health systems.
  • A Companion Report published along with the Country Health Profiles draws cross-cutting conclusions, links common policy priorities across EU countries, and explores the scope for mutual learning.
  • At the close of the two-year cycle, health authorities in EU countries can request voluntary exchanges with the experts behind the State of Health in the EU, to discuss findings and potential policy responses.

The research is undertaken by health experts and is designed to inform and support policy making, not to make recommendations. The cycle is aligned to the policy objectives set out in the 2014 Commission Communication on effective, accessible and resilient health systemsSearch for available translations of the preceding link