Tessa Richards at the European Health Forum Gastein, 3-6 October

By 0900 on the 3 Oct the hills of the picturesque Gastein valley in Austria were alive with the sound of some 600 politicians, policy makers, academics, industry leaders, and  NGO’s, exchanging views on the future of health care in Europe. Eight hours earlier it had been silent and chilly, as three of us prowled around a dimly lit and firmly locked hotel. Fortunately my companions, who work in DG Sanco (the European Commission’s health and consumer protection division) speak German and could read the note put out for late comers. We paged the number suggested and waited, and while we did so one gallantly lent me his coat, and under the lamp light, explained the evolution of the European Community which, among other things, accounts for the fact that DG Sanco is physically split between Luxembourg and Brussels.

Next morning, I caught up with the architect of ” Gastein”, as the European Health Forum Gastein is known for short, and ask him how the forum began. Professor Gunther Leiner, a nephrologist who runs the dialysis unit in Bad HofGastein takes me back a decade or so.

“When I was head of the health committee in the Austrian parliament, he said, “I was struck by the fact that many of the issues we dealt with at national level crossed borders, and would more logically be dealt with at a European level.  I was also very conscious of two disparate dialogues on health. One between doctors who wanted to influence (but had little say in) health policy, and the other between politicians who had little knowledge about health.”

This stimulated him to think about starting a European health forum to bring representatives from both camps, and from across the whole of the EU, together. The idea was germinating when he met Padraig Flynn, who was then the EU Commissioner for Health and Social affairs. Flynn was looking for an independent expert body to advise the small but growing health competence within the European Commission. The two got together and over the next ten years the forum has evolved to become a high profile meeting place for discussion on health policy in Europe and beyond.

When I asked Leiner his views about current health challenges in Europe it was health inequalities that he talked about first. He then listed a range of issues which he thinks warrant wider debate among EU parliamentarians including the rising tide of chronic disease, ageing populations, HIV/AIDS and medical migration. The latter, he underlines, has left some of the newer members of the EU – the Czech Republic for example, denuded of health professionals. He then moves on via rising health care costs, the potential of new health technologies and innovations, to talk about the need to rationalise health service provision across Europe, not least in border regions.  There are, for example, 11 hospitals in the Salzburg region, which, he suggested, is several more than is needed.  Europe has some way to go, he implies, before it thinks and behaves as a whole and plans services accordingly.

All of the topics he touched on were scheduled for discussion at the forum and the scene on health inequalities was set in the opening plenary session by Professor Sir Michael Marmot.  He presented the familiar data linking health with socioeconomic status which is driving the work of the WHO Commission on Social Determinants of Health. His take home message to forum delegates was clear and simple. “Put fair -equitable- health at the heart of your agenda.”

Whether countries will succeed in doing so is far from certain. Dr Mukesh Chawla, an economist from the World Bank, presented varied scenarios in the course of his exercise, con brio, on horizon scanning. He went on to urge delegates to think about the questions we will all be asking ourselves asking in 20 years time before going on to supply some answers.

“We will wonder   (a) Why we spent so much time introducing endless health care reforms, which achieved very little, and continued to promise patients more than we could deliver (b) Why we failed to get people to share the financial responsibility for their health and make them aware of the cost of the services they consumed (c) Why we did not tax unhealthy behaviours and finally (d) Why we allowed governments to interfere with the running of health services.

Fighting talk and I took up the case for taxing unhealthy behaviour with him later.  Obesity was the example he reached for, referring to the example of a town in Italy where the civic officials persuaded everyone to weigh themselves. Those who were deemed to be overweight were urged to lose their excess kg. A small “fat tax” of around 10 Euros was levied on those who failed to do so. It seems that the experiment faltered but Chawla sees no reason why similar initiatives should not be tried again. We have a preliminary go over coffee. Take your height in inches, he says, and subtract your waist circumference. If the result is less than 32 inches you need to lose weight. Mine is 28, so I do, and I should be charged a fee. Modesty forbids me to record my own measurements but I did ask Chawla if there was any evidence that financial inducements changed unhealthy or undesirable behaviour?  His answer was yes and he referred to another policy experiment in Slovakia.

In this instance all people, including the poor (who were given an extra annual stipend) were charged a nominal sum to attend out patients. The price was low, around the price of a beer. It resulted, he said, in a reduction in average OP visits from 12 or 13 to 9. Similar financial incentives, for doctors as well as patients, resulted in shorter hospital stays. When the new government reversed these policies the health care patterns reversed to their former state. What impact this experiment had on clinical outcomes is unclear but I find myself in sympathy with Chawla’s central argument that “health is a right but its not for free – and that everyone, irrespective of their socio- economic group needs to understand this.”

Taxing unhealthy behaviour is not part of the EU’s current health strategy, the overall thrust of which was presented by the Robert Madelin, director general of DG Sanco. Whether it could become so in the future is germane to the issue of “ethical consumption” which, among other topics, is raised in a new paper DG Sanco has just published on future challenges to health over the next in the next 10-20 years. Responses to this paper are currently being invited so if you wish to participate in the debate go to (http://ec.europa.eu/dgs/health_consumer/index_en.htm)

Madelin outlined his view of some of the new challenges that lie ahead for Europe and the first he cited were the need to respond to citizens’ desire to take more control over their health and to deal with the wide health and wealth gaps that have opened up as the EU has enlarged. He then mentioned the usual suspects including ageing populations, globalisation, new technologies, life style related disease, migration, climate change and the threat of pandemics. But  perhaps the biggest  challenge for health policy makers in Europe , he suggested,  is to persuade  policy makers outside the health  sector  to think a great deal more about  “the colourful salad of health problems” that accrue from  their policies. Public health experts should also persuade leaders in other sectors (from agriculture to transport) to think outside their conventional policy response boxes. Taking the rising cost of violent crime by teenagers as an example, he said that we should help formulate alternative solutions (to the strong arm of the law) such as mounting interventions in schools. (Geared perhaps,to promoting physical and mental health, promoting community solidarity, self worth, reducing absenteeism, improving educational attainment etc.) He ended with his own clear message on the need for health policy makers to market the fact that investing in health is good for wealth, and that action to promote it and extend healthy life years is good for the economy.

Moving to more specific issues, other sessions covered the economic cost and implication for service design of Europe’s growing army of people suffering from chronic disease. The projections are certainly sobering, not least for obesity and diabetes. The International Diabetes Federation predicts that by 2025 the number of diabetics will have increased globally by 150 million. The take home message here was that Europe’s citizens need to “wake up to their own risk,” (which again involves measuring waist circumference), and make changes to their life style to reduce the chances of developing the condition. At the same time health service providers need to work harder at earlier detection. On the service front the message was that in most countries these are still largely orientated towards acute care rather than care for chronic disease. More focus is needed on the latter, was the message here as well as empowering people to manage their own illnesses. A key determinant of outcomes in patients with chronic disease is how well they monitor and manage their illness. The most effective way of encouraging this is to improving people’s understanding of their health and so it was not surprising that health literacy was on the forum’s agenda.

Poor health literacy is costly- both to the individual and to the economy – and improving it is clearly important to help people make rational decisions about life style. It’s also important in the decision to access services, said Professor Friederich Schwartz, from the University of Hanover.  In Germany, he said, people have the right to choose which OP clinic they go to, they therefore need sufficient knowledge to make sensible choices.  How and when to impart the medical facts of life where then discussed briefly including the pros and cons of “mini med schools” (a US approach) and Patient Universities, such as the popular one in Hannover which Schwartz described.

A high level of health literacy is also needed, speakers at a session on genomics agreed, to make any sense of the growing number of  gene disease associations , diagnostic  genetic tests and measurements of biomarkers that are fast and furiously  coming on stream. The problem here is that there is no obligation on those who market genetic tests to produce guidelines for their use or an evaluation of their health impact. Furthermore, some are being marketed to the public in a less than scrupulous way. Europe needs to more to push for recommendation on good practice in this area, it was suggested.

At the end of a busy forum (of which this more glimpse than synopsis) enlivened by celebratory musical treats and fireworks, the meeting drew to a close with the presentation of the Gastein Award. This is to become an annual award for a study deemed to have contributed significantly to improving health care across Europe. The initiative chosen was one mounted by the European Alliance against Depression which succeeded in reducing suicide rates by setting up self help groups and conducting targeted educational interventions at GPs, teachers, pharmacists, and the clergy.

As I set out on my return journey I meet a pack of purposeful middle aged walkers  striding at speed, poles in hand, along the riverside path that links Bad Hofgastein with its neighbouring villages. The day they introduce common EU prescriptions for healthy life styles there are many of us who would benefit from two weeks walking in the in the hills in Gastein with twice daily swims in its thermal waters.

Further information about the European Health Forum Gastein and the content of this years programme and the can be found at www.ehfg.org.