Dealing with future challenges: opportunities and focal areas for policy and society

This Public Health Foresight Study provides detailed options for action for three future challenges (in Dutch), based on wide-ranging stakeholders meetings. The three challenges are:

• Cardiovascular diseases and cancer are health conditions that continue to occur frequently, will still be the cause of the majority of deaths in 2040, and have a major impact on patients’ lives.
• The group of older people living independently who have dementia and other complex problems is increasing significantly.
• Mental pressure on teenagers and young adults is increasing, and this may have consequences for their psychological health.

Vulnerable groups are a specific concern in the development of solutions for all three challenges. A summary of the key stakeholder-defined recommendations for the courses of action for these challenges is available here. Based on the options for action, a number of overarching opportunities and focal areas for policy and society have been identified. The options for action have shown that an integrative and personal approach is essential in dealing properly with a number of major future challenges. What is needed to truly take a step forward here? What are the most high-potential solutions in this context, and which established initiatives can they be combined with? These opportunities and focal areas are described in this web article.

Integrative and personal approach: what do we know?

Past experience with development of integrative policy highlights success factors

The options for action have shown that an integrative and personal approach is essential in dealing properly with a number of major future challenges. Experience has already been gained with developing an integrative approach. For instance, initiatives aimed at ‘population management’ have been launched in various regions. This approach entails that providers of prevention, care and social support, as well as health insurance companies, municipalities and citizens, make a joint effort to improve population health, quality of care, and managing costs, known as the triple aim. Nine of these types of collaborations have been designated by the Ministry of Health, Welfare and Sport as a test platform for ‘better health care at lower cost’. In addition to health care-related projects, these test platforms have also launched projects about the preconditions, such as new types of funding, joint data infrastructure and developing a shared vision of the future. More and more domain-spanning interventions are also designed and applied, such as experiments with the social teams for the neighbourhood and a joint prevention programme between a municipality and a health insurance company. Results of specific interventions (for instance regarding effective prescription) and of interventions aimed at a specific target group (for instance diabetes patients) have already produced tangible results. In addition, the experiences from the test platforms have provided insight into factors that will increase the chances of success in developing integrative policy. A shared ambition and visions as well as shared benefits are key in this. Mutual trust between the parties involved is also a crucial factor here (1). Other success factors include getting citizens involved in the development of policy and providing sufficient funding and capacity (2,3).

Experiences with test platform: sufficient room for developing integrative interventions, though there is a need for support

Executives and managers of primary and secondary health care organisations, municipalities, health insurance companies and other stakeholders in the test platform for ‘better health care at lower cost’ indicate that there is currently sufficient room in the health care system to develop an integrative approach to health care and support. These stakeholders therefore do not currently feel a need for changes in laws and regulations, but there is a need for support from the national government. For instance, executives and managers expect that it will take a change in budgets and boundaries to increase commitment to working towards an integrative approach and to accelerate the new approach, for instance shifting funding from secondary to primary health care, or adopting a more flexible attitude regarding the maximum growth threshold for hospital budgets. In that approach, they also expect the Ministry of Health, Welfare and Sport to provide additional support in the form of e.g. trust, clarity about what is permitted within the current system, or financial support for the necessary overarching investments such as coordination. Additionally, the executives and managers need more insight into supply and demand, as well as the selection, quality, costs and cost-effectiveness of interventions in the field of prevention, health care and well-being. The expectation is that such knowledge will contribute to awareness and a willingness to cooperate in changing the range of options on offer. It will also help in more focused development of the necessary improvements towards an integrative approach and the accountability for the necessary investments.

Personal health care proves to be hard to achieve in practice

The options for action (in Dutch) have shown that it is essential to supplement an integrative approach with a personal approach in dealing properly with a number of major future challenges. We already have some experience with this as well. However, those are often small-scale initiatives, where scaling up and structural embedding in the health care process has proven to be difficult. Achieving sustainable change will require adjustments in every layer of the health care system. This is not just about changes in the organisation of health care, but also for instance about changes in culture and behaviour, as well as helping health care providers develop new skills. Specific concerns in the continued development of excellent health care for patients suffering from multiple diseases and issues at the same time are shared decision-making and the engagement of the social environment, including informal carers. Taking a broader view than just their own medical discipline, and seeking collaboration with other involved professionals in the social domain and others, are key factors for success. Preconditions that can help in the development and application of personal health care include support from national and regional policy, financial support for innovation, and options for training and coaching (4,5).

Not much known about effectiveness of interventions, specifically about integrative approach

As described previously, some experience has been gained in developing integrative policy, and which conditions are necessary to get it off the ground. However, the effectiveness of these policies has not yet been assessed thoroughly. In general, information on effectiveness is only available for a small percentage of existing interventions. Little to no research has been done on this aspect for the majority of the interventions. The interventions that have been proven to be effective are often aimed at a single risk factor, or an isolated problem in a specific setting. Examples include a self-help programme to quit smoking, or a training programme to prevent older people from falling. In the field of integrative interventions, deploying actions in multiple areas at the same time, information is only available regarding the effectiveness of (tiny) aspects of those interventions. We know comparatively more about lifestyle interventions, and less about interventions aimed at societal and social issues among young adults and older people. For more information, see the background document about accredited interventions (in Dutch).

Technology and restructuring of the living environment provide opportunities

Technology can support people with chronic diseases and their informal carers

Technology has a high potential for improving our public health and making health care better and more efficient. People often think high-tech solutions when they hear technological innovation, such as robotic surgery and advanced scanning equipment. In actual fact, the more low-tech solutions seem most promising in the approach to a number of major future challenges. For instance, there are more and more technological applications to assist people with dementia and their care providers and informal carers, such as apps, sensors to monitor lifestyle, and alarm systems that can help set up night-time care more efficiently. Apps and self-measurement solutions also offer opportunities for supporting patients in managing chronic diseases effectively, such as diabetes and cardiovascular diseases. More and more people are keeping track of their own blood pressure, cholesterol level or blood sugar level.
Digital applications in health care are often referred to as eHealth. Quite a lot of experience has already been accrued in eHealth in the field of mental health care, both in secondary mental health care as well as among family doctors. There are for instance various eHealth interventions available for or concerning the treatment of anxiety and depression, and they are often demonstrably effective. In addition, people use video calling (calling where you can see and hear each other) more and more frequently, for instance when treating anxiety problems. These examples show that a great deal can be achieved with relatively simple solutions. Since over 82 percent of Dutch people use internet on a daily basis, the increase in eHealth interventions would work well in the digital climate in the Netherlands.

Achieving health care gains in multiple fields through the living environment

Changes in the structure of the living environment can provide a significant contribution to encouraging healthy behaviour. Consider for instance making the environment more accommodating of active leisure activities, making the food selection healthier, and banning smoking on school grounds and in queues. In these ways, the living environment can contribute to preventing chronic diseases such as cardiovascular diseases, cancer, diabetes and (vascular) dementia. Even more health care gains can be achieved by structuring the living environment more effectively. For instance, proper deployment of greenery and water in the living environment will not only encourage leisure activities, but also social interaction and relaxation. In addition, it aids in offsetting the health effects of climate change, such as heat stress. Such measures as minimising vehicle traffic in inner-city areas and promoting the use of public transport can improve air quality and at the same time encourage an active lifestyle. With the arrival of the Environment and Planning Act (‘Omgevingswet’), which will enter into force in 2021, the municipalities need to include health as a factor in their environmental vision and plan. This future law therefore provides opportunities for integrative and multi-sectoral policy, in which various environmental, physical and social environment factors are assessed in conjunction. In anticipation of that, various parties are already developing tools which will help in arriving at an integrative, carefully considered decision for local environmental policy. Examples are the Gelderse Gezondheidswijzer, the Guide to a Healthy Living Environment (Gids Gezonde Leefomgeving) and the Step by Step Plan for Setting the Agenda for Health and the Environment and Planning Act (Stappenplan agendasetting gezondheid en Omgevingswet).

These challenges demand a new way of working

Complex issues require a different way of gathering and assessing evidence

In public health, people usually operate on the basis of a direct causal relationship between an intervention and a health outcome. In the challenges we are facing, health is actually determined by multiple factors, which also influence each other. An approach that views the problem and the underlying factors as a coherent whole would therefore be more appropriate for these types of complex problems. We also refer to this as a systems approach. That means that the central question in public health research is not: ‘Will this intervention solve this problem?’, but: ‘Will this intervention help in beneficially adjusting the system, and if so, how?’ (6). A systems approach requires a different method of gathering and assessing evidence about the effects of interventions. Customarily, a study design is defined at the start of the study and maintained until the end of the experiment. Gaining control of complex issues requires a different approach – one with consecutive, short-term cycles of experimentation, monitoring and adjustment. In such an approach, it is also necessary to compile information not just on health impacts, but also on the process and on contextual factors. This is also important because it often takes a long time before the effects of interventions become visible in health outcomes. If the focus is limited exclusively to health outcomes, it would be possible to conclude wrongly that an intervention does not have an effect.

The golden standard in effectiveness research is the Randomized Controlled Trial (RCT). This is a study structure which includes an intervention group and a control group. The participants are assigned to one group or the other based on random chance. The RCT produces solid evidence and offers a good way to demonstrate causality. However, this structure is primarily suited for single interventions which can be carried out under controlled circumstances and is therefore not ideal for the more experimental study structure that is needed in a systems approach. In recent years, it has become increasingly apparent that there is a preference and need for more flexibility in research designs. However, there is still insufficient knowledge about how alternative designs work and which solution would be the best alternative for each setting (7). In addition, there is a need for developing more knowledge about how we can best assess and calibrate the results of research based on alternative designs.

New roles and skills required from policy makers, professionals, researchers and citizens

Many of the future challenges we face in public health are complex in nature and demand an integrative and personal approach. To be able to address these challenges effectively, we will need a different way of looking at public health and a different way of working. That will also lead to changes in the roles and skills of stakeholders. This not only applies to researchers, and to professionals in the fields of health care and public health, but to policy makers and citizens as well (see table).

New roles and skills required to deal with complex problems

Facilitating these role transitions will entail changing existing patterns and habits – and that will not be easy. A more facilitating role for the government, for instance, means accepting that there might be less control. Using other, less solid outcomes means accepting that not everything will be directly measurable and accountable. Health care professionals will have to grow accustomed to a situation in which patients will sometimes make decisions that are not in line with their own insights and guidelines. For researchers, this new way of working means amongst other things that they will initially have to swim against the current of prevailing scientific standards and values. Citizens will also have to get used to their new role. Learning how to handle technological applications which can support that active role will be part of that. However, not everyone will be able or willing to take on such an active role. These groups also need attention.

Many initiatives already emerging to learn from and continue building on

Society and the health care sector already adapting to be better prepared for the future

Many societal initiatives have already been developed which contribute to addressing the challenges we are facing. Health care cooperatives and other citizen initiatives, for instance, show how a community can arrange its own health care for older people. More and more new housing formats are emerging where older people can live independently, like ‘student housing’ for older people, communal residences or group homes, city districts where several generations live together, and courtyard communities where neighbours help each other. The health funds are also already making anticipatory plans regarding the future changes in our public health. One remarkable example is the Multi-year Programme for Healthy Generation of the Collaborative Health Funds. In addition, we see more programmes created which involve not just the government, but also a wide-ranging array of societal stakeholders. Examples are Delta Plan Dementia, Everything is Health (part of the National Prevention Programme), and the Care Pact for the Elderly.

Similar collaborations are also being established locally, such as the Teylingen Health Care Pact. This shows that social organisations and parties are increasingly aware of their role in tackling the major challenges to our public health, and also want to make their contribution. There are also many initiatives in the health care sector itself. Sometimes these initiatives arise in response to an acute problem, such as the increasing pressure on emergency care (and subsequently on hospital beds) because more and more older people are reporting to accident and emergency wards. But structural adjustments in order to ensure the long-term availability and accessibility of suitable health care are also being developed. Examples include the test platforms for ‘better health care at lower cost’, as discussed above. These test platforms have laid a solid foundation for further collaboration. Involved executives and managers therefore expect that it will be much easier to extend existing interventions to include bigger target groups and more health care providers. In addition, it is expected that new project ideas can be developed and implemented at an accelerated pace, because organisations now have faster channels of communication in place (1).

Future challenges intersect with current policy

Many of the imminent problems identified in this Public Health Foresight Study intersect with existing and proposed public health policy and agreements. For instance, in 2014 the National Prevention Programme (8) was launched, which has set goals for the focal areas: smoking, excessive alcohol consumption, overweight, physical activity, depression and diabetes. The three focus areas in the prevention agreement, which will be concluded in 2018, are smoking, problematic alcohol use and overweight. Those are the key determinants of cardiovascular diseases, cancer and other chronic diseases. A great deal of policy has recently also been developed for the fields of geriatric care, dementia, loneliness, the health care job market and mental health, and much is also still being developed. Under the banner of ‘the right care at the right place’, the Ministry of Health, Welfare and Sport is working to achieve structural change in health care; key concerns here include a shift in focus from disease to coping in daily life and self-reliance, as well as providing coherent care (9).

This overlap creates opportunities for a coherent approach, in which actions focused on addressing the long-term challenges identified in the Public Health Foresight Study can be aligned with the established policies. Considering long-term plans is a strategic exercise which provides insight into future challenges and goals, in addition to the problems which play a role here and now. For instance, the long-term perspective could lead to additional actions or shifts in current policy focus. The overlap is not just limited to the Ministry of Health, Welfare and Sport, but it also intersects with policies of other government ministries. That could for instance involve such measures as raising excise duties and other pricing measures, or limiting points of sale, but also setting up a living environment that encourages healthy behaviour, or measures that protect health, for instance aimed at clean air and safe working conditions. By creating a safe, clean and inclusive environment where people can live, work and learn, policies defined by other government ministries can be used to make a significant contribution to addressing future challenges to our public health.