1

WP 5 – Case MaterialBarrie DowdeswellDirector of Research, ECHAA

2

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

3

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

4

Context

5

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

6

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

7

Europe 2020 – health is not a specific, but more an implicit feature of the strategy document; but ---

8

Overall ranking of EU Health systemsAn issue of social cohesion

The ‘12’

9

Serious affordability problems for healthcare – in particular the 12

Per-capita spending, EU

Growth CEE

A potential risk to fiscal governance

10

Variations in (cervical) cancer survival rates 1998 - 2008

Source:OECD health data 2010

Health Inequalities, avoidable mortality, questions and sensitivities – Subsidiarity

11

Findings and preliminary conclusions

12

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

13

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

14

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

15

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

16

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?

17

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)

18

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

19

Project plan – before and after

Radiotherapy 2009

Radiotherapy 2012

20

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

21

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.“

22

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

23

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

24

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

25

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

26

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

27

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

28

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)

29

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.