Correspondence
450
400
Removal of medical card cover New prescription charges Higher inpatient charges Higher threshold for drug reimbursement Increase in emergency department charges
350
300
€ million
250
200
150
100
50
0 2008
2009
2010
2011
2012
2013
Year
Figure: Estimates of cost-shifting from the government to households, 2008–13 We used data from Health Sevice Executive Performance reports,2,3 Primary Care Reimbursement Services Annual reports, and government budgets. For the Primary Care Reimbursement Services Annual reports see http://www. hse.ie/eng/staff/PCRS/PCRS_ Publications/ For the government budgets see http://budget.gov.ie/ budgets/2013/Documents/ Expenditure%20Report%20 2013%20Part%20I.pdf
1546
emergency departments, and slightly lower average lengths of stay.3 Were the only message more productivity and improved efficiency —then a mild and brief austerity programme might be the boot camp needed for a lagging health system. Nevertheless, the prolongation of austerity, coupled with other less appealing adjustment policies, has yielded increased rationing. First, despite increased efficiencies, waiting lists are rising. Whereas, there were some improvements in reducing wait times for elective public hospital care between 2011 and 2012, these were lost in the first 9 months of 2013. Designated numbers of public hospital beds fell by about 900, or around 10%, between 2008 and 2012 and not surprisingly the system is now showing strain. Also other cutbacks in services relate to home-help hours, which are projected to be 18% lower in 2013 than in 2008. This is despite a policy to care
for more people in their homes in the community, keeping older and sicker people out of hospitals. Nevertheless, Ireland has provided substantial financial protection for the worst off in the health sector through the crisis bailout period. More people than ever before have medical cards (which ensures free family doctor and hospital care and medications at low charge) due to higher unemployment rates and decreasing incomes. Yet, there has also been considerable but quiet cost-shifting by government back onto households. Ireland, despite being a tax-based system, had user charges at all levels of care even before the crisis.4 Now, increasingly the costs of care are being transferred onto patients (figure). Throughout the austerity period, tariffs have risen (in terms of inpatient day charges, emergency department attendance charges, and the introduction and escalation of prescription charges, even for those with medical cards) and eligibility for subsidies has been eroded (the threshold for reimbursement of drug payments has increased) or been revoked for some groups (no longer automatic free care for people older than 70 years). In 2013, such cost-shifting meant that every person in Ireland was on average paying about €100 in additional costs for accessing care and prescribed drugs. More specifically the burden is on sick and old people. All this is happening when the government’s policy is to achieve universalisation by extending free access to family doctor care and introducing universal health insurance. Yet that policy, hampered by the recession, is only just beginning with the promise of free family doctor access for children younger than 5 years in 2014. Austerity has forced the Irish Government to scrutinise all healthcare activities and costs. This is not a bad thing. However, the depth of cuts needed means that easy cost-saving measures have now been exhausted. Structural reform is required to manage
costs down further, such as moving much of the care for chronic disease out of hospitals and into primarycare settings. Yet this takes time and the governance capacity to do this is absorbed with trying to hold the system together and transition to universal care. Although austerity can produce windfall gains through reducing costs and galvanising change, its benefits dissipate over time. Conversely, the risks of genuine harm increase through loss of entitlements, cutting of services, and increased burden on already struggling households. We declare that we have no competing interests.
*Steve Thomas, Sara Burke, Sarah Barry [email protected] Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Ireland 1
2
3
4
European Commission. Stability and growth pact. http://ec.europa.eu/economy_finance/ economic_governance/sgp/ (accessed Nov 15, 2013). Health Service Executive. Health service national performance assurance report. August 2013. http://www.hse.ie/eng/services/ Publications/corporate/performance assurancereports/perfassuranceAug13.pdf (accessed Nov 1, 2013). Health Service Executive. Annual report and financial statements 2012. http://www.hse.ie/ eng/services/Publications/corporate/ annualreport2012.pdf (accessed Nov 15, 2013). Department of Health and Children. Report of the Expert Group on Resource Allocation and Financing in the Health Sector. Government Publications, Dublin, 2010.
Economic recession and maternal and child health in Italy Greece’s dramatic downward trend in livebirth rates has been decribed as a component effect of the ongoing economic crisis.1 This pattern has been noted in other European countries,2 especially in Italy—where the recent economic recession has worsened social conditions and further increased unemployment. Increased poverty and youth unemployment (42·3% of individuals younger than 25 years are www.thelancet.com Vol 383 May 3, 2014
Correspondence
unemployed according to the Italian statistics bureau, know as ISTAT) have been associated with reduced birth rate and increased women’s age at childbirth. According to ISTAT, in 2012 there were 534 186 infants born in Italy—about 12 000 fewer than in 2011 and about 42 000 fewer than in 2008 (a 7·4% decrease between 2008 and 2012).3 The provisional data for 2013 show a further 4·3% decrease in birth rate. The decrease in fertility rate is more pronounced in Italian women: fertility rate in 2012 was 1·42; 1·29 for Italian women and 2·37 for foreign women. Furthermore, there has also been an increase in the age of Italian women at childbirth— the highest in the European Union, with 34·7% of women giving birth at 35 years or older.4 Infant mortality rate has progressively declined in Italy, reaching 3·2 per 1000 livebirths in 2011— although there are regional disparities: infant mortality rate is about 30% higher in the poorest southern regions, according to ISTAT. Babies born to women living in disadvantaged conditions (eg, immigrants) or with little access to prenatal services during pregnancy are at increased risk of disease.5 Worringly, childhood poverty is increasing dramatically.6 Even during this economic crisis, the government should not cut health and social subsidies to avoid further deterioration in maternal and child outcomes. I declare that I have no competing interests.
Mario De Curtis [email protected] Department of Paediatrics and Neuropsychiatry, University of Rome La Sapienza, 00161 Rome, Italy 1
2
3
Vlachadis N, Vlachadi M, Iliodromiti Z, Creatsas G. Greece’s birth rates and the economic crisis. Lancet 2014; 383: 692–93. Lanzieri G. Towards a “baby recession” in Europe? Differential fertility trends during the economic crisis. Eurostat 2013. http://epp. eurostat.ec.europa.eu/cache/ITY_OFFPUB/KSSF-13-013/EN/KS-SF-13-013-EN.PDF (accessed Feb 22, 2014). ISTAT. Natalità e fecondità della popolazione residente: caratteristiche e tendenze recenti. http://www.istat.it/it/archivio/104818 (accessed April 16, 2014).
www.thelancet.com Vol 383 May 3, 2014
4
5 6
Europeristat. The European perinatal health report 2010. http://www.europeristat.com/ reports/european-perinatal-healthreport-2010.html (accessed April 14, 2014). De Curtis M. Worrying increase in child poverty in Italy. BMJ 2013; 346: f1061. De Curtis M. Crisis puts health of children at risk. Financial Times, June 29, 2012. http:// www.ft.com/cms/s/0/ecf9d18a-bc90-11e1a470-00144feabdc0.html#axzz2ysTJb7bh (accessed April 14, 2014).
A charter for the rights of the dying child The death of a child is a devastating and tragic event for all those involved: the family members distraught by grief and the health-care providers who are called on to address the child’s complex care needs, where professionalism, ethics, deontology, and practice must reckon with personal emotions, experiences, and fears. But, it is the children who pay the highest price, suffering, and coping directly with the burden of incurable illness and death, the trauma of separation, the loss of their future and often, in solitude, the consequences of their illness, fears, and emotions. Sometimes, the people closest to them refuse to accept the negative progression of the disease and, consequently, do not recognise terminal illness and death as real and imminent issues to be addressed. As a result, these children are subjected to unrealistic decisions and treatment choices. More frequently, although fully aware of the reality of the situation, those caring for the child try to protect the child from a truth that they consider too difficult and painful to cope with by avoiding it in conversation, justifying it as the price to pay for an imaginary better future or, despite the obvious state of affairs, blatantly denying it. In both cases, even if the protagonist is the child, he or she becomes the object of treatment, care, and love, and is deprived of his or her role as a person able to speak out, decide, express, and discuss personal feelings, wishes, hopes, and deepest fears.
It is certainly not an easy problem to address, since the factors conditioning and influencing behaviour and choices are complex and deep rooted. However, the difficulties encountered in addressing this problem cannot hinder the undertaking nor generate doubts and misgivings regarding the rights of these children and the duties of those accompanying and caring for them during the final phase of their life. In September, 2012, a group of professionals working with children affected by incurable illness in Italy launched a project, supported and promoted by the Maruzza Lefebvre D’Ovidio Foundation, to formulate a charter of rights for children approaching the end of their lives. The goal was to develop a document that could be applied in any clinical situations or circumstances and used as a guide by professionals and families caring for children in the terminal stages of an illness. The project was
For ISTAT see http://www.istat. it/en/
Panel: The rights of the dying child—the Trieste Charter proposal • To be considered a person until death irrespective of age, location, illness, and care setting • To receive effective treatment for pain, and physical and psychological symptoms causing suffering through qualified, comprehensive, and continuous care • To be listened to and properly informed about his or her illness with consideration for his or her wishes, age, and ability to understand • To participate, on the basis of his or her abilities, values and wishes, in care choices about his or her life, illness, and death • To express and, whenever possible, have his or her feelings, wishes, and expectations taken into account • To have his or her cultural, spiritual, and religious beliefs respected and receive spiritual care and support in accordance with his or her wishes and choices • To have a social and relational life suitable to his or her age, illness, and expectations • To be surrounded by family members and loved ones who are adequately supported and protected from the burden of the child’s illness • To be cared for in a setting appropriate for his or her age, needs, and wishes and that allows the proximity of the family • To have access to child-specific palliative-care programmes that avoid futile or excessively burdensome practices and therapeutic abandonment
1547
450
400
Removal of medical card cover New prescription charges Higher inpatient charges Higher threshold for drug reimbursement Increase in emergency department charges
350
300
€ million
250
200
150
100
50
0 2008
2009
2010
2011
2012
2013
Year
Figure: Estimates of cost-shifting from the government to households, 2008–13 We used data from Health Sevice Executive Performance reports,2,3 Primary Care Reimbursement Services Annual reports, and government budgets. For the Primary Care Reimbursement Services Annual reports see http://www. hse.ie/eng/staff/PCRS/PCRS_ Publications/ For the government budgets see http://budget.gov.ie/ budgets/2013/Documents/ Expenditure%20Report%20 2013%20Part%20I.pdf
1546
emergency departments, and slightly lower average lengths of stay.3 Were the only message more productivity and improved efficiency —then a mild and brief austerity programme might be the boot camp needed for a lagging health system. Nevertheless, the prolongation of austerity, coupled with other less appealing adjustment policies, has yielded increased rationing. First, despite increased efficiencies, waiting lists are rising. Whereas, there were some improvements in reducing wait times for elective public hospital care between 2011 and 2012, these were lost in the first 9 months of 2013. Designated numbers of public hospital beds fell by about 900, or around 10%, between 2008 and 2012 and not surprisingly the system is now showing strain. Also other cutbacks in services relate to home-help hours, which are projected to be 18% lower in 2013 than in 2008. This is despite a policy to care
for more people in their homes in the community, keeping older and sicker people out of hospitals. Nevertheless, Ireland has provided substantial financial protection for the worst off in the health sector through the crisis bailout period. More people than ever before have medical cards (which ensures free family doctor and hospital care and medications at low charge) due to higher unemployment rates and decreasing incomes. Yet, there has also been considerable but quiet cost-shifting by government back onto households. Ireland, despite being a tax-based system, had user charges at all levels of care even before the crisis.4 Now, increasingly the costs of care are being transferred onto patients (figure). Throughout the austerity period, tariffs have risen (in terms of inpatient day charges, emergency department attendance charges, and the introduction and escalation of prescription charges, even for those with medical cards) and eligibility for subsidies has been eroded (the threshold for reimbursement of drug payments has increased) or been revoked for some groups (no longer automatic free care for people older than 70 years). In 2013, such cost-shifting meant that every person in Ireland was on average paying about €100 in additional costs for accessing care and prescribed drugs. More specifically the burden is on sick and old people. All this is happening when the government’s policy is to achieve universalisation by extending free access to family doctor care and introducing universal health insurance. Yet that policy, hampered by the recession, is only just beginning with the promise of free family doctor access for children younger than 5 years in 2014. Austerity has forced the Irish Government to scrutinise all healthcare activities and costs. This is not a bad thing. However, the depth of cuts needed means that easy cost-saving measures have now been exhausted. Structural reform is required to manage
costs down further, such as moving much of the care for chronic disease out of hospitals and into primarycare settings. Yet this takes time and the governance capacity to do this is absorbed with trying to hold the system together and transition to universal care. Although austerity can produce windfall gains through reducing costs and galvanising change, its benefits dissipate over time. Conversely, the risks of genuine harm increase through loss of entitlements, cutting of services, and increased burden on already struggling households. We declare that we have no competing interests.
*Steve Thomas, Sara Burke, Sarah Barry [email protected] Centre for Health Policy and Management, Trinity College Dublin, Dublin 2, Ireland 1
2
3
4
European Commission. Stability and growth pact. http://ec.europa.eu/economy_finance/ economic_governance/sgp/ (accessed Nov 15, 2013). Health Service Executive. Health service national performance assurance report. August 2013. http://www.hse.ie/eng/services/ Publications/corporate/performance assurancereports/perfassuranceAug13.pdf (accessed Nov 1, 2013). Health Service Executive. Annual report and financial statements 2012. http://www.hse.ie/ eng/services/Publications/corporate/ annualreport2012.pdf (accessed Nov 15, 2013). Department of Health and Children. Report of the Expert Group on Resource Allocation and Financing in the Health Sector. Government Publications, Dublin, 2010.
Economic recession and maternal and child health in Italy Greece’s dramatic downward trend in livebirth rates has been decribed as a component effect of the ongoing economic crisis.1 This pattern has been noted in other European countries,2 especially in Italy—where the recent economic recession has worsened social conditions and further increased unemployment. Increased poverty and youth unemployment (42·3% of individuals younger than 25 years are www.thelancet.com Vol 383 May 3, 2014
Correspondence
unemployed according to the Italian statistics bureau, know as ISTAT) have been associated with reduced birth rate and increased women’s age at childbirth. According to ISTAT, in 2012 there were 534 186 infants born in Italy—about 12 000 fewer than in 2011 and about 42 000 fewer than in 2008 (a 7·4% decrease between 2008 and 2012).3 The provisional data for 2013 show a further 4·3% decrease in birth rate. The decrease in fertility rate is more pronounced in Italian women: fertility rate in 2012 was 1·42; 1·29 for Italian women and 2·37 for foreign women. Furthermore, there has also been an increase in the age of Italian women at childbirth— the highest in the European Union, with 34·7% of women giving birth at 35 years or older.4 Infant mortality rate has progressively declined in Italy, reaching 3·2 per 1000 livebirths in 2011— although there are regional disparities: infant mortality rate is about 30% higher in the poorest southern regions, according to ISTAT. Babies born to women living in disadvantaged conditions (eg, immigrants) or with little access to prenatal services during pregnancy are at increased risk of disease.5 Worringly, childhood poverty is increasing dramatically.6 Even during this economic crisis, the government should not cut health and social subsidies to avoid further deterioration in maternal and child outcomes. I declare that I have no competing interests.
Mario De Curtis [email protected] Department of Paediatrics and Neuropsychiatry, University of Rome La Sapienza, 00161 Rome, Italy 1
2
3
Vlachadis N, Vlachadi M, Iliodromiti Z, Creatsas G. Greece’s birth rates and the economic crisis. Lancet 2014; 383: 692–93. Lanzieri G. Towards a “baby recession” in Europe? Differential fertility trends during the economic crisis. Eurostat 2013. http://epp. eurostat.ec.europa.eu/cache/ITY_OFFPUB/KSSF-13-013/EN/KS-SF-13-013-EN.PDF (accessed Feb 22, 2014). ISTAT. Natalità e fecondità della popolazione residente: caratteristiche e tendenze recenti. http://www.istat.it/it/archivio/104818 (accessed April 16, 2014).
www.thelancet.com Vol 383 May 3, 2014
4
5 6
Europeristat. The European perinatal health report 2010. http://www.europeristat.com/ reports/european-perinatal-healthreport-2010.html (accessed April 14, 2014). De Curtis M. Worrying increase in child poverty in Italy. BMJ 2013; 346: f1061. De Curtis M. Crisis puts health of children at risk. Financial Times, June 29, 2012. http:// www.ft.com/cms/s/0/ecf9d18a-bc90-11e1a470-00144feabdc0.html#axzz2ysTJb7bh (accessed April 14, 2014).
A charter for the rights of the dying child The death of a child is a devastating and tragic event for all those involved: the family members distraught by grief and the health-care providers who are called on to address the child’s complex care needs, where professionalism, ethics, deontology, and practice must reckon with personal emotions, experiences, and fears. But, it is the children who pay the highest price, suffering, and coping directly with the burden of incurable illness and death, the trauma of separation, the loss of their future and often, in solitude, the consequences of their illness, fears, and emotions. Sometimes, the people closest to them refuse to accept the negative progression of the disease and, consequently, do not recognise terminal illness and death as real and imminent issues to be addressed. As a result, these children are subjected to unrealistic decisions and treatment choices. More frequently, although fully aware of the reality of the situation, those caring for the child try to protect the child from a truth that they consider too difficult and painful to cope with by avoiding it in conversation, justifying it as the price to pay for an imaginary better future or, despite the obvious state of affairs, blatantly denying it. In both cases, even if the protagonist is the child, he or she becomes the object of treatment, care, and love, and is deprived of his or her role as a person able to speak out, decide, express, and discuss personal feelings, wishes, hopes, and deepest fears.
It is certainly not an easy problem to address, since the factors conditioning and influencing behaviour and choices are complex and deep rooted. However, the difficulties encountered in addressing this problem cannot hinder the undertaking nor generate doubts and misgivings regarding the rights of these children and the duties of those accompanying and caring for them during the final phase of their life. In September, 2012, a group of professionals working with children affected by incurable illness in Italy launched a project, supported and promoted by the Maruzza Lefebvre D’Ovidio Foundation, to formulate a charter of rights for children approaching the end of their lives. The goal was to develop a document that could be applied in any clinical situations or circumstances and used as a guide by professionals and families caring for children in the terminal stages of an illness. The project was
For ISTAT see http://www.istat. it/en/
Panel: The rights of the dying child—the Trieste Charter proposal • To be considered a person until death irrespective of age, location, illness, and care setting • To receive effective treatment for pain, and physical and psychological symptoms causing suffering through qualified, comprehensive, and continuous care • To be listened to and properly informed about his or her illness with consideration for his or her wishes, age, and ability to understand • To participate, on the basis of his or her abilities, values and wishes, in care choices about his or her life, illness, and death • To express and, whenever possible, have his or her feelings, wishes, and expectations taken into account • To have his or her cultural, spiritual, and religious beliefs respected and receive spiritual care and support in accordance with his or her wishes and choices • To have a social and relational life suitable to his or her age, illness, and expectations • To be surrounded by family members and loved ones who are adequately supported and protected from the burden of the child’s illness • To be cared for in a setting appropriate for his or her age, needs, and wishes and that allows the proximity of the family • To have access to child-specific palliative-care programmes that avoid futile or excessively burdensome practices and therapeutic abandonment
1547
