WP 5 – Case Material Barrie Dowdeswell Director of Research, ECHAA
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Transcript of WP 5 – Case Material Barrie Dowdeswell Director of Research, ECHAA
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WP 5 – Case MaterialBarrie DowdeswellDirector of Research, ECHAA
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Case material - Purpose
Review the effectiveness of the SF process through examination of
a cross section of case studies (ESF / ERDF) Programme cycles, 2000/6, 2007/13
Thematic focus
Geographical spread
Context, Social Cohesion - Health Inequalities, Health is Wealth, Modernisation
Aim, provide evidence to support improvement in the process and to
provide knowledge and competency development support to
relevant member states and regions
Methodology: On site interviews and evaluation – transcript based
Desktop research
Thematic analysis and Integration with the EuregioIII scientific paper
Evidence for EIII workshops and masterclasses
Web based resource and ongoing reference ‘library’
Reports and publications
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Case studies
Asset based
Modernisation
Greece, Cancer Centre Malta, Cancer Centre Portugal (Saude) Masterplan,
(plus) Hungary Masterplan (plus) Estonia, Hospital Reconfiguration Sicily, Technology Diffusion Greece, Mental Health Services
eHealth / ICT
Quality and Efficiency
Brandenburg, Germany, changing focus and locus,the patient as co-producer of care
Sicily, needs assessment Finland, Lapland, remote population
telecare service delivery & the patient as co-producer of care
Slovenia, whole systems ICT investment
Non SF comparators have been identified (already available on the web site) to provide benchmarks for evaluation, wider range at:Capital investment for health: case studies from Europe. World Health Organization, on behalf of the European Observatory on Health Systems; 2009. http://www.euro.who.int/en/home/projects/observatory/publications/studies/capital-investment-for-health.-case-studies-from-europe
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Context
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Health and the State / Region‘Health is wealth’ or ‘Health as Cost’
HEALTH
geneticslifestyle
education
healthcare
wealth
other socio-economicfactors
environment
labour supply
productivity
education
capitalformation
ECONOMICOUTCOMES
McKee et al LSHTM
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An accelerating and increasingly complex trajectory of change in healthcare in the EU
Cumulative growthIncremental change
ModernisationQuality improvement
Technology diffusion
Transformational change
Intersectoral investment
Public Private Partnerships
The patient as co-producer of care
Complexity& risk
Low
High
2000/6 2007/13Creditcrisis
Healthtransitions 20/20
Deficitreduction
Age gappensionscrisisAll happening within the current cycle
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Europe 2020 – health is not a specific, but more an implicit feature of the strategy document; but ---
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Overall ranking of EU Health systemsAn issue of social cohesion
The ‘12’
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Serious affordability problems for healthcare – in particular the 12
Per-capita spending, EU
Growth CEE
A potential risk to fiscal governance
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Variations in (cervical) cancer survival rates 1998 - 2008
Source:OECD health data 2010
Health Inequalities, avoidable mortality, questions and sensitivities – Subsidiarity
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Findings and preliminary conclusions
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Lisbon Strategy evaluation document
“Earmarking of Structural Funds has helped mobilise considerable investments for growth and jobs although there is further to go”
Need to enhance policy effectiveness Difficulties with the process Weak capacity Lack of strategic approach Poor integration of process Weak outcome assessment Need to strengthen leverage – “through financial
engineering”
Euregio findings reflect the Lisbon evaluation and add further specific insight
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Case studies - examples
Brandenburg Germany – eHealth The patient as co-producer of care / change
Sicily, Italy - Clinical Technology Investment Evidence based investment / masterplanning
Greece – Mental Health Transformational service delivery / change
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Brandenburg / GermanyChanging the axis of regional healthcare The patient as co-producer of care
Reshaping health services (following reunification)
Support from structural funds, 2000-2006 regional development
convergence region:• Reduce health inequality
• Wider economic development
• New medical technology innovation
The Region – core problems High unemployment rate, poor access to higher education
Run-down rural infrastructure; need for modernisation (generic)
Previous (biased) healthcare investment strategies: Closure of previously state run polyclinics in favour of single physicans
offices
Preferred investment into ‘big hospitals‘
Neglecting accessibility and dissemination
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Existing healthcare challenges
Legacy of former healthcare system Local agendas Underinvestment & lack of resources
“Brandenburg (sharing structural similarities with the new member states) in some aspects is a laboratory for health investments as means for stimulating new regional policy.“
Lack of trained workforce Funding of large scale hospitals “I think the true philosophy behind this is, if you have limited
amount of money, say in funds or whatever, you can go and look and say, okay, the big towns, the big cities will get the most. The philosophy, in contrary should be to say, medicine has to go to the people where they live. It is in the 21st century not true that MRI or heart surgery is so spectacular that it only could be in great metropolitan areas.”
Lack of appropriate health infrastructure in rural areas Need to introduce innovation and telemedicine
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Project aims and emerging outcomes
Move more care into locally and more accessible community settings – the patient in greater control
Increase accessibility of health equipment, technology diffusion Move towards new technology/introduction of telemedicine,
innovation Competency development, professionals and citizens
“What to do”:
“Whole system change (away from big hospitals into community settings; shift towards prevention and rehabilitation
Putting the patient back in charge – an issue of belief and trust Increase awareness of interactions between different system
components, and stakeholder groups” – how does it all fit together?
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Sicily, Italy: current healthcare system problems
• Overspending
• Administration inefficiency (need for accountability)
“It is very well built, but managed in a terrible way.”
• High pharmaceutical consumption (a typical)
new (medicines) technology diffusion problem
• Ageing population
• High passive mobility (patients get treated in other regions of Italy)
• Out-dated, insufficient clinical technology
• Lack of resources
• Inequality (limited access to care, especially pronounced in rural
• regions)
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Sicily: Multiple project objectives
Introducing Centralized Tenders – procurement efficiency
Cost containment
Trimestral Performance Monitoring and Evaluation
Fill gaps in care (& tackle inequality) – health access in rural areas
Upgrade emergency services
Laboratories: centralise diagnostic capacity and improve quality
Reshaping hospital network, territorial and social care
Organizational innovation (hub and spoke networks - hospital-
territory)
Technological innovation
Improve infrastructural facilities
Integrate services, residential, public-private joint venture
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Project plan – before and after
Radiotherapy 2009
Radiotherapy 2012
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An EU comparative viewCapital investment (MRI) it is not how many - but effectiveness of return on investment
9 months One week 4 months
Waiting times
Scanner range 1 to 30 per million populationEuropean recommendation 10 to 12 per million
1
30
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Sicily: identified SF project issues (1)
Lack of strategic alignment
“There is a need to integrate the master plan in investments
at regional and local level.”
Missing outcome measures
Inappropriate quality measures
Poor integration of processes
Product hospitals and facilities based on outmoded
principles
“[...] avoid funding and building (just) prestigious projects.“
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Identified SF process challenges (2)
Time consuming
Very prescriptive
Missing guidance from EU and government
Administrative procedures a barrier to innovation
“ [...] there should be a contest of ideas, choose the projects according to
quality [...]“
Missing alignment of different EU funding streams
“[...] seek to reach synergy between ERDF and ESF.““The integration of the
different funds, different European funds, should be improved, because
now it seems that the division into the assistance of different funds, like
the health, and so on, are too sectorial and too limited to itself, and not
sufficient integration among them.”
Competing interests in other fields e.g. education
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Greece Mental Health Service TransformationPSYCHARGOS B programme
ProblemInstitutionalised (asylum) care for almost all psychopathologies – large, overcrowded psychiatric hospitals with quality, accessibility, workforce and ‘outmoded’ service issues
Target
Replacing institutional care with primary, extramural (local community) and acute care service delivery
Reform stimulated by Greece entry to the EU
Redesign supported by advice from the WHO and EU, but very slow progress in the period 1989 -1998
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PSYCHARGOS B programme
PSYCHARGOS B 2000 – 2009 programme aimsDe-institutionalised mental care delivery in community-based structures and facilities;
Development of an integrated network of primary and acute mental care services
Promotion of illness prevention, social and labour market inclusion Cost of programme: € 216.2ml (2000); € 255.2mio (2008)
Committed funding: ESF: 182.6ml, ERDF: 21.5ml, national funds: 51.1ml
Challenges Modernisation of physical infrastructure Development of primary care structures Promotion of preventive healthcare and social inclusion Investment strategy: use of national and EU funds Culture change and professional development
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PSYCHARGOS B 2000 – 20009 Programme Outcomes
Closure of asylum wards in 5 psychiatric hospitals, reduction of patients in 5 remaining hospitals: 68% reduction of hospital beds
Operation of new extramural (community-based) care structures for up to 2,050 patients
Operation of 80 employment promotion structures Training of 3,000 mental care professionals
Recommendations Programme duration of 5 years too short: programme activities are still being pursued
in 2011, as part of the 4th programming period of 2007 -13, a spending overhang; Philanthropy, 3rd sector funding options need to be formally assessed and included in
programme design and delivery Private actor participation needs to be better supported through (i) care quality control
framework, (ii) simplified procurement processes De-institutionalisation may start once community-based care structures, care quality
control framework have been established
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EIII specific observations (1)(Subject to ongoing thematic analysis)
“Process bureaucracy is process bureaucracy”
Risks of a ‘tick box’ approach
Risks of over-ambition and over-statement
Decisions, but with uncertain accountability - & ownership of ROI
Can be ad-hoc and opportunistic basis for SF proposals
Tendency towards tactical, as opposed to strategic investment
Scale of ‘legacies’ can create overwhelming problems:
Short-term easement of pressures in place of transformational
change
Absorption capacity
Political uncertainty
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EIII specific observations (2)
Difficulties over integration of projects and programmes -
masterplanning weaknesses and implementation problems
E.g. Disconnection - eHealth / Capital Asset provision (handout)
Questionable financial realism & some evidence of over-
expectation spirals
In comparison with non-SF and ‘progressive’ health systems – a
weakness in visioning, innovation and transformational change
Under-estimation / under-exploitation of the dramatic changes
underway in healthcare
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Critical success factorsSF investment in future health-care
Accountability – and owning performance and evaluation Strategic vision and tactical competence Financial realism Integrated masterplanning and programming, including
investing for continuous change Accessing (and applying) technology diffusion Investing for measurable ROI (return on investment)
Population health status Health outcomes Economic impact
An understanding of and commitment to social cohesion The three integrated elements of healthcare delivery:
Service delivery models (disease management and pathways) Workforce Capital (infrastructure, technology and ICT)
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Why sustained change is critical for EUsocial and economic cohesion
The Paradox - substantially enhanced by the economic situation
More progress needs to be made more quickly to reduce inequalities: Population Health Status
Healthcare Quality e.g. health outcomes, avoidable mortality (a growing factor is the quality of cross border care)
There is also an urgent need for (investment-led) transformational change to reconcile revenue cost and affordability, but: Capital investment is challenged by debt management / reduction needs
Service investment is threatened by affordability within the volatile and fragile economic climate
PPP presents affordability risk
For the ’12’ in particular, If there is no progress, poor health and the impact of ageing populations will: Threaten social cohesion, and
Challenge economic growth and stability – impact of the high cost burden
There is a risk that the ’12’ (in particular) will be locked into ongoing legacy problems, which in turn generate fiscal governance problems.