EU regulation of health services but what about public health?


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Highlights some of the issues with the planned approach by the EU to regulate healthcare services and social welfare services across Europe. Raises questions about public health and the importance of civil society (NGOs) as service providers and building social capital

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  • EU regulation of health services but what about public health?

    1. 1. An EU framework for Health Services - but what about public health? Tamsin Rose, Tamarack Ltd June 2006
    2. 2. Key points <ul><li>Health is linked to socio-economic determinants: poverty, social exclusion affect individual health. This link is critical to public health which differs from curative health services. </li></ul><ul><li>90 % of health issues are dealt with through primary care - the area of greatest impact for public health </li></ul><ul><li>Social capital is built through meaningful connections between people, eg through clubs, associations and NGOS. </li></ul><ul><li>Many public health services are delivered through the voluntary sector which is an investment in social capital as well as meeting performance targets. </li></ul><ul><li>Public funding is often awarded to NGOs to deliver services </li></ul><ul><li>This specific characteristic needs to be recognised in the legal framework. Currently personal social services are addressed by the DG EMPL initiatives. The SANCO activity is exclusively focused on curative health systems </li></ul>
    3. 3. Healthy societies are equitable and cohesive <ul><li>Poverty is the largest single determinant of health . Living in an area of deprivation is associated with intergeneration transmission of poverty and disadvantage. Social exclusion also affects individual health . </li></ul><ul><li>Despite the existence of welfare systems of social and healthcare, significant health inequalities exist within countries and across the EU . </li></ul><ul><li>Health status is improved by social capital , for example feeling included and supported emotionally, being valued and able to make meaningful decisions improve health status. Social capital can shape behavioural norms through control of risk behavior, provision of mutual aid and support, and informal ways of information exchange. Health structures could be measured by their ability to increase social capital . </li></ul>
    4. 4. Health and the labour market <ul><li>Lisbon agenda : EU needs to increase investment in human capital. Productivity and competitiveness dependent on well-educated skilled, adaptable workforce. </li></ul><ul><li>BUT the incidence of work related disability is high and rising across Europe e.g >10 % in NL, 6 % in SE/FI </li></ul><ul><li>In some countries, more people registered as too sick to work than as unemployed. The causes of illness amongst the working population have been changing in recent years - more chronic illnesses such as stress, depression etc result in long term absence from work . </li></ul><ul><li>Rehabilitation and reintegration are difficult to achieve , particularly for older people and those with mental illnesses. This often leads to exclusion from the labour market . </li></ul>
    5. 5. Meeting the needs of the most vulnerable in society <ul><li>Health inequalities are often underlined by : </li></ul><ul><li>Poverty and social exclusion (68 million people or 15%) </li></ul><ul><li>Little awareness of services that are available </li></ul><ul><li>Low literacy levels and inability to navigate through ‘the system’ </li></ul><ul><li>Tangible barriers - physical accessibility and transport </li></ul><ul><li>Intangible barriers - language, culture, administration </li></ul><ul><li>Mistrust of authority </li></ul><ul><li>Low self-esteem and limited ability to control the social and physical environment </li></ul><ul><li>Socio-economic inequalities have the greatest impact on children’s health. </li></ul>
    6. 6. Getting the balance right in health service delivery <ul><li>Those in most need of health services are least likely to receive or access these services. </li></ul><ul><li>Approximately 90 % of health issues are addressed at primary care level, where access to is fairly universal. Strengthening primary care delivers better health outcomes and preventative care. But significant differences exist in access to speciality care. </li></ul><ul><li>The health sector could invest strategically to improve health - offering targeted employment opportunities and re-training, fostering local growth through procurement and purchasing, integrate better with urban planning to link with public transport, waste management and green spaces. </li></ul>
    7. 7. Social capital - a key part of society <ul><li>Social capital can be considered as a by-product of social relationships resulting from reciprocal exchanges between members involved in social associations or networks and can be recognized as a public good that generates positive externalities facilitating cooperation for the achievement of common goals. </li></ul>
    8. 8. People who need people.. <ul><li>Two concepts: bonding social capital and bridging social capital. </li></ul><ul><li>Bonding : value assigned to social networks between homogeneous groups of people. Bridging refers to social networks between socially heterogeneous groups. Typical examples are that criminal gangs create bonding social capital, while choirs create bridging social capital. </li></ul><ul><li>Bridging social capital is argued to have a host of benefits for societies, governments, individuals, and communities; Robert Putnam (Harvard) notes that joining an organization cuts in half an individual's chance of dying within the next year. </li></ul><ul><li>Horizontal networks of individual citizens and groups that enhance community productivity and cohesion are said to be positive social capital assets whereas self-serving exclusive gangs and hierarchical patronage systems that operate at cross purposes to societal interests can be thought of as negative social capital burdens on society. </li></ul>
    9. 9. Public health, NGOs and social capital <ul><li>Health promotion and prevention are critical to improving population health should be considered integral elements of health systems . Currently under-funded and under-valued. </li></ul><ul><li>NGO service providers have have high levels of interaction with their clients and have established relationships of trust and proximity to local communities. </li></ul><ul><li>Demographic change, increased demand and growing burdens of chronic disease threaten the sustainability of health systems. NGO and support groups are critical to helping patients with self-care and disease management . </li></ul><ul><li>Pharmacists can support individuals to make lifestyle changes and are authoritative sources of practical advice. </li></ul><ul><li>Pharmacists could play a key role in reaching pregnant women, mothers and children . This can also positively impact on the health of all family members. </li></ul>
    10. 10. Common features of EU health systems, Health Council conclusions, June 2006 <ul><li>Healthcare services out of the Services Directive but the Commission will prepare a Community Framework for safe, high quality and efficient health services </li></ul><ul><li>“ The Council considers that health systems are a central part of Europe ’s high levels of social protection and make a major contribution to social cohesion and social justice.” </li></ul><ul><li>Shared Values : Universality, Access to good quality care, Equity and Solidarity. </li></ul><ul><li>Operating principles : Quality, Safety, Care that is based on evidence and ethics, Patient involvement, Redress, Privacy and confidentiality </li></ul><ul><li>Shared goal of promoting more efficient and accessible high-quality healthcare in Europe. </li></ul>
    11. 11. Issues for EU frameworks for social and health services <ul><li>Different legal frameworks for Health and Social services are proposed: but how are these defined ? They are not separate but represent a continuum of support services. Current proposals exclusively address healthcare systems, but do not cover public health, much of which is embedded . </li></ul><ul><li>What about rehabilitation, counselling, re-training, home care, disease self-management, education and awareness raising, parenting circles, breakfast clubs? </li></ul><ul><li>NGOs are active in these areas, often with public funding. If these services are not included in the Healthcare framework (e.g exempt from the Services Directive) would internal market rules apply? Could NGOs compete with multinationals? What about the social capital elements of NGO service providers? </li></ul>
    12. 12. Issues (continued) <ul><li>There is no precise definition of social and health services at Community or even Member States level. The rapid development of social and health needs is causing these services to evolve rapidly, for instance with the emergence of new social services linked to social inclusion or ageing and the development of medico-social services. (Austrian Presidency Conference doc) </li></ul><ul><li>Health and social services in the EU share key features : </li></ul><ul><li>The low impact of these services on intra-Community trade given their local and inter-personal dimensions. </li></ul><ul><li>These services are exclusively destined for individuals. </li></ul><ul><li>A large proportion of these services are targeted at the dependant or vulnerable who do not have the ability to choose or who have no autonomy as regards meeting their basic social needs in the same way as other consumers. </li></ul><ul><li>The co-existence of service providers and of non-profit-making associations, extensive volunteers involved in service provision. </li></ul>
    13. 13. Issues (continued) <ul><li>Definitions : health and social services </li></ul><ul><li>Coverage : ensure that the healthcare services directive also covers public health </li></ul><ul><li>Financing : would public funding be considered as a state aid? If so, would it need to comply with EU rules </li></ul><ul><li>Tendering : how can tendering processes take account of the added value of social capital, e.g advocacy role, local anchoring of the service, civic engagement and role of volunteers, involvement of the recipient.. etc </li></ul>