Dr Paul De Raeve, General Secretary of the European Federation of Nurses Associations, explores how the COVID-19 outbreak has highlighted the need for a European Health Union.
‘Health policy’ is a concept covering all aspects of healthcare provision, including the delivery of healthcare to the population; the regulation of health professionals; the protection of public health; and health promotion. The concept of a unified EU-wide health policy has not always been an obvious one: instead, it has been developing over time as EU health crises emerged on the political agenda.
However, the ongoing COVID-19 outbreak has greatly impacted the EU political debate as the virus heavily impacted EU citizens’ life. The EU was not prepared at first, and a solidarity network among Member States on equipment – including PPE, masks, and ventilators – and human resources (nurses and doctors) came into operation when the crisis had already hit many Member States hard. Although the 2013 Ebola crisis had already alerted EU politicians that ‘we are not prepared unless we are all prepared’, we now find ourselves in a situation of ‘non-preparedness and each country doing its own thing’.
All politicians and policymakers, together with key health stakeholders, now need to learn together from this crisis and reflect on how we can be better prepared for the next pandemic. All EU health stakeholders need to move towards the best co-ordination solution for EU citizens and be better prepared. A holistic and altruistic approach to EU Health Policy design is key for future preparedness within the EU.
The state of play of healthcare policy in the EU
The biggest development in EU Health policy design occurred with the Treaty of Lisbon (2010), which granted additional powers to the EU in relation to public health. Article 168 of the Treaty of Lisbon1 adds that the Union shall in particular encourage co-operation between the Member States to improve the complementarity of their health services in cross-border areas. Most of the EU’s public health advancements today are justified by the existence of this article. Thus, the EU can only adopt health legislation within the limitations of protecting public health (ibid., art. 168), approximation of laws (ibid., art. 114) or social policy (ibid., art. 153).
The principles of conferral (arts. 4 and 5, Treaty on European Union [TEU]) and subsidiarity (Article 5, TEU) make it impossible for the EU to develop a consistent, effective and efficient healthcare co-ordination policy and a healthcare ecosystem on an EU-wide level. However, Article 14 (eHealth) of Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare does not deal with the essence of the problem, which is the EU’s healthcare ecosystem fragmentation.
The EU’s ‘Decision No 1082/2013/EU’ on serious cross-border threats to health does not solve the core issue, because the EU still must respect Member States’ autonomy in operating their own health systems – even during global pandemics. Hence, now is the time for the Member States to reflect on what role the EU should play during healthcare crises and focus on the boundaries of the current European treaties. It is unacceptable for EU citizens that still, in the year 2020, the subsidiarity principle is hindering their protection from and preparedness for COVID-19 due to the EU’s inability to act as a union, tackling the crisis at the European level, instead of taking ‘country-by-country’ actions.
As Europe begins to explore the political, legal and financial tools to construct a European Health Union, including an embedded European Health Research Programme, with the ambition of making the European healthcare ecosystems work together holistically, the Commission, the EU Member States and the European Parliament could convince EU citizens of the rationale for developing a better Health Union.
Subsidiarity and EU co-ordination
The EU institutions can and must play a role to serve as a platform to co-ordinate emerging healthcare crisis at the European level. Co-operation between Member States towards protecting and promoting public health is a key driver for EU health policies.
The COVID-19 outbreak has proved the need of a holistic and integrated approach that goes beyond the above-mentioned Directives and the subsidiarity principle. EU countries must not be left acting alone in an unco-ordinated manner. In turn, this means that the way the EU institutions understand their work together with the Member States need to be turned around.
For example, looking at that the European Semester Country reports and recommendation, the European Commission should reflect on what it needs to co-create to support Member States with a well-functioning co-ordination mechanism to save lives and provide economic stability to the European Union. This latter point will be looked in more depth in the following section.
The European Semester Country Reports: the need for a co-creation approach
The COVID-19 outbreak has resulted in a situation in which national Governments are taking different decisions (on PPE, on masks protocols, on lockdowns, etc), depending on varying expert epidemiological advice. On the other side of the spectrum, EU citizens expected and demanded clarity and co-ordination on the rules and decisions taken.
Moreover, the COVID-19 outbreak occurred in a context in which most EU healthcare systems were already under heavy pressure due to already existing challenges: the rise in life expectancy, the ageing population, the growing number of people living with co-morbidities and chronic diseases, etc. Some already existing structural weaknesses – as outlined in the different Country Reports of the European Semester – have now deepened. The aftermath of the economic crisis of 2008, which negatively influenced health workforce-related policies and recruitment, has shown that Europe’s healthcare systems need to be strengthened to be better prepared to future possible scenarios such as the current pandemic. Therefore, it is helpful looking back at the 2016-2020 European Commission’s Country Reports, identifying the underlying themes that could help co-designing the European Health Union.
Prevention and primary care
The logic behind prevention is simple: one does not have to treat or cure what can be prevented. Hence, prevention is the most cost-effective healthcare action one can advocate for. Throughout the Country Reports, the European Commission points towards prevention as the way forward together with fostering primary care. However, advocating for prevention requires a strong shift in the way healthcare is provided across many EU countries. It would require that healthcare budgets are shifted away from hospital care towards primary care models.
Those countries whose healthcare systems perform well are those with strong primary care systems. Primary care has many strengths as opposed to hospital/inpatient care. First and foremost, it can be provided at ‘simpler’ and less demanding healthcare facilities that can be closer to citizens. This is particularly useful for those countries in which the population may be spread across large rural areas, where significant regional differences between the largest populated cities and rural areas occur. As outlined in the Country Reports, the optimal implementation goes by shifting away from the traditional medical-oriented model of organising care, supported by a strong primary care network of community care nurses, having an alleviation for the hospital sector.
Hospital and inpatient care
Hospital and inpatient care are more expensive, requires more complex and expensive facilities, and can only be provided at high technology facilities, which normally are present in big urban areas, or close to them, where the concertation of the population is higher. Traditional models of healthcare have greatly focused on diagnosis, cure and treatment, not on preparedness, nor prevention and primary. The EU healthcare ecosystem should free up space in hospitals, fostering other means of care such as primary care, home care and/or long term care.
Long term care
In the context of ageing populations, most EU Member States lack strong and well-functioning long-term care systems for the elderly and the people who need it. Long term care systems are necessary for taking care of people who are now too old to be able to be fully self-sufficient, and to do so with the maximum human dignity possible. As of now, most long term care is provided at home by family members (mainly women), providing care at their own expense, with no remuneration. However, as the population is ageing, EU Member States are starting to develop and implement long term care systems to alleviate the situation. Deficiencies in long term care systems have been exacerbated by the COVID-19 crisis.
Sufficient and safe workforce staffing levels are key for the right functioning of healthcare ecosystems. The Country Reports indicate that those countries with worse scoring health indicators are also those where shortages of healthcare professionals persist. When shortages occur, these tend to be more acute for the nursing profession. Workforce shortages lead to many problems which can only be solved with policies that empower the health workforce.
As outlined in the Country Reports, there are a number of reasons accounting for workforce shortages. Namely insufficient, poor working conditions, wrong retention measures, as seen by the high number of nurses leaving the profession across many countries, or simply insufficient funding in the system, making frontline staff redundant. In the context of the ongoing COVID-19 crisis, workforce shortages have become more significant than ever before. Several EU countries have introduced emergency measures such as hiring back retired healthcare professionals or introducing student nurses as assistants. Of course, these measures are not taken without a risk.
EU health research budget
Although the previous European Commission, under the mandate of President Juncker, made clear that the health programme would be absorbed by other programmes into the enlarged European Social Fund, COVID-19 has changed that political perspective. A standalone health programme is needed to be able to act during health emergencies and to better protect frontline healthcare professionals and workers. This standalone health programme should be fit for purpose, improving the health conditions across all EU Member States through better prevention, access, and continuity of care. This shift would give the EU institutions greater capacity to act during future health emergencies.
Furthermore, a European health data space is needed to enable the pooling of health data from EU citizens in a defined and standardised manner, with the Electronic Health Record as key foundation for continuity of care. This would have a positive influence on being better prepared for the next upcoming health crisis.
When a health crisis occurs, the nursing profession is always at its frontline serving citizens and patients. This has been part of the European history since the time of Florence Nightingale. In times of war and pandemics, when the populations need healing and support, the nurses are always at the frontline day and night. For that reason, the European Nursing Research Agenda should be part of the European Health Research Programme, aiming at providing the evidence for EU and national leaders, as well as health stakeholders, to take concrete and immediate actions to support and protect the European Citizens.
To fulfil the urgent needs of the frontline nurses and healthcare professionals, as well as the citizens, the EU should empower the nursing profession and nursing research to co-create the European Health Union, making sure future EU health policies are fit-for-purpose.
The COVID-19 outbreak and the EU Ebola crisis show significant similarities in the measures needed to protect EU citizens. To be better prepared for the next outbreak, we need to be all prepared (EFN, 2015):
- Support the EU health workforce, in particular nurses, to respond to the challenges of Infectious Diseases of High Consequences (IDHC) without compromising its safety and wellbeing, through co-ordinating and building capacity in the nursing workforce, providing further access to vital education and training that includes opportunities for regular drills on donning and doffing PPE, and assuring the provision of adequate resources and support for a safe working environment;
- Explore the causes, mechanisms and consequences of stigmatisation related to the care and treatment of IDHC within the European Health Research Programme and based on outcomes, take appropriate actions to tackle stigmatisation;
- The new coronavirus outbreak has brought stigmatisation with it. Frontline healthcare professionals, including nurses, has been unfairly stigmatised by some citizens as dangerous and disease carriers. Other citizens consider them to be modern heroes; however, popular support needs to be translated into professional and political support;
- Continue to encourage investment in preparedness, learning from the lessons and knowledge gained so far, and enhancing monitoring and follow up initiatives. Protecting the health workforce, as well as the public, from future health threats should continue to remain a priority for all Member States individually and the European Commission collectively, ensuring that relevant protective equipment, appropriate education and training, and protocols are made available to frontline staff;
- Ensure the public and health professionals are well aware about an existing network of IDHC centres or the national civil protection authorities ensuring that information and support is provided across all healthcare settings, including community care and elderly care homes;
- Co-creating and co-designing with frontline nurses fit-for-purpose political decision-making processes and policies for IDHC preparedness is a must. This is a challenge for the European Commission as their only counterparts are the Member States and sometimes academics who they ask for advice, but not frontline healthcare professionals. Healthcare professionals and NGOs are often kept out of the decision-making equation, making political actions often unfit-for-purpose. This accounts for the lack of pragmatism in the decision taken by the European Commission handling the COVID-19 crisis. Past exercising of best practices and fulfilling academic frameworks do not draw an EU strategy for supporting the nursing frontline. The new coronavirus outbreak proves that more EU support to the frontline is needed when emergencies emerge. EU citizens need EU policies that protect frontline staff from working overtime and of being continuously understaffed;
- Analyse the impact that the economic crisis and the cuts in healthcare (decreased resources, decreased staff, overtime, etc.) have on the capacity of healthcare ecosystems and health professionals in responding to Ebola, COVID-19 and other IDHC outbreaks; and
- It is essential to explore how different healthcare systems are responding to this crisis and to monitor and measure the impact of the COVID-19 on the nursing workforce. Then, the nursing workforce will need to be better equipped to be able to handle the next pandemic. The Union Civil Protection Mechanism (UCPM) could be the key to strengthen capacity and future EU co-ordination.
The COVID-19 outbreak is having an unforeseen impact across all EU countries, and it is affecting all layers of society. COVID-19 is reshaping the EU political priorities and strategies to get the European Union acting as one. The European Commission continues being a stakeholder with whom the nursing profession engages in constant dialogue, but a new area of co-operation has arisen co-ordinating actions to tackle the health crisis with the EU Member States.
However, the main takeaway of the COVID-19 outbreak is that the European Commission needs to look for formulae to solve the subsidiarity nightmare, at least in the context of health crisis, to ensure that the EU can act in a co-ordinated and even manner across all EU countries. This is a need and a demand of nurses at the frontline, as well as of citizens. If the EU politicians fail in creating a European Health Union, the whole of the EU institutions risk to be perceived merely as a bureaucratic complex of institutions that are not reliable in the context of health emergencies.
Therefore, the European Union should not only facilitate collaboration among Member States but should aim to increase its number of competences in the health area.
The European Commission needs to start looking at the European Semester Country Reports on a different way, particularly after the COVID-19 crisis. The Country Reports identify a series of health trends in which there is room for improvement across all Member States. The next step would be to liaise with the nursing profession to formulate EU policies that benefit Member States in improving their healthcare ecosystems as needed. The EU institutions should actively co-engage with all EU health stakeholders, especially the nurses, to be better prepared frontline. That way, all EU countries will be much better prepared for the next pandemic / health emergency.
Finally, the EFN continues being engaged with all interested EU and health stakeholders to do what is best for the frontline nursing profession across the EU and Europe, and in doing so, maximising the health outcomes of patients affected by the COVID-19 disease.
- Treaty of Lisbon: http://eur-lex.europa.eu/JOHtml.do?uri=OJ:C:2007:306:SOM:EN:HTML
Professor Dr Paul De Raeve, RN, MSc, MStat, PhD
European Federation of Nurses Associations
This article is from issue 14 of Health Europa. Click here to get your free subscription today.