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КОНЦЕПЦИЯ РАЗВИТИЯ ЕВРОПЕЙСКОГО ЗДРАВООХРАНЕНИЯ ДО 2040 ГОДА — ВЗГЛЯД В БУДУЩЕЕ *
Лазебник Л. Б., Стефанюк О. В.
ГБОУ ВПО «Московский государственный медико-стоматологический университет им. А. И. Евдокимова»
LOOKING INTO THE FUTURE OF DIGESTIVE HEALTH
Lazebnik L. B., Stefanyuk O. V.
State Budget Educational Institution of Higher Professional Education (SBEIHPE) «A. I. Evdokimov Moscow State University of Medicine and Dentistry» Ministry of Healthcare of Russia
* Материал презентации к статье — на цветной вклейке в журнал.
Резюме
Комментарии к концепциям развития европейского здравоохранения до 2040 года на примере гастроэнтерологии. Лазебник
Леонид Борисович
На Европейской Гастронеделе, проходившей в октябре 2014 года в Вене, был представлен масштабный научный проект, определяющий развитие здравоохранения Европы до 2040 года.
Огромный труд высокопрофессионального коллектива.
Lazebnik Leonid B. E-mail:
Leonid.borisl@gmail.com
Инициатива по проведению данного футурологического исследования исходившая от ирландских ученых, была поддержана руководством Объединенной европейской гастроэнтерологической ассоциации. Работа поручена коллективу профессиональных аналитиков и прогнозистов. В качестве переменных было использовано огромное количество показателей — социологических, промышленных, научно-исследовательских, экологических, медицинских, статистических, политических, демографических и т. д.
Экспериментальная и клиническая гастроэнтерология 2015; 117 (5):51-57
Summary
The article describes comments to the concepts of development of the European health until 2040 on the example of Gastroenterology. UEG's major project "Healthcare in Europe 2040: Scenarios and implications for digestive and liver diseases", was launched at UEG Week in Viena, in October, 2014
Eksperimental'naya i Klinicheskaya Gastroenterologiya 2015; 117 (5):51-57
Press material предоставленный Polly Cooper PR & Media Relations
United European Gastroenterology (UK Office)
Tel: +44 (0) 1444 811099 Email: media@ueg.eu Twitter: @UEGMedia
Выдвинуты три концепции развития здравоохранения Европы до 2040 года на примере моделей колоректального рака и заболеваний паренхимы печени, т. к. именно эти заболевания являются самыми быстрорастущими по распространенности.
Были представлены три модели — ледниковая, силиконовая и золотая. В оригинале они обозначены как «age». В русскоязычном изложении мы употребили термин «период». Заранее приносим свои извинения, принимаем все замечания, если перевод термина покажется не совсем корректным.
Первая модель — «ледниковый период» — основана на старых подходах, когда финансирование бюджетного здравоохранения в любых странах не может быть достаточным, хотя бы в силу быстро развивающихся высоких лечебно-диагностических технологий и огромных затрат на производство новых высокоэффективных лекарственных препаратов.
Бюджет ни одной самой богатой страны не выдержит нарастающих потребных объемов финансирования здравоохранения. Как бы декларативно не объявляли заботу о здоровье населения — проплатить всем нуждающимся, например, качественную химиотерапию в полном объеме невозможно.
Поэтому если в Европе будет работать старая модель на фоне обнищания здравоохранения и недостатка финансирования произойдет обеднение как населения, так и врачей, и они будут переезжать в экономические более развитые страны. Прежняя модель XIX-XX веков неизбежно делит здравоохранение на бюджетное и коммерческое, т. е. для бедных и богатых. Подобная ситуация уже сейчас наблюдается в новых странах Евросоюза, в частности бывших странах соцлагеря и бывших советских республиках. В значительной мере это можно отнести и к нам.
В этой ситуации колоректальный рак в любом случае будет диагностироваться на поздних стадиях, как в группе богатых, так и в группе бедных. Согласно этой модели средний возраст больного с впервые диагностированным колоректальным раком составит 50 лет. Причина — позднее обращение к врачу (уже на 3-4 стадии) из-за отсутствия ярко выраженных симптомов. На первые признаки заболевания — запоры, неустойчивый стул и небольшие кишечные кровотечения, как правило, никто не обращает внимания. Мировая практика показывает, что диагноз ставится по факту обращения.
Стоит отметить, что у нас, в России, сейчас запущены скрининговые программы, которые позволяют сделать это гораздо раньше.
Вторая концепция — «силиконовый период».
Технологически она означает мощный рывок вперед. Согласно этой концепции, каждому новорожденному жителю Евросоюза (или уже внутриутробно) проводится генная диагностика всех будущих заболеваний. Генная диагностика помогает заподозрить и предположить заболевание тогда, когда у человека еще нет никаких признаков болезни, определяемых общепринятыми методами исследования, но есть так называемые «гены предрасположенности». В таком случае уже и пациент, и врачи нацелены на прицельное обследование. Тогда средний возраст больного колоректальным раком, следовательно и продолжительность жизни будут зависеть от раннего его выявления и времени проведения операции и соответствующей химиотерапии. Отличие «силиконовой модели» развития здравоохранения заключается в том, что она делает ставку на e-medicine (электронную медицину), когда каждый больной имеет в своем личном распоряжении биодатчики, которые определяют состояние его здоровья.
Непосредственный контакт «врач и пациент», в привычном нам смысле в этой модели прерван. Общение идет только через электронные системы: все данные поступают в call-центр, врач анализирует результат и дает рекомендации, также он может дистанционно задать любой вопрос пациенту и быстро получить на них ответ.
Фактически это так называемые облачные технологии, которыми мы сейчас все успешно пользуемся. В «облаке» уже хранится информация о геноме, и врач знает все о пациенте. Когда от больного поступает, к примеру, информация, что у него появились следы крови в кале в 25-летнем возрасте, врач тут же направит его на обследование, чтобы исключить или подтвердить диагноз «колоректальный рак». О развитии болезни еще никто не знает, там может одна молекула гемоглобина «выпала» из пораженной опухолью клетки, но врач уже принял «звонок» и сделает все возможное, чтобы сохранить здоровье человеку.
Следующая модель — «золотой век» — золотой период европейского здравоохранения, такая модель представляется немного утопичной, поскольку может быть реализована только в процветающих Соединенных Штатах Европы (СШЕ). В качестве примера рассматривается следующая ситуациия: человек с малосимптомными кишечными расстройствами, живущий в Англии, обратив внимание на свой симптом, обращается в аптеку (именно в аптеку, а не к врачу), покупает (или получает бесплатно) эндоскопическую капсулу, соответствующим образом готовится, проглатывает ее. Капсула передает получаемую картинку в единый электронный центр, который находится условно в Нидерландах, куда поступает электронная информация из всех проглоченных жителями Евросоюза радиоэндокапсул. Там «облако» анализирует полученную информацию и дает рекомендацию этому больному ехать, например, в южную Италию, поскольку только там находится единый европейский клинический центр, занимающийся только этими формами колоректального рака. На первый взгляд все оперативно и достаточно результативно. Однако даже при таком развитии событий средний возраст жителя СШЕ с впервые диагностируемым колоректальным раком составит 58 лет. Потому что бюджет золотого века объединенной Европы не выдержит нагрузки, чтобы всех бесплатно обеспечить химиотерапией.
Более подробно читатель может ознакомиться с любезно представленным нашему журналу руководством UEG текстом самого доклада и материалами презентации
Looking into the Future of Digestive Health
UEG Week is the largest and most prestigious gastroenterology meeting of its kind in Europe and provides the best clinical and translational science together with high-class education. With around 14,000 delegates from 118 countries attending this year's 22nd UEG Week
Current burden of GI disease
in Vienna (18-22nd October), it provided the perfect opportunity to launch UEG's Pan-European Survey of Digestive Health and Healthcare in 2040 scenarios, to inform decision making and help shape a future high-quality European healthcare system.
Digestive disorders and diseases currently represent a health time bomb in Europe. Their combined burden in terms of financial cost, decreased quality of life and patient mortality is on an upward trend that shows little sign of significantly slowing down. From Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD), to colorectal and pancreatic cancers, the clinical symptoms of many digestive conditions can be extremely debilitating, mentally and physically, with some having high levels of mortality.
To draw together all the available evidence and provide up-to-date information on the human health consequences and public health burden of GI disorders, UEG commissioned the Survey of Digestive Health1 Across Europe in the spring of 2013, at the request of its own Future Trends Committee. An experienced research group from Swansea University in Wales, UK, initiated a detailed assessment of digestive health
Changing trends in GI disorders
According to the survey results, many European countries have witnessed increases in the incidence of major GI disorders such as upper GI bleeding, inflammatory bowel disease [IBD], coeliac disease, alcoholic liver disease, gallstone disease, and colorectal and oesophageal cancer, with disease rates highest amongst older people. Incidence or prevalence rates were found to be higher in many Eastern European countries compared with other regions in Europe, with mortality from GI disorders (other than cancer and infectious diseases) highest in Eastern and North
across Europe, focussing on the clinical and economic burden of disease and the organisation and delivery of gastroenterology services across 28 European Union (EU) member states, Norway, Switzerland, Liechtenstein and Russia.
The results of the survey were announced at UEG Week and revealed changing trends in the incidence and prevalence of many important GI and liver diseases as well as worrying inequalities in the provision of healthcare services across the continent. "This extensive survey has highlighted major differences between countries in terms of both the risk of developing GI disorders and their long-term health outcomes," explains UEG President, Professor Michael Farthing. "We are particularly concerned about the increasing incidence of most major GI disorders across Europe and the clear differences in outcomes for patients between Eastern and Western nations."
Eastern countries and lowest in parts of Scandinavia and the Mediterranean Islands.
GI cancer is now the leading cause of cancer death in Europe, and while mortality rates for colorectal cancer (CRC) have fallen for several decades in almost all Western, Northern and Central European countries, rates continue to rise in many parts of Eastern Europe and some parts of Southern Europe. "We need to look more closely at the reasons behind these worrying statistics and find ways to overcome the regional differences observed and reduce the growing burden of GI cancers," said Professor Farthing.
1 Roberts SE, Samuel DG, Williams JG, et al. Survey of Digestive Health across Europe. Part one: The burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe. Report for United European Gastroenterology. October 2014. Anderson P, Dalziel K, Davies E et al. Survey of Digestive Health across Europe. Part two: The economic impact and burden of gastrointestinal diseases across Europe. Report for United European Gastroenterology. October 2014.
Подробнее схема представлена на цветной вклейке в журнал.
Inequalities in healthcare provision
Major inequalities in healthcare provision across Europe were also identified in the Survey of Digestive Health. While CRC screening programmes are now well established in most European countries, participation rates vary widely and there is no standardised approach to screening. Upper GI bleeding is managed variably across Europe, with a lack of consensus on best practice. Endoscopy services are patchy and not currently viewed as a priority by policymakers, which could have serious implications for meeting future
service demands. Training of medical students in gastroenterology varies between countries and is poorly documented.
"This survey was wide-ranging and has highlighted some areas of good practice, but many areas that require attention at both a national and European level," said Professor Farthing. "Our hope is that, ultimately, the survey and the reports generated will help to improve care and health outcomes and reduce inequalities across the continent."
Healthcare in 2040: Scenarios and Implications
UEG's major project "Healthcare in Europe 2040: Scenarios and implications for digestive and liver diseases", was also launched at UEG Week. Over the past year, UEG's Future Scenarios Working Group has been collaborating with specialist scenario planners to develop a set of plausible, relevant and challenging scenarios that may impact the delivery of GI healthcare in 2040.
By combining expert knowledge, quality research, hard work, dedication and a lot of imagination, three
very different scenarios — entitled Ice Age, Silicon Age and Golden Age were developed and presented at a symposium, engaging with more than 600 gastro and liver disease specialists as well as a wide range of stakeholder groups. The aim is for them to challenge current thinking and encourage the gastroenterology community to anticipate the changes that might be required in the approach to education, training and in identifying future research strategies in a rapidly changing healthcare environment.
Future Scenarios in GI Healthcare: Why do we need them?
Digestive diseases — gastrointestinal and liver disorders — are common across Europe, causing more than 500,000 deaths in 2008 in the 28 EU member states (and more than 900,000 deaths in the whole of Europe, including Russia and other non-EU states).
They are one of the most common reasons for primary care consultations and hospitalization. Over one-third of all acute hospital admissions are due to GI diseases, and most Europeans will visit a gastroenterologist at least once in their lives.
Furthermore, current models for healthcare delivery in Europe are unsustainable. A rapidly ageing
population supported by a shrinking workforce presents major challenges and requires new thinking.
"We know that the incidence and prevalence of most major GI disorders are rising across Europe and there is already poor access to care in many countries," said Professor Farthing. "Since changing the way we deliver healthcare in the future seems inevitable, we decided to take a bold approach and highlight possible scenarios, inspiring everyone to get involved and play their part in shaping a better future for digestive and liver disease healthcare," Professor Farthing explains.
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Healthcare in Europe 2040: Our Scenarios
The three scenarios envisage, firstly, an optimistic view of the future encapsulated by an economically thriving and a politically integrated Europe. The second scenario
sees a future driven by technology with less doctor-patient interaction and the third, is a pessimistic scenario where poorly integrated EU is in economic decline.
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First Scenario: The Ice Age
This is the first scenario, where European impoverishment will have led, by 2040, to two-tier medicine and eventually to the collapse of public healthcare in Europe.
During the Ice Age, depletion ofnatural resources, climate change, the ageing population, and the economic crisis have all contributed to the widespread impoverishment ofEurope.
Health and healthcare
The Ice Age sees the development of a two-tier healthcare system and eventually to the collapse of public healthcare in Europe. An ageing population with an increase in age-related chronic diseases like cancer, antibiotic resistance as well as a lack of new drugs and outbreaks of infectious disease epidemics all threaten the population.
Poverty and poor healthcare have led to high rates of morbidity and mortality within the general population. Most individuals have little or no access to healthcare and are also plagued by diseases associated with alcohol, tobacco and obesity. In desperation, people
Second Scenario: The Silicon Age
During the Silicon Age, advancements in technology, science and social interactions will have led, by 2040, to very extensive automation of diagnoses and treatments and redirected health behaviour, resulting in a positive change in healthcare.
This scenario envisages global trends and crises will lead to changes at every level: individual behaviour, social priorities, industrial strategies and government policies.
The European Union (EU) no longer exists, most of the population is poor, unemployment is high, religious groups and alternative "health" sects have a strong influence and environmental hazards, including pollution and increased exposure to potential carcinogens, contribute to this toxic mix.
are turning to alternative medicine and uncontrolled self-medication.
For the rich minority, there is excellent healthcare available in the private sector. Science is market- driven and healthcare services, primarily provided by profit-hungry insurance companies, are only available to those who can pay.
Healthcare workers are leaving Europe seeking better conditions and access to the latest technology and treatments. Patients are increasingly seeking healthcare outside Europe or from off-shore floating hospitals.
Population growth has encouraged innovation and there is widespread acceptance of technology. Social media has become highly influential across the healthcare sector.
The EU still exists and has contributed to the modernization of health legislation across Europe. There is a large non-EU immigrant population relying on social security and draining resources and escalating healthcare expenditure.
Health and healthcare
Whilst inequalities in healthcare still exist, the dominance of technology in the silicon age has provided a means of delivering high-tech, cost-effective care to the majority.
E-algorithms, detailing risk profiles for multiple diseases are developed through genomic screening at birth. Individuals take responsibility for self-monitoring, self-cure and prevention assisted by comprehensive lifestyle and health data stored in their personal electronic patient cloud record.
Automated diagnostics and interventions, including robotics, are readily available by self-referral.
With the adoption of e-health, the role of the doctor has fundamentally changed from delivering health care to assisting individuals with navigating and understanding their medical e-data.
Collaborative ventures as well as innovative public and private partnerships work for the benefit ofthe patient. Widespread use ofsocial media platforms has helped to integrate significant advances in medical research and data capture.
Alongside e-health is a shift into a new e-Economy which includes novel monetary systems which carry the risk of using unofficial currencies and unethical and even criminal activities. Social media and advanced technology bring with them privacy concerns, some poor-quality health practices as well as complex systems which are hard to navigate.
Third Scenario: The Golden Age
This last scenario sees a strong, well-coordinated, unified Europe which will, by 2040, ensure high- quality healthcare for ALL European citizens.
An influx of immigrants and widespread cross-border movement of Europeans has resulted in a more multi-cultural and united Europe. Here we see a United States of Europe (USE), with no borders, homogenized education, taxation and legislation systems and universal access to healthcare for all. Economic growth has slowed, environmental issues are being addressed, and preventive health is high on the agenda. The resultant peace and stability denotes a Golden Age for Europe.
Health and healthcare
Whilst dictated by a strong centralized public sector, the private sector has helped implement "mandatory" prevention programs. Children are formally educated about the importance of health and all have a positive attitude towards illness prevention. Consistent Europe-wide prevention-based strategies, policies and practices are in place. Good quality, cost-effective healthcare is available to all, delivered primarily via e-Health initiatives, outpatient clinics, low-cost healthcare centers and care at home.
There is total European cohesion in healthcare with consistent medical education and training across the continent. Doctors continue to play a traditional role and deliver patient centred care. Patients increasingly use e-mail and dedicated electronic platforms to liaise with their healthcare professional and travel freely across the United States of Europe to access the best healthcare providers and specialist centres.
These scenarios have been developed with the aim of encouraging Europe-wide debate on the future of care of people with digestive and liver diseases.
"They could all form the shape ofhealthcare in Europe in 2040 and will help focus our thinking and encourage
us to have courageous conversations about the future of gastroenterology practice," said Professor Farthing.
"We hope everyone will join the debate and work together to deliver high-quality care whatever the future holds."
The Road Ahead: Mobilising politicians, patients and primary care
Although 30 % of the European population is affected by a GI disease at least once during their lifetime, gas-troenterology is still not a priority on the European health agenda.
UEG has been proactively raising the profile of gastrointestinal and liver diseases in Brussels for several years now, with the primary objective of increasing the quality and accessibility of healthcare services for patients across Europe, as well as encouraging increased investment in research in those diseases that have a high
impact on morbidity and mortality. The data from the Survey of Digestive Health provides further evidence for more funding to be made available to improve service provision and support Europe-wide research.
UEG promotes gastroenterology at a political level, to raise awareness among decision-makers in Brussels and every European country. As representative for all the major European societies with an interest in the digestive system, UEG is the ideal stakeholder for the EU.
UEG support of "The EU Alcohol Strategy"
As an example of UEG's commitment to encouraging greater political action at EU and national level to address issues which impact on the gastrointestinal system, it is supported the second annual Awareness Week on Alcohol-Related Harm (AWARH — November 24th — 28th).
Europe is by far the world's heaviest- drinking region, suffering a socio-economic loss of more than € 155 billion through alcohol2. Alcohol itself is linked to more than 60 diseases, including many ofthe digestive tract. AWARH'14 therefore calls for a renewal of the EU Alcohol Strategy, which expired in 2012, and for the adoption of national alcohol strategies that live up to the commitments of the World Health Organisation.
The week drew attention to the negative health effects of alcohol consumption and encouraged greater political action, with events in Strasbourg and Brussels,
including a roundtable and exhibition in the European Parliament in Strasbourg and a meeting of health attachés under the Latvian Presidency of the Council of the EU. The week ended with the 6th European Alcohol Policy Conference in Brussels (27th and 28th November).
Throughout the Conference, UEG hosted a bo oth to make known the harmful impact of alcohol intake on the gastrointestinal system. In addition, UEG and the European Association for the Study of the Liver (EASL), jointly organized the workshop "Health and Research" during the Conference where medical experts provided scientific evidence on the impact of alcohol consumption on the health of key parts of the human body. The current state of research was portrayed as well as those areas where more research is still needed, with the goal of identifying priorities for future research policies.
JOIN THE "HEALTHCARE IN 2040" DEBATE
Help plan for a better future for people with digestive and liver diseases Visit www.ueg.eu / research / gi2040/ and vote for the scenario you think is most likely.
Post your thoughts and comments on the future of digestive and liver diseases throughout Europe @my_UEG #GI2040.
2 WHO-Europe, 2012, Alcohol in the European Union — consumption, harm and policy approaches, http://ec.europa. eu/health/alcohol/docs/who_ alcoholintheeu_2012_en.pdf
UEG's commitment to education
UEG's new e-learning developments provide a unique education platform with exciting innovations for the gastroenterology and hepatology community.
The UEG e-learning portal has grown exponentially and now includes thousands of categorised and searchable documents, media clips, CME courses as well as meeting content. As Dr Charles Murray, gastroenterologist at London's Royal Free Hospital and Chair ofUEG's e-learning Taskforce, explains in the October edition of the UEG Journal, "The strength and advantage of the UEG educational platform is that the UEG Member Societies and UEG National Society Members feed into it, shaping a unique and comprehensive portal with extensive GI-related material and educational resources."
UEG provides high quality, accessible and independent education and training in gastroenterology. We carry out a range of activities, including training courses (both as e-learning and hands-on residential courses), hosting a huge online library and providing the latest GI news, fostering debate and discussion.
"UEG now look to improving their educational resources. We aim to do so by further engagement with Member Societies and National Societies through sharing of information, research and news and look forward to any ideas from members and specialists. UEG Education is at the beginning of an exciting stage in its development and we value input in shaping the future," adds Dr Charles Murray.
The challenges offered by disorders and diseases of the gastrointestinal tract and liver will not diminish in Europe in the near future, although there is little doubt that the pattern ofdisease is likely to change, driven by a variety of factors including diagnostic advances, better treatments, prolonged survival and an increasing ageing population.
By voicing the need for increased awareness, training and research in this changing environment, UEG is looking towards a future when the focus and recognised success in gastroenterology will be on the prevention rather than treatment of digestive diseases and disorders across Europe.
К статье
Концепция развития европейского здравоохранения до 2040 года — взгляд в будущее (стр. 51-57).
Z - G ASTRO AND LI VE R PISE ASE IN EURO P E
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