BMJ

LONDON, SATURDAY 4 APRIL 1992

Health policy in Europe Many changes will result from new chapter on public health This week's journal contains the final article in its series on medical issues in Europe.' The series has shown that European health policy stands at the crossroads. The agreement reached by members of the European Community at Maastricht in December includes a new chapter on public health to be incorporated in the Treaty of Rome. Whereas previous health initiatives developed in the European Community in an ad hoc way from a fragile legal base,' in future there will be a specific mandate for action. As a consequence, the community's influence on health policy is likely to increase, particularly in relation to public health. The wording of the new chapter indicates that the main priority will be given to disease prevention and health promotion. Its aim is to tackle "major health scourges" through research and health education. This will probably mean extending previous initiatives on cancer, AIDS, and drug misuse. In addition, the chapter emphasises that "health protection demands shall form a constituent part of the community's other policies," which opens up the prospect of taking action on policies in related areas, such as the environment and agricultural policy, which affect health. This would make it difficult to justify subsidies to tobacco growers that far outweigh the resources devoted to combating cancer.2 European health ministers, including William Waldegrave,3 have taken pains to point out that no attempt will be made to harmonise the financing and provision of health services. Here the community principle of subsidiarity operates4; these issues are regarded as better handled by national and regional governments. Any move to establish health services on a common basis would be firmly resisted at this stage, although in the longer term pressures may well emerge to reduce differences between national systems. These pressures are most likely to arise through completion of the single market. The greater mobility of people accompanying the development of a single market will make more transparent the variations that exist among member states.5 Not only will this test the strength of the community's procedures for dealing with the provision of health care to citizens of one state who work or live in another but it could also lead to demands for convergence in the provision of services. Those responsible for policies relating to social protection in the European Commission are already beginning to think through these issues, and over time greater comparability of entitlements and standards between countries may result.' Regardless of any official initiatives the 1990s are likely to BMJ

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1992

see more medical tourism. Patients from southern states such as Italy and Greece will travel in greater numbers than previously to centres of excellence elsewhere in the community. Equally, people who live in border areas with good transport links may opt for medical treatment in states other than where they live. Purchasers and providers of health care are already operating across national frontiers. For example, a Danish hospital flies 30 patients each week to its hospital in Malaga for recuperation at a cost (including airfare) substantially lower than that for similar treatment in Denmark. The largest German private health insurance company has opened offices in Belgium, the Netherlands, Spain, France, and the United Kingdom. Closer to home, private insurers in Britain are beginning to offer subscribers the option of treatment outside the United Kingdom, and a group of NHS managers are seeking to market their services in Europe. In parallel with patient mobility, closer European integration may result in greater movement of health care professionals. To date this has been limited, even though the European Community has promoted mutual recognition of qualifications. Language and cultural differences undoubtedly inhibit extensive interchanges, although staff shortages and surpluses in different countries may encourage greater mobility than in the past. If this were to happen it might force the community to take a closer interest in manpower planning and distribution to ensure an adequate supply of properly trained professionals in different countries. As these comments indicate, much uncertainty remains about the future. Nevertheless, one thing is clear: the new chapter on public health provides a basis for more concerted action than in the past, and an opportunity now exists to develop cooperation between member states to tackle the principal causes of morbidity and death in Europe. Because of the vague wording of the chapter, almost everything hinges on interpretation in practice. Of particular interest is the commitment to use "incentive measures" to ensure a high level of health protection. This is a new phrase in the vocabulary of the community, and it indicates that public health policy will not be characterised by the directives and regulations that have legal force in other areas of European policy. Instead alternative approaches will be emphasised, the nature of which have yet to be specified. In this respect, as in the definition of public health to be adopted by the tommission, there is much to play for. Now is therefore the time for interested parties to mobilise 855

to help shape European public health policy. The commission itself has only a small staff working on this topic, and it relies heavily on advice from experts and professional associations. Although the Standing Committee of Doctors in the European Community has found it difficult to exert influence in the past,7 the British Medical Association has recently committed resources to strengthening the work of the standing committee. Other organisations are also getting their act together, as the recent establishment of the European Public Health Alliance indicates. Although attention is likely to be focused on the public health chapter, other areas of policy should not be ignored. Health services may well be affected by generic European legislation (as in relation to the liability of suppliers for negligence4), and those working in the health sector will need alerting to the implications of innocuous sounding directives emanating from the community. Apart from seeking to influence Brussels, recognising the need to work through national governments is also important. In England the Department of Health has recently reorganised its international division to give more emphasis to European Community activities, and it is vital that the work of the division feeds directly into the mainstream of NHS management. In the second half of the year the British government holds the presidency of the community, which creates an opportunity for it to exercise leadership in the

development of European policy. There is talk of a public health initiative to coincide with the presidency, and this would set the direction for the future. With The Health Of The Nation providing the framework for action in England8 an initiative to establish a strategy on the health of the community would be an imaginative way for the government to demonstrate the possibilities contained in the new public health chapter. CHRIS HAM

Fellow in Health Policy and Management, King's Fund College, London W2 4HS PHILIP BERMAN

Director, European Healthcare Management Association, Clonskeagh, Dublin 6, Republic of Ireland

1 Smith R. European research: back to pre-eminence? BMJ 1992;304:899-903. la Richards T. 1992 and all that. BM3' 1991;303:1319-22. 2 Bosanquet N. Europe and tobacco. BMJ 1992;304:370-2. 3 Waldegrave W. The health of Europe. BMJ 1992;304:370-2. 4 Hughes C. European law, medicine, and the social charter. BMJ7 1992;304700-2. 5 Stallnecht K. Nursing in Europe. BMJ 1992;304:561-2. 6 Schneider M, Dennerlein RK, Kose A, Scholtes L. Health care baskets. Augsburg: BASYS, 1991. 7 Richards T. Who speaks for whom? BMJ 1992;304:103-6. 8 Secretary of State for Health. The health of the nation. London: HMSO, 1991.

Avoiding amputation Specialist investigation helps The revascularisation of critically ischaemic limbs by thrombolysis, embolectomy, angioplasty, or arterial bypass grafting is often successful and spares many patients the mutilation and disability of an otherwise inevitable amputation. The use of Doppler ultrasonography, pulse generated run off,' and arterial exploration with intraoperative angiography may show distal limb vessels suitable for bypass grafting, that conventional angiography may fail to identify. As shown by the study of Sayers et al (p 898),' some patients are still being advised on inadequate evidence that.amputation is the only surgical option. la Unnecessary amputation will be avoided only when all patients have ready access to the investigational and technical facilities of a specialist vascular service. How then may the certainty of vascular surgeons that revascularisation saves the legs of many patients be reconciled with the apparently contradictory findings of the Johns Hopkins Medical Technology and Practice Assessment Group?2 The group estimated that between 1979 and 1989 the annual rate of percutaneous transluminal angioplasty for arterial disease of the lower limbs increased from one to 24 per 100 000 residents of Maryland and peripheral bypass surgery from 32 to 65 per 100 000 residents. Over this time, however, the rate of amputation remained constant at 30 per 100 000 residents. The only mandatory indication for revascularisation is critical limb ischaemia, which is the harbinger of amputation unless arterial inflow is improved. Ischaemia of recent acute onset or that worsens suddenly also usually warrants attempts to restore blood flow to its previous level-even when the viability of the limb is not in doubt. But most patients with arterial occlusive disease of the lower limb present with intermittent claudication, and all interventions to relieve this 856

symptom are discretionary. When treatment relies solely on the judgment of the patient or doctor intervention rates are likely to vary widely and be influenced by factors unrelated to the disease, such as the number of doctors, the available resources, the system of health care delivery, and the expectations of the patient. Experience in Oxford indicates that the annual incidence of critical limb ischaemia is 30 per 100 000, although others have estimated figures up to three times higher.3 In 1989 the rate of bypass surgery was two and a half times higher in Maryland than Oxford, although the rate of percutaneous transluminal angioplasty was almost the same. Despite a higher rate of vascular bypass operations three times as many legs were amputated per 100 000 residents in Maryland. One explanation for these differences could be that all patients who need revascularisation in Maryland are not receiving it and for many patients undergoing revascularisation intervention is not essential (though possibly beneficial). The unexplained racial differences between those undergoing revascularisation and amputation support this: two in five amputations were in black people, although this group accounted for only 15% of angioplasties and 24% of peripheral bypass operations. Discrepancies of this magnitude (p

Health policy in Europe.

BMJ LONDON, SATURDAY 4 APRIL 1992 Health policy in Europe Many changes will result from new chapter on public health This week's journal contains th...
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