Investing in Prevention and Early Intervention

Advances in medicine and public health, improved nutrition and better sanitation have sharply reduced infant mortality. Life expectancy at birth is projected to increase from 76.7 years in 2010 to 84.6 in 2060 for men and from 82.5 to 89.1 for women. By contrast, the fertility rates in the EU are projected to climb only modestly, from 1.58 births in 2012 to 1.71 in 2060.

This combination of low fertility rates and increased life expectancy means that the proportion of the population aged 60 or over is expected to reach 37% by 2050.

Improved life expectancy as a consequence of medical, social, cultural and economic advances represents great progress. It does, however, present unintended challenges. Longevity can potentially increase the number of years lived with disability and illness. The impact on the economic and social lives of millions of patients and their families adds considerable cost to healthcare.

Simultaneously, disease profiles have changed fundamentally from life-threatening infectious diseases, maternal-child illness and malnutrition to the increased prevalence of chronic disease. This has been exacerbated by a parallel increase in the risk factors, including sedentary lifestyles, unhealthy diets, obesity and smoking.

Chronic disease now accounts for more than 87% of deaths in Europe

The prevalence and related mortality rates are expected to rise sharply in the future.

Moreover, most of those with a long-term disorder have more than one chronic condition, but existing health systems are often dominated by single-disease approaches

Healthcare expenditure continues to increase in many countries and, in many cases, at a faster rate than the growth of GDP. The financial sustainability of healthcare systems has become a major concern for European governments. Current approaches mainly focus on short-term cost savings rather than long-term sustainability. Without fundamentalchanges, average public spending on health and long-term care in OECD countries will rise to over 10% of GDP.

Many have argued that the lack of long-term focus is because actions are required which take longer than the lifespan of a parliamentary term. However, targeted initiatives and the scaling-up of best practices can substantially improve the sustainability of healthcare systems. Bold actions are required to drive a new paradigm dynamic. A transition is needed from acute care to prevention and chronic care management in a community setting, from medical paternalism to citizen empowerment, from hospital dependency to integrated care, and from volume-based to value-based financing mechanisms.

A truly sustainable healthcare model should place greater emphasis on reducing the incidence of disease. Effective prevention often delivers the best outcome and value.

Efforts need to be focused on prevention and earlier intervention to delay the onset and progression of disease.

Every citizen eventually becomes a patient. We need to ensure that they are empowered to play a central role in the management of their own health and to take responsibility for behavioural changes. This requires equipping them with the skills needed to critically assess and interpret appropriate and informed health information so that they can make the necessary decisions to maintain a healthy lifestyle. Health information and literacy are key drivers in making lifestyle decisions; disease understanding is an important factor in self-management of conditions, treatment decisions and adherence to treatment. If individuals participate in pro-actively managing their health, outcomes will be improved. Of course, this is only possible for those who have the capability to make these choices. This caveat highlights the need for these measures to be embedded in broader policies to alleviate poverty, promote economic security, and foster inclusive and participative societies based on social, economic and political rights.

Many aspects of healthcare systems will need to be restructured if they are to continue to deliver high-quality, equitable and affordable services. In the future, the emphasis should shift from the acute hospital to out-patient, community and home settings. This would result in a much more cost-effective system with better health outcomes and higher patient satisfaction.

Healthcare systems generate huge amounts of data. This data offers considerable potential for policymakers, healthcare professionals, and patients if gathered and used appropriately. It could inform and improve prevention policies and strategies, allow better planning of treatment and care, and empower citizens and patients. However, in most countries the collection, organisation and deployment of data is not effectively set up and used. Issues such as patient confidentiality, civil liberties and the complexity of data sets across organisations and systems must be addressed. The challenges have become much greater as a consequence of recent revelations on the scale of surveillance undertaken by some states and the resulting loss of public trust. Concerns about the commercial use of data also pose a challenge. Addressing these challenges will unlock the huge potential presented by healthcare information and technology.

Health is a value in itself. It is also a precondition for economic prosperity. The health of individuals influences economic outcomes in terms of productivity, labour supply, human capital and public spending. Some health expenditure is an investment in society that is growth-friendly. Policymakers need to ensure that short-term cost saving is not detrimental to long-term sustainability. The financing of innovation and decisions around therapy funding both need forward thinking, where value and benefits are both rewarded and widely diffused.

As in all innovation, great value will rightly attract great reward. Truly transformative pharmaceutical innovation creates societal value way beyond the innovator, the therapy, the device or the price. For patients, the value of lives transformed and lives saved by innovative therapies can never be fully reflected in a price. We recognise that the widest diffusion of innovation, and the creation of greatest value, happens when we adapt to the great variety of purchaser needs and constraints. With due reward, innovation is best supported by facilitating its widest diffusion, spreading and sharing the value created.

It is commonly recognised that diabetes, stroke, respiratory disease and certain cancers are major drivers of healthcare expenditure.

Conversely, many of these diseases are avoidable. According to the World Health Organisation, about 80% of cardiovascular disease and diabetes, and at least 40% of cancers can be prevented simply by a change in lifestyle.

Evidence clearly shows that these diseases can be avoided by means of targeted and personalised preventive strategies. Despite this, insufficient investment and effort have been made to reduce the risk factors. In Europe, only 3% of healthcare expenditure is allocated to prevention and public health programmes, and in some countries it is as low as 1%.

Financial and human resources need to be switched from treatment to prevention and health promotion. Smart investment in prevention and early intervention can generate significant savings in health and social welfare.

Health literacy programmes should be included in school curricula with the objective of encouraging the adoption of a healthy lifestyle from childhood. When tackling substances that may be harmful, such as energy-dense food and drinks, tobacco and alcohol, governments must focus primarily on the most effective levers which include price, availability, and marketing. Increasing taxes on tobacco, alcohol or sugar, implementing public information campaigns and ensuring health-friendly controls on advertising and sponsorship can have a positive impact.

Healthcare systems should be assessed on the basis of 'diseases avoided' rather than 'diseases treated'. New sets of performance indicators and outcome measurements should be developed to assess and evaluate preventive policies and programmes, so as to accurately appraise health prevention and unlock the true potential of successful prevention programmes.

Smart investment in prevention and early intervention to minimise disability and restore health can lead to tangible savings in health, social welfare, and reduce absenteeism from work as illustrated by the Early Intervention Clinic project carried out by Hospital Clínico San Carlos in Spain. By reducing disability through early diagnosis, referral and intervention programmes, the Early Intervention Clinic has demonstrated that every €1 spent can generate total savings of €11 in health and social welfare. Prevention through behavioural change is probably the most successful strategy to produce cost savings. For example, in the US, the National Economic and Social Forum suggests that universal early childhood care and education on health literacy offers a return on investment of between €4 and €7 for every €1 spent.

Research also showed that reducing sodium intake to 2,300 milligrams (i.e. a teaspoon) per day in the US adult population could save $18 billion in healthcare costs annually.

The Centre for Economic and International Studies in Italy, in partnership with the OECD, is now conducting a research project to examine the implications for health expenditures if no preventive action is taken. “A micro-simulation model to inform health policy: Making our health expenditure sustainable in the future” aims to develop statistical and econometric tools to measure the sustainability of EU healthcare systems. If successful, this model should help estimate future demand and the impact and cost of proposed health policies. This will help policymakers and decision-makers by providing valuable information to make informed decisions.In order to maximise their effectiveness, prevention and early intervention strategies should be tailored to different age groups according to differences in lifestyle, behaviour, and biological risk factors. Cultural and ethnic differences must be considered when developing preventive strategies. It is rarely too early to start prevention programmes. Targeting the youngest will ensure that investment in prevention will ultimately outweigh the cost of future disease.

Prevention and early intervention should not be the sole responsibility of doctors and patients.

Since the majority of the population spends over half of their lives at the work place, employers and occupational health professionals have an important role to play in prevention and early intervention. It is essential to keep the workforce healthy and employable for as long as possible. Governments, social service providers, company doctors, patient advocates, employers and worker representatives have begun to work together and adopted an interdisciplinary approach to develop practical solutions and interventions. Germany is bracing itself for the loss of 5 million workers over the next 15 years. The proposed legislation in Germany, the Prevention Act, which was not ratified in previous years, has been put on the table again for 2015. It seeks to strengthen prevention and the promotion of health in environments, including kindergartens, schools and the work-place. The legislation, which is currently being debated in the German Parliament, would include all social insurance carriers and would authorise occupational health physicians and sick funds to agree on early and appropriate health interventions. Funding agencies are running regional pilot projects for occupational health. The outcomes of these pilots will be closely monitored and measured so as to assess the potential of scaling up the initiatives.A US literature meta-analysis on costs and savings associated with workplace disease prevention and wellness programmes found that every dollar invested can cut medical care costs by $3.27 and reduce absenteeism costs by $2.73.

Too often public health, occupational health and social support for citizens operate in silos and fail to communicate with each other. A project in Poland demonstrates the benefits of a participative model of cooperation. The main objective was to prevent the social exclusion of people with chronic diseases, helping them remain in work. The promotion of physical activity and early intervention can lead to a stable work environment with substantial benefits to individuals and the economy. This requires a holistic approach involving multiple stakeholders, promoting the benefits to society.

Health literacy and education programmes should not only take place within medical clinics, but also in schools and other public and social settings. Governments and public health authorities should put in place appropriate and easily understood health information targeted at the general population to influence behavioural change in all aspects of their lives.

We need an expanded role for nurses and pharmacists in the provision of health services, mainly in the area of health promotion, screening and administration of appropriate interventions for those suffering from chronic diseases and vulnerable populations.

These interventions can include vaccinations, health checks such as monitoring of blood pressure, cholesterol and blood glucose or chlamydia testing. Co-operation by a variety of healthcare professionals demonstrates that when different groups are mobilised they can improve efficiency and maximise health outcomes. In addition, making use of unconventional settings can also improve access to prevention and early intervention initiatives.

In the US and the UK, pharmacists provide flu vaccinationsmainly for vulnerable groups like the elderly and pregnant women.

Healthcare systems generate huge amounts of data. This data , if gathered and used appropriately, offers considerable potential to improve patient care, inform and improve prevention policies and strategies, and support patient empowerment.

The Irish Longitudinal Study on Ageing (TILDA) is one of the flagship studies in Europe that showcase best practice in proactive and systematic data collection and analysis with the purpose of informing policy development. Launched in 2006 by Trinity College Dublin, the study explores the health, lifestyles and financial situation of over 8,500 people as they grow older, and observes how their circumstances change over a 10 year period. TILDA provides a comprehensive and accurate picture of the characteristics, needs and contributions of older persons in Ireland that will be invaluable for policymakers and public sector service planners, voluntary sector actors engaged in activities that seek to enhance the social integration of older citizens and many private sector companies in the insurance and services industries.

In addition to data and information related to the general public, chronic disease registries are very important in informing policy development and treatment strategies. In Denmark, for example, the Danish DANBIO registry provides nationwide data on the disease course of patients with inflammatory rheumatic diseases. Since the year 2000, more than 22,000 patients have been included. The aim of DANBIO is to collect information on patients with rheumatoid arthritis as well as all the patients treated with biologicals. The data is being used to ensure efficient treatment of the individual patient, and is furthermore an important asset in scientific studies. DANBIO serves as an electronic patient 'chronicle' in routine care. Monitoring an individual patient's treatment over time can inform better treatment strategies and lead to improved quality of care and better treatment outcome and efficiency.

In a clinical and epidemiological research conducted in 2014, based on the results from the DANBIO registry, a significant reduction in diagnostic delay was observed in the large cohort of 13,721 patients with Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis.

These results will potentially assist policy makers to evaluate and assess the effectiveness of relevant awareness and intervention programmes.