Plenary 3: Incorporating health promotion in disease management programs for NCDs
Value-based health care - implications for tackling dementia, disability and dependence
Better Value Healthcare Ltd, Oxford, GBR
Erica is a public health practitioner specialising in the identification of unwarranted variation to increase value in healthcare. Erica edited the English NHS Atlases of Variation 2010-2017. She is currently working with Welsh Government to develop an Atlas Programme, and there are plans for a similar programme in Scotland.
Erica also specialises in health impact assessment and health in all policies, working as an Expert Advisor to the World Health Organization European Healthy Cities Network since 2003 including tool development, training and skills development, mentoring and support, and evaluation. In 2005 Erica was awarded the Individual Achievement in Impact Assessment by the International Association for Impact Assessment, and made an Honorary Member of the English Faculty of Public Health.
Health services worldwide face three major problems, the first of which is unwarranted variation in the provision of care to the population in need. Unwarranted variation is variation that cannot be explained by need or patient preference; its presence reveals the other two major problems: the underuse of effective interventions, which often discloses inequity in provision, and the overuse of interventions. Despite the healthcare developments over the last few decades – the prevention of disease, the uptake of evidence-based medicine, quality and safety improvement and increased efficiency (cost reduction) – unwarranted variation has persisted or increased. It has done so in the context of increasing need and demand, rising expectations, financial constraints and consequences of global climate change.
A new paradigm is needed to enable the health sector to tackle unwarranted variation, known as value-based or ‘Triple value’ healthcare. In a Beveridge-based healthcare system such as that in Italy or the UK, value is not ‘value for money’ but value in terms of the outcomes of treatment (benefits minus harms) for the right patients at the right time in relation to the resources invested (including financial cost, time, staff and carbon).
There are three components to value: personal value, determined by how well the outcome relates to the values of the person being treated; allocative value, determined by how well resources are distributed to different subgroups in the population in need; and technical value, determined by how well resources are used for all the people in need in the population. Personal value relates to individual people being treated, whereas allocative and technical value relate to populations and comprise important aspects of population healthcare. Population healthcare is focused on population groups defined by a common need such as a symptom or characteristic and not on institutions or specialties. The aim of population healthcare is to optimise value for those populations in need and the individual people within them.
To increase value for individuals and populations it is important to take a systems approach and identify systems of care for those population groups defined by a common need. Two important activities follow: not only to identify unmet need in the population but also to identify low-value interventions and shift the resources to increasing rates of high-value interventions and to introducing high-value innovations. Resources can be shifted from within a system of care, such as from treatment to prevention, or across systems of care within a programme.
The role of health-promoting hospitals can play in implementing value-based and population healthcare will be outlined, especially with reference to addressing the problems of dementia, disability and dependence.
Examples and contributions of HPH to mental health promotion and mental illness prevention
Head of the Regional Knowledge Center for Mental Health within the Region of Västra Götaland, SWE
Lise-Lotte Risö Bergerlind is a psychiatrist and trained psychotherapist. She worked as manager for a psychiatric clinic and also as manager for the psychiatric division in a hospital in Borås, Sweden. In the last 4 years at that hospital, she was manager for the development department for somatic and psychiatric care, and developed a process-oriented way of working. Since 6 years now, she is in charge of the Regional Knowledge Center for Mental Health within the Region of Västra Götaland, Sweden.
The WHO definitions of health and the Ottawa Charter describe mental health as an integral part of health. Like health promotion, mental health promotion also includes measures to help people to adopt and maintain a healthy lifestyle and create supportive living conditions or environments for health.
In December 2016, the HPH Governance Board approved the Task Force on Mental Health as a new international task force within the International Network of Health Promoting Hospitals and Health Services (HPH Network). The Task Force will focus on three areas:
- One area concerns the mental health of young people, as more and more young people suffer from mental illness and antidepressants are increasingly being used. Today, we know that early detection and non-pharmacological treatment involving lifestyle factors in a family setting can be sufficient to prevent further diseases.
- The second focus is the somatic health of people with mental illnesses such as schizophrenia or bipolar disorders, for whom the average life expectancy is 20 years shorter than for the rest of the population. The cause of early death is not only explained by suicide, but mainly by not receiving the same treatment as the rest of the population for their somatic diseases such as diabetes and cancer and by life style factors. Working with lifestyle factors in psychiatry raises interesting and difficult ethical questions, for example about non-smoking psychiatric wards.
- The third area focuses on the perspective of “recovery” and not only freedom from symptoms as a goal in mental health care. This means that patients, including their relatives, are involved in all parts of the treatment as an equal part of the psychiatric team and different techniques such as shared decision-making are used. Their life goals are as important as reducing their symptoms.
Evidence-based policies and practices for health promotion in disease management programs for NCDs
Former Chair of the HPH Governance Board, Azienda Sanitaria Universitaria Integrata di Udine, ITA
Raffaele Zoratti, born in Udine (Italy) on 1963. MD, appointed at Internal Medicine Department, Udine University Hospital since 2001, with skills in "Management of internal disorder in the surgical patient". Graduated at University of Trieste School of Medicine on 1989. Medical Residencies in Internal Medicine and Endocrinology and Metabolic Diseases. Masters Degree in "Quality Management in the European Healthcare Systems" on 2011 and "Diagnosis and Management of Eating Disorders" on 2015.
Postdoctoral Fellow at UCSF (USA) and Wynn Division of Metabolic Medicine in London (UK). Expertise in Clinical issues regarding "Pain Management" and "Clinical Nutrition" for Joint International Accreditation implementation programs. Joining Health Promoting Hospitals and Health Services International Network since 2012, as Governance Board Vice-Chair (2012-2014) and Chair (2014-2016).
Noncommunicable diseases (NCDs) are one of the major health and development challenges of the 21st century. The human, social and economic consequences of NCDs are felt by all countries but are particularly devastating in poor and vulnerable populations; in the absence of evidence-based actions, the costs of NCDs will continue to grow and overwhelm the capacity of countries to address them. Reducing the global burden of NCDs is an overriding priority and a necessary condition for sustainable development. In 2012 NCDs were responsible for 68% of the world’s 56 million deaths and caused 16 million of premature deaths under age 70 years, the majority of them occurring in low- and middle-income countries. Addressing NCDs, through International cooperation and advocacy, is now recognized as a priority not only for health but also for social development and investments in people.
To accelerate national efforts to address NCDs, in 2013 the World Health Assembly adopted a comprehensive global monitoring framework, with 25 indicators and nine voluntary global targets for 2025:
- 25% reduction in premature death of people aged 30 to 70 from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases;
- 10% reduction in the harmful use of alcohol;
- 10% reduction in prevalence of insufficient physical activity;
- 30% reduction in salt/sodium intake;
- 30% reduction in tobacco use;
- 25% reduction in the prevalence of high blood pressure;
- Halt the rise in diabetes and obesity;
- Ensure that 50% of eligible people receive drug therapy and counseling to prevent heart attacks and strokes;
- Establish 80% availability of affordable technology and essential medicines, including generics, to treat major NCDs in both public and private facilities.
Current medical paradigm focuses on identifying high-risk individuals and treating their individual risk factors, but population-based approaches choices are essential to shift the population distribution towards greater overall health.
Health Promoting Hospitals and Health Services International Network has to strengthen national capacities and leadership in supporting NCDs prevention, control and treatment, to reduce modifiable risk factors, promote high-quality research and strengthen health systems to gain better health even with ongoing limited resources.
Examples and contributions of the Taiwanese HPH Network to improve primary and secondary prevention of NCDs
Director-General, Health Promotion Administration, Ministry of Health and Welfare, TWN
Director-General, Health Promotion Administration, Ministry of Health and Welfare, Taiwan, Associate Professor, School of Medicine, Tzu Chi University, Taiwan
Dr. P.H., School of Public Health & Tropical Medicine, Tulane University, U.S.A.
M.P.H., School of Public Health & Tropical Medicine, Tulane University, U.S.A.
M.D., School of Medicine, National Taiwan University, Taiwan
Director, Department of Medical Humanities, School of Medicine, Tzu Chi University
Director, Heart Lotus Care Ward, Buddhist Tzu Chi General Hospital
Secretary-general, Taiwan Society of Health Promotion Hospitals
Council member, Asia Pacific Hospice Palliative Care Network
Director, Department of Family Medicine, Buddhist Tzu Chi General Hospital
Director, Center for Faculty Development and Instructional Resources, Tzu Chi University
Deputy Director General, Bureau of Health Promotion, Department of Health, Taiwan
Attending Physician, Department of Family Medicine, Buddhist Tzu Chi General Hospital
Attending Physician, Department of Geriatrics, Taipei Hospital
Resident, Department of Family Medicine, National Taiwan University Hospital
Major Research Area
Family Medicine, Palliative Care, Community Health, Health Promotion, Medical Education
The International Network of Health Promoting Hospitals was established by the World Health Organization in 1990, and Taiwan become the first member in Asia in 2006. Through policy development, the Health Promotion Administration assists medical institutions to transform from medical service provider into a holistic health promotion provider, seizing on the opportunities of patient contact to offer preventive services and improve the quality of non-communicable disease prevention.
Health promotion in Taiwan is based in medical institutions. Through certification process, hospitals will regularly examine the hardware, software environments and care processes to develop a patient-centered health service modality. For example, in care of chronic diseases:
- Primary prevention: enhanced chronic disease risk factor management for patients through lifestyle and overall risk assessments.
- Secondary prevention: early screening and diagnosis. Taiwan is the only country in the world to offer government-subsidized cancer screening and adult health preventive services. Hospitals develop and implement active reminder systems to notify medical personnel to actively promote screening services for suitable patients, and provide referral and subsequent care for positive cases to achieve better prognosis.
- Tertiary prevention: continuous care, rehabilitation and hospice care. Integrated chronic disease management is put in place to offer comprehensive care and guidance to prevent complications, as well as mental, physiological, occupational rehabilitation and long-term care. Hospice care for various diseases are also promoted to raise awareness on respect for life.
Strong promotion by the Taiwanese Government and participation by Taiwan’s medical institutions have increased the number of HPH members to 163 as of the end of 2017; adult preventive health services have served over 1.8 million individuals, 29.3% (530,000) of which were provided by hospitals; 5.1 million have undergone the four-cancer screening, 53.7% (2.75 million) of which were performed in hospitals. These results showed that hospitals are becoming the optimal environment to promote healthy lifestyles and health promotion. In the future, Taiwan will incorporate similar health issues (aging, environment-friendly and health literacy) into the Health Hospital certification system, coinciding with the adjustment made to the international HPH standards, and hopes to create a better work environment for hospitals.
CEO of the International HPH Secretariat, Copenhagen, DNK
Hanne Tønnesen’s work centres on evidence-based clinical health promotion. She started her early career working with addiction and later, in 1996, she became a specialist of surgery. In 1999, she became Head of the Clinical Unit of Health Promotion at Bispebjerg Hospital in Copenhagen, and in 2003 she finished her dissertation on the increased risk of surgical complications among alcohol abusers. Since 2004 she has been Director of the WHO-CC in Copenhagen, and from 2005 also CEO of the International HPH Secretariat. She is a professor at Lund University in Sweden and the University of Southern Denmark. Her research focuses on effective interventions and programs in the area of clinical health promotion regarding tobacco, alcohol, nutrition, physical inactivity and co-morbidity.
Director of Clinical Governance, Local Health Authority of Reggio Emilia, ITA