Final Report to 24th BSPC Volume I August 2015

Baltic Sea Parliamentary ConferenceThe BSPC Working Group onInnovation in Social- and HealthcareFinal ReportAugust 2015Baltic Sea Parliamentary ConferenceThe BSPC Working Groupon Innovation in Social- andHealthcareFinal ReportAugust 20152The BSPC Working Group The Baltic Sea Parliamentary Conferenceon Innovation in Social- and Healthcare (BSPC) was established in 1991 as a forum forpolitical dialogue between parliamentariansfrom the Baltic Sea Region. BSPC aims at rais-© Landtag Mecklenburg-Vorpommern, ing awareness and opinion on issues of currentSchwerin 2015 political interest and relevance for the BalticText: Julie Helmersberg Brevik, Bodo Bahr, Sea Region. It promotes and drives various in-Kim Kleine itiatives and efforts to support a sustainableEditing: Bodo Bahr, Kim Kleine environmental, social and economic develop-Layout: produktionsbüro TINUS ment of the Baltic Sea Region. It strives at en-Photos: BSPC Secretariat, shutterstock.com hancing the visibility of the Baltic Sea RegionPrint: produktionsbüro TINUS and its issues in a wider European context.Copies: 250 BSPC gathers parliamentarians from 11Printed on environmentally-friendly paper national parliaments, 11 regional parliamentsPrinted in Germany and 5 parliamentary organisations around theBaltic Sea. The BSPC thus constitutes aunique parliamentary bridge between all theEU- and non-EU countries of the Baltic SeaRegion.BSPC external interfaces include parlia-mentary, governmental, sub-regional and oth-er organizations in the Baltic Sea Region andthe Northern Dimension area, among themCBSS, HELCOM, the Northern DimensionPartnership in Health and Social Well-Being(NDPHS), the Baltic Sea Labour ForumBaltic Sea Parliamentary Conference (BSLF), the Baltic Sea States Sub-regional Co-www.bspc.net operation (BSSSC) and the Baltic Develop-ment Forum.Bodo Bahr BSPC shall initiate and guide political ac-Head of BSPC Secretariat tivities in the region; support and strengthenbb@bspc.net democratic institutions in the participatingstates; improve dialogue between govern-ments, parliaments and civil society; strength-en the common identity of the Baltic Sea Re-BSPC Secretariat gion by means of close co-operation betweenc/o Lennéstraße 1 national and regional parliaments on the basis19053 Schwerin of equality; and initiate and guide political ac-Germany tivities in the Baltic Sea Region, endowingPhone (+49) 385 525 2777 them with additional democratic legitimacyand parliamentary authority.The political recommendations of the an-nual Parliamentary Conferences are expressedin a Conference Resolution adopted by con-sensus by the Conference. The adopted Reso-lution shall be submitted to the governmentsof the Baltic Sea Region, the CBSS and theEU, and disseminated to other relevant na-tional, regional and local stakeholders in theBaltic Sea Region and its neighbourhood.3ContentsPurpose of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Summary - Political recommendations for the24th Baltic Sea Parliamentary Conference . . . . . . . . . . . . . . . . . . .91. Mandate and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152. Challenges for Social- and Healthcare . . . . . . . . . . . . . . . . . .173. Innovation in Social- and Healthcare . . . . . . . . . . . . . . . . . .234. Working Group Composition and Activities . . . . . . . . . . . . .375. Political Recommendations . . . . . . . . . . . . . . . . . . . . . . . . .57Purpose of the Report 5Purpose of the ReportThe purpose of this Report is to present a set of political recommen-dations from the BSPC Working Group on Innovation in Social- andHealthcare (WG ISHC) to the 24th BSPC in Rostock in Mecklen-burg-Vorpommern 1 September 2015.The report also gives a cursory account of some trends and challeng-es that the WG sees as drivers behind the need for innovation in so-cial welfare and healthcare services. A definition of the concept ofinnovation in social- and healthcare is also presented, together withbrief remarks on its potentials and barriers.6 Opening of the ConferenceForeword 7ForewordOlaug BollestadMany countries today face the same type of challenges within socialwelfare and healthcare – an ageing population, health inequalities,an increase in lifestyle-related diseases and financial pressure on theservice systems.We know that the percentage of elderly is increasing at the sametime as the number of young people entering the workforce is de-clining.We also fear health inequalities between different socio-economicgroups as well as between rural and urban areas. Further, a risingneed for treatment of the ageing population, but also medical inno-vation and progress, increase the financial pressure on the servicesystems.More or less all countries have to cope with these challenges causedboth by external development trends, such as the financial crisis,but also by internal transformations. As a consequence, we need tolearn to think differently. Innovation could be an important tooland strategy to counter these challenges. In this way they could beperceived as main drivers of innovation, while innovation can also8 Forewordbe considered a main strategy and tool to meet and manage thesechallenges.The Working Group was established in August 2013 in order toraise the political attention on these issues. The aim has been tocontribute to exchange of knowledge and best practices and to de-velop a set of recommendations that should be pursued in nationalparliaments and governments.In this report you will find summaries from our six Working Groupmeetings, study trip and visits to different institutions and actorswho have given us input during these two years of work. We havelearned from each other, shared best practices and discussed a rangeof issues related to innovation, prevention and care. This report alsoincludes a Volume II, which contains details of the WG meetingprogrammes, expert presentations, and WG homework. Volume IIcan be accessed via the BSPC website at http://www.bspc.net/page/show/694.As members of the Working Group and parliamentarians from ninedifferent countries, we will do our best to follow up the recommen-dations in our national parliaments. On behalf of the WorkingGroup I therefore encourage you to engage in these essential issuesfor our future.Olaug Bollestad, MP, Parliament of NorwayChairperson of the BSPC Working Group on Innovation in Social-and Healthcare 2013-2015Summary – Political recommendations for the 24th BSPC 9Summary – Politicalrecommendations for the24th Baltic Sea ParliamentaryConference1On the basis of its mandate, the Baltic Sea Parliamentary Confer-ence Working Group on Innovation in Social- and Healthcare pro-poses the following political recommendations as a result of itswork. The recommendations are also a result of deliberations andproposals of the meetings of the Standing Committee of the BSPCin Brussels (21 January 2015) and Stralsund (29 May 2015) and in-clude the contribution of the BSPC to the 4th Northern DimensionParliamentary Dialogue with regard to the Northern DimensionPartnership in Public Health and Social Well-being. The followingpolitical recommendations will be conveyed to the 24th BSPC inMecklenburg-Vorpommern on 30 August – 1 September 2015:The BSPC Working Group on Innovation in Social- and Health-care calls on the Governments, and where appropriate the Parlia-ments, of the Baltic Sea Region:Regarding Cross-border Cooperation in Healthcare• to expand and deepen cross-border cooperation in healthcarein the Baltic Sea Region because of the common challenges allBaltic Sea Region countries face in the field of social- andhealthcare, and therefore• to support the Northern Dimension Partnership in PublicHealth and Social Well-being (NDPHS) as a highly valuedand innovative regional network, significantly contributing tothe improvement of peoples’ health and social well-being inthe Northern Dimension area, including its efforts to coordi-nate the new NDPHS 2020 Strategy and its Action Plan and• to launch and develop concrete cross-border healthcare initia-tives, such as ScanBalt or the WHO’s Healthy Cities project;• to improve the borderless cooperation and medical1 For details see chapter 5.10 Opening of the ConferenceOpening of the Conference 1112 Summary – Political recommendations for the 24th BSPCspecialisation in treatment of rare diseases, bearing in mindthe cost-effective usage of medical equipment;• to broaden the scope of the Könberg report to the entire BalticSea Region, in order to gain a comparable overview of the sta-tus of health and care in the Baltic Sea Region and• to intensify exchanges of experience and the cooperation withthe aim of fighting multi-resistant microbes and to implementresearch in this area;• to spread innovative practices throughout the Baltic Sea Re-gion to become a model region in healthcare and continue thedevelopment of the Baltic Sea Health Region;• to strive to introduce same standards in the treatment of con-tagious infectious diseases on a high level all around the BalticSea Region;Regarding Health Economy• to use synergies with existing strategies, such as the ScanBaltStrategy 2015-2018;• to improve the support for the development of innovations inhealthcare to undertake measures in order to prevent a braindrain;• to improve the conditions to support the development of in-novations in healthcare, especially in the fields of e-health andtelemedicine;• to improve early intervention to strengthen a good publichealth through social investment like vaccine programmes,and work towards a stronger alcohol, tobacco and illicit use ofdrugs prevention, diabetes and other lifestyle illnesses;• to support the usage of cost-reducing methods for better life qual-ity, like cultural and physical health-related activities in treatment;• to foster the development of health-related services within thetourism strategies of the Baltic Sea Region countries;Summary – Political recommendations for the 24th BSPC 13Regarding Sustainable and Accessible Social- andHealthcare• to ensure affordable healthcare for everybody and emphasisethe focus on the needs of the patient;• to raise the awareness of the people living in the Baltic Sea Re-gion to support approaches for more responsibilities of the pa-tients;• to take strong measures to ensure equitably available socialwelfare and healthcare services, e.g. between urban and ruralareas and between socio-economic groups;• to develop and strengthen strategies addressing the demo-graphic change, an important issue affecting all partner re-gions;• to carry out studies with the aim of developing preventionstrategies in healthcare, such as the North-Trøndelag HealthStudy (HUNT);• to create incentives to improve the conditions of the nursingand care professions;• to install geriatric healthcare centres and modify social rehabil-itation centres to ensure healthcare in rural areas as well as toimprove age-appropriate medicine;• to recognise that strong social partners in the social- andhealthcare professions exist, and to protect their activities;• to consider health in all policies;• to commission a regular report on the status of health in thecountries of the Baltic Sea Region.14 1. Mandate and Scope1. Mandate and Scope 151. Mandate and ScopeThe WG members in Riga, Latvia at their inaugural meetingMandateThe Working Group was established by the 22nd BSPC on 27 Au-gust 2013. It is constituted as an ad-hoc Working Group under theauspices of the Standing Committee of the Baltic Sea ParliamentaryConference in accordance with the BSPC Rules of Procedure.The overarching objective of the Working Group is to elaborate po-litical positions and recommendations pertaining to innovation insocial- and healthcare.The Working Group and its members should aim at raising the po-litical attention on innovation in social- and healthcare, for instanceby pursuing those issues in their national parliaments and with theirgovernments. Moreover, the Working Group should contribute tothe exchange of knowledge and best practices within its area of re-sponsibility.16 1. Mandate and ScopeScope of WorkThe overarching scope of the Working Group should include, butnot be limited to, areas such as:• Social innovation, with focus on social- and healthcare• Innovation in healthcare systems and services• Innovation in social care systems and services, with focus onelderly people.The Working Group should place great weight on prevention in so-cial- and healthcare. The issues and priorities of the Group are fur-ther described in the separate Scope of Work of the Working Group.The work should cover the following main issues:• Innovation in Social- and Healthcare (ISHC) –general concepts• Trends and challenges in social- and healthcare• Progress in ISHC, including best practices• Barriers for ISHC• Action to promote ISHCOutputThe core output of the WG is its political recommendations onthe subject of ISHC. The first part of the political recommenda-tions was presented to the 23rd BSPC in 2014 (see part 5.1). Thefinal and consolidated recommendations can also be found in theconclusive part of this report and are submitted to the 24th BSPCin 2015 (see part 5.2).2. Challenges for Social- and Healthcare 172. Challenges for Social- andHealthcareSocial welfare and healthcare systems and services face a number ofchallenges, which are caused both by external development trendsand internal transformations. These challenges can also be per-ceived of as main drivers of innovation. Conversely, innovation canbe seen as the main tool to meet and manage the challenges.The WG sees the following main challenges of social- and health-care today and tomorrow.2.1 AttitudesAt the individual and social level, there are ingrained attitudes aboutwhat mental and physical health means, about the roots and causesof somatic and mental illnesses, and about the means by which so-cial and medical services should be provided and mental and phys-ical illnesses treated and cured. For generations, people have beenaccustomed to associate social services and mental and medicaltreatment with large public systems and programmes, hospital andinstitutionalised care, and prescription of pharmaceuticals. Howev-er, the demand for social, mental and medical services is growingand changing, and it is doubtful whether it can be satisfied withinexisting paradigms and structures. Efforts will be necessary to createand disseminate a heightened awareness of social- and healthcareand the ways it should be delivered and implemented, placing muchemphasis on prevention.2.2 The Ageing Population and the DemographicStructureThe population is ageing. Those aged 65 years or over will accountfor 29.5% of the EU-27’s population by 2060 (17.5% in 2011).The share of those aged 80 years or above in the EU-27’s popula-tion is projected to almost triple between 2011 and 2060. Thenumber of young people entering the workforce is declining. Thiswill affect the state of public health and is exacerbated by an age-ing population and ensuing care requirements. The needs for18social- and healthcare services will increase, and it will also causestructural and spatial changes on social- and healthcare service de-livery and funding.2.3 Health InequalitiesFrom a social- and healthcare perspective, and within predicted so-cio-economic trends, an ageing population could mean on the onehand that a growing share of the population is becoming more afflu-ent and educated, meaning they will be more active in demandinghigh quality social and medical services. They are also reaching ad-vanced age in a more healthy fashion, meaning they will demandthese services for a longer period of time. On the other hand, the19socio-economic development could also produce a growing segmentof the older population that will become poorer, sicker and less capa-ble of seeking and paying for qualified care, meaning that there arerisks that their needs are not adequately, or only perfunctorily, met.Medical and social services are unevenly distributed, and the qualityof care varies both spatially and socially. Rural and sparsely populatedareas are particularly afflicted, with long distances to healthcare andsocial service infrastructure. Deprived urban areas are also vulnerable.There is a need of reducing the risk of poverty, especially preventingpoverty in old age, since this is directly related to health and socialwell-being. Such a development would entail great perils of growingdivides between the richer and poorer parts of the population in gen-eral and in the ageing population in particular, leading to marginali-sation and more pronounced social stratification. Both cases will in-crease the pressure on social- and healthcare services.20 2. Challenges for Social- and Healthcare2.4 The Increasing Burden of Communicable andNon-Communicable DiseasesAn ageing population will also cause changes in somatic and mentalhealth patterns. There will be a growth in lifestyle-related diseases,and hence a more complex clinical picture. New types as well as anincrease in multi-resistant bacteria will emerge. Today 86% ofdeaths and 77% of the disease burden in the WHO European Re-gion are caused by non-communicable diseases such as cardiovascu-lar diseases, cancer, diabetes and chronic respiratory diseases. Thiswill cause increased expectations and demands on the social servicesand health systems. Preventive strategies and actions will play an in-creasing role to reduce premature mortality and morbidity, both atan institutional and individual level.2.5 Financial Pressure on Healthcare and SocialService SystemsEconomic constraints together with demographic pressure limit thepossibilities to increase social- and healthcare funding and to ensuresustainable and equitable social- and healthcare. The rising costs areincreasingly a result of a rising need for treatment of the ageing pop-ulation, but also of medical innovation and progress. The number ofrecipients of social benefits grows, while the number of payers to thesocial insurance systems decreases. New models for funding of social-and healthcare systems are needed. NGOs and non-state actors mightget a stronger role in social- and healthcare.2.6 Ensuring High Quality and Evidence-BasedTreatment and CareNew IT and biotechnology solutions must be introduced and inte-grated within existing care systems, recognising i.e. their ethical andequality dimensions. There will be a growth of e-health develop-ment and implementation. Alternative forms of service infrastruc-ture and institutional social care, such as home care, will be devel-oped. Effective social- and healthcare provision requires thoroughquality control. There will also be growing demands of includingand empowering patients in health and social care, which will re-quire legislative reforms.2. Challenges for Social- and Healthcare 212.7 Progress and EthicsA challenge, which is also an opportunity, is posed by the break-throughs and innovations that are made in medical and psycholog-ical fields. They have resulted, and will result, in new medicines,cures, therapies and treatments. They will lead to an improved andbroadened capability to diagnose, prevent, treat and remedy variousexisting ailments, but also to an expanded ability to provide a morequalified and patient-adapted treatments over a broader spectrumof stages of an illness. The challenge of such a development is thatthe enhanced therapeutic capacity is likely to drive costs upwards,which in turn necessitates difficult but necessary ethical, medicaland social considerations on how to prioritise scarce resourcesamong different illnesses, patient groups and other competing in-ternal and external interests.2.8 Social- and Healthcare Workforce DevelopmentThere is a rising shortage of skilled workers and difficulties in re-cruiting new generations for the tasks of healthcare. The lack ofqualified personnel is mainly caused by unattractive conditions. Thecare of the elderly will require a growing availability of multi-profes-sional staff to work with prevention, activating and rehabilitation.There is a problem of brain-drain and out-migration of social andhealth professionals.2.9 Vested InterestsThe vested interests of the pharmaceutical and medical industries poseanother kind of challenge. It is a well-known fact that e.g. the pharmaindustry is extremely lucrative, and it is reason to believe that this goesfor the medical industry as well. Innovation in these fields has indeedproduced more efficient and widely available medicines and therapies,which can cure illnesses better and remedy previously incurable diseas-es. The development has also escalated the costs of medicines andtreatments. There is, to put it bluntly, sizable profits to be made fromcuring people ́s illnesses, and it is important to ensure that productionand innovation is primarily devoted to the improvement of people ́shealth and not to the enrichment of companies. Public authoritiesmust ensure fair and sound competitive rules and conditions for thepharma and medical industries, that monopolistic practices are bannedand prosecuted, and that public procurement rewards transparentcompetition, high quality and low costs.22 2. Challenges for Social- and Healthcare3. Innovation in Social- and Healthcare 233. Innovation in Social- andHealthcare3.1 DefinitionAn established overriding and generic definition of innovation isthe one found in the OECD Oslo Manual on Guidelines for Col-lecting and Interpreting Innovation Data (2005):“An innovation is the implementation of a new or significantly im-proved product (good or service), or process, a new marketingmethod, or a new organisational method in business practices,workplace organisation or external relations.”Innovation in social- and healthcare can be seen as a way of adapt-ing to changing conditions for the social welfare and the healthcaresystems. Demand for social welfare and health services is escalatingand changing character, while the resources for such services are be-coming more constrained. Hence, there is a need to use resourcesmore efficiently and creatively, in order to secure a continued andfair distribution and access to social and health services.The view by the Working Group is that innovation in social welfareand healthcare is a means of securing the provision of qualitativeand equitably available social and medical services to the citizens ina situation of changing demographics, altering patterns of somaticand mental ailments, and constrained financial resources.3.2 PotentialsAs the changing global economy generates further fiscal and socialpressures, continued reform approaches will be necessary. A com-prehensive Health Economy approach should be fostered in orderto promote the strategies, products and services that are conduciveto an efficient and equitable social- and healthcare system, as well asthe political, legal economic and organisational infrastructure thatis needed to support it.Policymakers have already introduced a considerable range of institu-tional reforms in response to the financial and organisational pres-sures that their health systems confront. There are already numerous24 3. Innovation in Social- and Healthcarepractical examples of strategies, programmes, plans and projects onISHC. Experiences and lessons have accumulated, and new poten-tials are constantly identified. These can be grouped in clusters suchas care philosophies and policies, care practices, care organisation andmanagement, and R&D and business opportunities.3.3 Best PracticeThe WG has through study visits, expert presentations and ex-change of knowledge, collected and compiled examples of best prac-tices gleaned from Working Group meetings, the study trip and vis-its to different institutions and actors.E-health EstoniaThe Estonian e-health system is used for health information, dig-ital prescription, health insurance, public health and quality regis-ters, and for telemedicine tools. The central system is built on acommon platform with one-entry configuration, making securitya prime concern. It was decided early on that the system should bea stand-alone structure and not be subordinated to a ministry.Currently, about 93% of the population has documents in thecentral system, and e-prescription is used in 97% of the cases. Thecentral system consists of a number of sectorial sub-systems forvarious kinds of patient information. The information in thesub-systems can be combined, but there are different levels of au-thorisation in order to define the level and extent of access by dif-ferent users. In other words, everyone does not have access to allthe information. The insurance system, for example, does nothave automatic access to patient information. A patient can alsochoose to block information from external access. Spouses, how-ever, can automatically access each other’s patient information,and it is not possible for one partner to block the informationfrom the other. Patient information for persons up to 18 years ofage is automatically accessible by his/her parents. By permission ofa patient, his/her information can be made available for others. Apatient can follow the log of his/her journal.The perceived benefits of the system so far are greater efficiency inpatient handling and care, lower health costs, better quality of care,and raised patient awareness. Some of the lessons learned are that3. Innovation in Social- and Healthcare 25user-friendliness is of decisive importance that data quality is cen-tral for the functioning if the system, and that there is a precariousbalance between usability and security. Certain reluctance fromhospitals to implement the system has been noted, and therefore itis important to use both carrots (funding) and sticks (legislation) topropagate it.HUNTThe Nord-Trøndelag Health Study (The HUNT Study) is one ofthe largest health studies ever performed. It is a unique database ofpersonal and family medical histories collected during three inten-sive studies. The strategy is to earn and maintain the confidence ofthe population we work in and with, as is necessary for any success-ful population study. This strategy has been successful and has re-sulted in extraordinarily high participation rates. There is enthusias-tic public and political support for HUNT and for the HUNT Re-search Centre. This has created a good basis for further health sur-veys in the county and an excellent research environment.The WG members at HUNT Research Facility26 3. Innovation in Social- and HealthcareThe Norwegian Competence Centre for Arts and HealthThe Centre is based on Government White Paper 29 Future Care(2012-2013), entered into Care Plan 2020. It is managed by theNorwegian Directorate of Health, and is a partnership betweenHUNT Research Centre (NTNU), Nord-Trøndelag Health Trust,Levanger Municipality, Nord-Trøndelag County and the UniversityCollege in Nord-Trøndelag (HiNT).The background is recent research and practical experiences whichshow that systematic use of song, music and other cultural expres-sions seems to work positively in treatment, quality of life, use ofmedicines and personnel resources within the health field. Thisapplies both to care for the elderly/patients with dementia, tomental health work and towards other vulnerable groups.The main agenda for the Competence Centre is to contribute tothe development and use of cultural activities in daily nursingand care and promote/initiate research, competence and develop-ment of good practice. The Centre shall further develop the in-teraction between research, education, and practice and shall be aresource for municipalities, research organisations, educationalinstitutions, hospitals, and other interested parties. The Centrehas developed a separate continuing education study course inarts and health at HiNT (7.5 ECTS) which will start autumn2015 and new study programmes are under development. Thecentre works with rhythmic training for persons with a diagnosisof Parkinson’s disease, and they have artists who work with peo-ple suffering from dementia, etc.The Competence Centre will collaborate with other disciplines andresearch environments in the field and has established formal co-op-eration with Norwegian National Advisory Unit for Ageing andHealth (www.aldringoghelse.no/english). The Centre also participatesin international networks.See further www.kulturoghelse.no/english/Steno Diabetes Centre, DenmarkSteno is a world-leading institution within diabetes care and pre-vention. Steno is owned by Novo Nordisk A/S and is a not-for-prof-it organisation working in partnership with the Danish healthcaresystem. Steno treats around 5600 people with diabetes. Steno’s3. Innovation in Social- and Healthcare 27vision is to become leaders in diabetes care and translational re-search with focus on early disease and prevention.In 2014 Steno Diabetes Centre was awarded the prestigious‘Golden Scalpel’ award by Dagens Medicin, the leading medicalnewspaper in Denmark. The prize was given to Steno DiabetesCentre for innovating and improving the quality of care for theindividual diabetes patient in a way that is adapted to the life ofthe patient.Steno Diabetes Centre is organised in four areas that work closelytogether: 1. Steno Clinic, 2. Research, 3. Health Promotion Re-search and 4. Education.1. Steno Clinic: Steno is one of the few centres globally that focus ondiabetes only and have research, education and health promotionclosely connected to the clinical care of patients. Steno Clinic has aunique position in Denmark offering:• All-in-one service through multidisciplinary team-based care• Diabetes specific electronic medical record enabling constantfocus on quality of care• Specialised clinics to personalise treatment and prevent com-plications• Fully integrated clinical research unit to optimise care• Day hospital with a focus on the newly diagnosed and patientsin need of extra support• Foodlab - a nutritional laboratory and hands on training facil-ity for patients• Online service through ‘My Steno’ and 24h nurse counsellingtelephone service.The patient base of around 5600 patients is from the Capital Re-gion of Denmark. The centre serves as an integrated part of thepublic health care system and is under contract with the Capital Re-gion. The clinical staff of 90 in the centre includes doctors, nurses,dieticians, patient coordinators, podiatrists and lab technicians.2. Research: Biomedical Research at Steno Diabetes Centre is trans-lational. The aim is to apply knowledge and findings from researchin the clinic to improve outcomes for patients with type 1 and type2 Diabetes. Research is organised in the areas:• Complication research: Understanding the prevention andtreatment of diabetic micro- and macrovascular complicationsof diabetes28 3. Innovation in Social- and Healthcare• Clinical epidemiology: Developing preventive strategies forpersons with reduced glucose metabolism and early treatmentstrategies for persons with type 2 diabetes• Translational patophysiology: Understanding genetic, cellular,physiological and behavioural mechanisms that lead to diabe-tes and its complications• Systems Medicine: System-level understanding of metabolismand translation of this knowledge into novel solutions to ben-efit human health3. Health Promotion Research: Health Promotion is a humanistic re-search and development department focusing on Patient Educationand Prevention. The aim is to establish cross-disciplinary coopera-tion with partners at Steno as well as with external institutions inDenmark and abroad. The focus is on research with the potential topromote health in real life settings and practices. Research in HealthPromotion is based on five principles for social and human changethat permeate all research projects and ensure a clear direction forthe methods and knowledge developed:• Active involvement and participation of the target group as abasis for development of ownership and sustainable healthpromoting change• A positive and broad concept of health, which focuses on theperson as a whole instead of just risk factors and the disease• Development of people’s competence to take action to controltheir own life as well as their living conditions• Acknowledging the context in which people live and to in-clude this in the intervention carried out• Increasing equity in health by paying attention also to theleast resourceful members of the communityCurrently, more than 25 different projects are on-going. Due to thisincrease of activity and substantial external funding during 2012,the number of overall staff is now at 35 people, covering a broadrange of academic fields such as public health, anthropology, psy-chology, pedagogy, social science and design.4. Education: The main focus of Steno Education is to disseminatethe clinical competencies, front-line research results, and patientfocused treatment- and care practices that are present at Steno Di-abetes Centre. This is done through educational collaborationwith Novo Nordisk affiliates and international recognised key3. Innovation in Social- and Healthcare 29opinion leaders. The target audience for education is endocrinol-ogists, nurses, dieticians and other health care professionals andteams who treat diabetes on a daily basis. The teaching is per-formed as state-of-the-art knowledge sharing at seminars, sympo-siums, or interactive workshops. The teaching faculty consists ofexperts from Steno and, often, skilled endocrinologists and health-care professionals (HCP) from the host country, thereby ensuringthat all key core competencies necessary for optimal treatment ofdiabetes are covered.National Centre of Integrated Care and Telemedicine (NST) inTromsø, NorwayNST is the world’s largest centre for research and development intelemedicine and e-health. The centre has strong interdisciplinaryexpertise, and aims to shape the healthcare of the future. Throughuser-oriented research and development, NST has contributed tointegration of care between levels in the health sector since 1993.Telemedicine solutions and e-health give patients easier and betteraccess to health services. Effective collaboration makes the skills andservices of health personnel available to more people, and society’sresources are used more effectively.Telemedicine, e-health and welfare technology are very importanttools in the realisation of the Integrated Health Care Reform. TheNST has valuable knowledge and experience in this field, and has aresponsibility to ensure that the reform will have the best possibleoutcomes for both patients and health professionals.NST’s core expertise is defined as knowledge, solutions and tech-nology that will support interaction with and collaboration be-tween patients and health professionals. Through research and ser-vice development, NST contributes to competence and knowledgesharing between health professionals, and between the health ser-vice and the user.New technology can simplify, but may also change the developmentof skills and knowledge sharing both across disciplines and levels inthe health service, and between health professionals and users. NSThas knowledge, methods and models for the organisational changesneeded in connection with the introduction of e-health and tele-medicine services.30 3. Innovation in Social- and HealthcareProjects where the university hospital in Tromsø is involved:www.slutta.no – a website for smoking cessation – part of the na-tional health portal.www.sjekkdeg.no – a website for youth about sexual health, contra-ception and how to avoid sexually transmitted diseases. Informa-tion is provided through text, short videos and gaming.Electronic Welfare report, FinlandThe healthcare actors in Finland follow a holistic understanding of“health promotion” as spelled out in the Ottawa Charter for HealthPromotion, 1986, according to which it comprises health promo-tion policy and management, living environments, cooperation andparticipation, competencies, services, and monitoring andassessment of health promotion; health determinants are under-stood to also include living and working conditions. One of thegreatest challenges in healthcare has been the fact that healthExpert presentation about Pirkanmaa Hospital District, Finland3. Innovation in Social- and Healthcare 31inequalities between men and women by income have increased.The problem is further complicated by the fact that 20% of patientsuse 80% of the resources in healthcare. To reduce health inequali-ties the National Development Programme for Social Welfare andHealthcare (Kaste) was introduced in Finland; a strategic steeringtool that is used to manage and reform social- and health policy.The targets of the Kaste programme are 1) that inequalities inwell-being and health will be reduced, and 2) that social welfare andhealthcare structures and services will be organised in a client-ori-ented and economically sustainable way. To this end, an electronicwelfare report was introduced to support local strategic manage-ment, which is used by over 250 local authorities in Finland. Thereport includes a welfare evaluation of both the outgoing and in-coming local council, spelling out priorities, national, municipaland regional plans and programmes, as well as a plan for health pro-motion and well-being during the council office. The report is ap-proved as part of the operating and financial plan of the municipal-ity. As a consequence, the challenges of welfare promotion are mettogether with the financial challenges; the welfare perspective is in-cluded in local strategic management and in the implementation ofthe municipal strategy; and all administrative branches take moreresponsibility for the welfare of residents. The presentation clearlydemonstrated that the definition of “public health” in Finland in-cludes more aspects than merely the absence of illness; local author-ities are very involved in the way healthcare and welfare are organ-ised and implemented in Finland.Municipality of Sastamala, Finland – focusing on men’s healthOnce a year the male personnel of the municipality organise a sem-inar for men. It has been a real success with more than 300 partici-pating at each event. They arrange competitions, impart diet infor-mation, organise physical activities and invite celebrities to moti-vate and attract. The municipality also organises different cam-paigns such as “one cent of your waist for the health” and healthpromotion events and well-being weeks.32 3. Innovation in Social- and HealthcareThe WG members are briefed on sustainable Nordic welfareDealing with the challenges of non-communicable diseases in theNordic countriesTobacco and alcohol are two socially accepted stimulants in muchof the world, even though they contribute to poorer public health.The renewed national public health policy bill in Sweden particular-ly recognises the challenges of non-communicable diseases (NCDs).The Swedish government has also approved a five-year national ac-tion plan on alcohol, illicit drugs, doping and tobacco. The SwedishNational Institute of Public Health is assigned by the governmentto support implementation of the action plan at local and regionallevels by doing various tasks. The increase in Swedish life expectan-cy over the past decades is due mainly to decreased mortality fromnon-communicable coronary and respiratory diseases, and recentpolicies such as the ban on smoking in public places and initiativesto counteract physical inactivity aim to maintain this trend.A number of studies, among them the aforementioned Könberg re-port, point out an association between life expectancy in the Nordic3. Innovation in Social- and Healthcare 33countries and the consumption of alcohol and tobacco. The Nordicregion generally has lower alcohol and tobacco consumption thanthe rest of Europe – one major determinant of the higher life expec-tancy rates in the Nordic countries. Still, the Könberg report assertsthat much is to be done to improve public health in the Nordic re-gion, despite the strong increase in life expectancy and despite whatalso seem to be healthy years added to life. According to the report,the two most important areas, and which can also be influenced bypolitical decisions, are the use of tobacco and the misuse of alcohol.The importance of this issue was also highlighted by the EuropeanCommissioner for Health and Consumer Policy, Mr Vytenis Andri-ukaitis, at the meeting of the BSPC Standing Committee on 23January 2015 in Brussels. Among others, the Commissioner identi-fied the use of alcohol and tobacco as the main issues in healthcare.Regarding alcohol consumption the Commissioner informed thathe had set himself a five-year action plan, in which he would like toaddress, amongst others, questions of taxation policy and customscooperation in order to reduce the use of alcohol in the Union.Diabetes Prevention in FinlandThe Finnish Diabetes Prevention Study DPS has shown that diabe-tes incidence was 58% lower after mean follow-up of 3.2 yearsamong individuals at high risk for type 2 diabetes (T2D), who hadsuccessfully achieved goals regarding weight reduction, moderatefat, low saturated fat, high fibre intake and physical activity. Theseencouraging results led to the Finnish Development Programme forthe Prevention and CARE of Diabetes, DEHKO 2000-2010, whichwas implemented by the FIN-D2D project, 2003-2007. Five hos-pital districts are partners in the FIN-D2D project, along with 400healthcare centres, 200 occupational health centres and over 2000healthcare professionals, covering 1.5 million people. Fundingcame from all levels, including the Finnish Diabetes Association, to-talling 8.4 million euros. Goals of the project included the identifi-cation of individuals with T2D, the generation of new models forthe prevention of T2D, the evaluation of the effectiveness, feasibil-ity and cost-effectiveness of the project and awareness-raising forT2D and its risk factors among the population. As one of the pro-jects results, a diabetes risk assessment form (FINDRISC) was in-troduced, which became an integral part of routine healthcarecheck-ups. The questionnaire was supplemented with various inter-ventions on weight management, exercise, healthy cooking etc.Healthcare centres and occupational health units received resources34 3. Innovation in Social- and Healthcareand needs for the prevention of T2D, working methods, tools, ma-terials, education and training. A protocol for the prevention andcare of T2D was set up in order to know what unit takes responsi-bility for the treatment and care of T2D. Among the lessons-learnedand results are: there are a lot of people with pre-diabetes and a lotof people not being aware of their illness; the more weight peoplelost during one-year follow-up, the less likely they were to show in-cidences of diabetes; the D2D model has been adopted in mosthealthcare centres and some occupational health units for screeningand intervention, and has been included into the local and regionalT2D prevention care protocols; large-scale screening and effectivelifestyle intervention for preventing T2D are possible in primaryhealthcare settings.Expertise in tick-borne diseases in ÅlandÅland is very experienced in the fight against tick-borne infectiousdiseases. For instance, it has started a mass vaccination programmeagainst tick-borne encephalitis (TBE); About 70% of the Ålandicpopulation has used the free service of basic vaccination againstTBE provided through the programme. One of the most importantactors in the field of infectious diseases in Åland is Bimelix Biomed-ical Laboratory, which provides laboratory services in microbiologyfor healthcare in Finland and other Nordic countries. It providesservices for hospitals, laboratories, clinics in the private sector etc.Most importantly, it possesses high-level expertise in the field oftick-related diseases and specialises in borreliosis (Lyme disease).The Bimelix test algorithm for borreliosis is the result of decades ofresearch and clinical experience, and combines different commer-cially available test systems for optimal results. For the clinical sideof borreliosis management and research, Bimelix relies on a closeconnection with Åland’s Medimar Borrelia Clinic. The MedimarBorrelia Clinic offers a comprehensive care package including theservices of specialised physicians, nurses, physiotherapists and CBTtherapist, as well as blood tests, treatment, rehabilitation, follow-upand further investigations regarding differential diagnoses if needed.The clinic also attracts patients from outside of Åland.3. Innovation in Social- and Healthcare 35The Danish delegation deliberating scope & mandate of the WG3.4 Barriers and legal aspectsMany efforts are being made to further innovation in social- andhealthcare, though as with most sweeping reforms this does not oc-cur without a number of obstacles. They consist for instance ofweak public awareness and a political reluctance to invest in inno-vation in healthcare, lack of knowledge about new solutions for so-cial- and healthcare issues, unclear or inadequate legislation, lack offiscal and financial incentives or poor resources for Research andDevelopment. The Working Group has, through study visits, expertpresentations and exchange of knowledge, collected examples ofsuch barriers. They are compiled here from the input provided bythe responsible government bodies of the member states, and reflectthe barriers that can be found in some of the countries and regionsacross the Baltic Sea Region.First and foremost, many member states face financial difficulties inachieving their goals. The scope of the reforms that have to be realisedacross the Baltic Sea Region are without a doubt substantial, and mak-ing the systems fit for the increasingly daunting task will be taxing onmany a budget. Some member states are forced to rely on Europeanfunds, and worry about the moment those funds run dry, fearing thatthey will face difficulty replacing them with a national source.36 3. Innovation in Social- and HealthcareThe lack of funds does not only lead to slow innovation in a mo-ment where time is of the essence, it also leads to a cap on humanresources. Many member states need a large infusion of skilled la-bour and hence need to make healthcare an attractive field of pro-fession again – something that is (amongst other aspects) stronglyrelated to better remuneration.In some cases, the lack of sufficient funds stems from weak politicalsupport and reluctance to back indispensable plans. There seems toexist a poor understanding of the potential technological solutionsoffered, and hence a hesitancy to support them. Communicatingthe necessity of these innovations and reforms is crucial in raisingpolitical attention and thus in securing funding. However, the con-trol of the purse strings is not they only reason political attention iswarranted. It will also be highly necessary in order to dissolve cur-rent legal obstacles that block the road to successful remodelling ofthe social- and healthcare landscapes, for instance in the case of fur-ther integrating different types of care.Drawing the attention of the political class alone is not enough. Theproblems with cooperation and communication can be detected indifferent layers of social- and healthcare. A number of governmentspoint out there is poor exchange between the R&D departments ofthe innovation industry, the healthcare professionals and the differ-ent government agents. Some member states agree that even withinthe healthcare sector there are too many actors, each with their ownagenda. Furthermore, innovation in social- and healthcare needs tobe brought to the attention of the general public. It is pointed outthat there is public resistance to innovation schemes, simply be-cause misunderstandings exist about their use and potential abuse.The different examples of poor communication lead to weak andunstable support for the overhaul beyond necessary.4. WG Composition and Activities 374. WG Composition andActivities4.1 Composition (as of June 2015)Ms Olaug Bollestad, MP, Norway, Chair of the WGMr Wolfgang Waldmüller, MP, Mecklenburg-Vorpommern,Vice Chair of the WGMs Liselott Blixt, MP, DenmarkMr Andre Sepp, MP, EstoniaMs Hanna Tainio, MP, FinlandMr Franz Thönnes, MP, GermanyMr Uwe Lohmann, MP, HamburgMr Romualds Razuks, MP, LatviaMs Giedrė Purvaneckienė, MP, LithuaniaMs Sonja Mandt, MP, NorwayMs Irina Sokolova, MP, Russian FederationMr Bernd Heinemann, MP, Schleswig-HolsteinMr Roland Utbult, MP, SwedenMs Annette Holmberg-Jansson, MP, Åland IslandsSubstitutes:Mr Julian Barlen, MP, Mecklenburg-VorpommernMs Agneta Börjesson, MP, SwedenFormer members:Mr Raimonds Vējonis, President of Latvia, former WG Chair Septem-ber 2013 - February 2014Mr Atis Lejiņš, MP, LatviaMr Jānis Vucāns, MP, LatviaSecretariat / staff:Mr Bodo Bahr, WG Secretary, BSPCMs Julie Helmersberg Brevik, WG Secretary, NorwayMr Florian Lipowski, WG Secretary, Mecklenburg-VorpommernSubstantive input at secretary level was also provided byMs Beate Christine Wang, Senior advisor, Nordic CouncilMr Dan Alvarsson, International advisor, Sweden38 4. WG Composition and ActivitiesThe WG at the Latvian parliament4.2 ActivitiesThe BSPC Working Group on Innovation in Social- and Health-care (WG ISHC) held its inaugural meeting in Riga on 4 November2013. The meeting was led by the then WG Chairman RaimondsVējonis. The meeting appointed Olaug Bollestad, Norway, andWolfgang Waldmüller, Mecklenburg-Vorpommern, as vice Chair-men. An expert presentation on “Innovation in Social- and Health-care - An Ecosystems Approach” was delivered by Thomas Karopka,Project Manager of ScanBalt HealthPort. The meeting was primar-ily devoted to a reconfirmation of the WG mandate and delibera-tions over its scope of work, priorities and mode of work.The BSPC Working Group on Innovation in Social- and Health-care held its second meeting in Tromsø on 27-28 March 2014. Themeeting unanimously elected Ms Olaug Bollestad, Norway, to suc-ceed Raimonds Vējonis as Chair of the WG, since Mr Vējonis wasappointed Minister of Defence of Latvia in January 2014. An open-ing expert presentation was provided by Ms Pille Kink from the Es-tonian E-Health Foundation. After the meeting, the WG made astudy visit to the Norwegian Centre for Integrated Care and Tele-medicine, where briefings were given on coordinated care and de-mographic challenges in rural areas, telemedicine innovation and4. WG Composition and Activities 39Tromsø, Norwayimplementation, flexible e-learning in healthcare, homecare andprevention, and barriers and legal aspects of cross-border telemedi-cine.The BPSC Working Group on Innovation in Social- and Health-care convened its third meeting in Birštonas, Lithuania, on 19-20June 2014. The meeting itself was preceded by an extensive studytour of the balneological and rehabilitation resort of Birštonas, withseveral sanatoriums and a wide range of high-quality recreational,rehabilitational and medical services (see www.visitbirstonas.lt). TheWG meeting received initial greetings from the Mayor of Birštonas,Ms Nijole Dirginciene, who is also President of the Lithuanian As-sociation of Resorts. Her introduction was followed by a presenta-tion on The Role of Resorts in the Baltic Health Tourism Sector byMs Jurgita Kazlauskiene, Vice President of the European Spas Asso-ciation. The WG meeting primarily engaged in deliberations overthe WG Mid-Way Report, to be presented to the 23rd BSPC inOlsztyn on 24-26 August 2014, and its first set of political recom-mendations.The BSPC Working Group on Innovation in Social- and Health-care held its fourth meeting in Copenhagen on 13-14 November2014. The meeting itself was preceded by a visit to Steno40 4. WG Composition and ActivitiesThe WG at the Danish parliamentDiabetes Centre with the focus on lifestyle-related diseases / di-abetes and innovation. Steno Centre is a world-leadinginstitution within diabetes care and prevention. It is owned byNovo Nordisk AS and is a non-profit organisation working inpartnerships with the Danish healthcare system. The WorkingGroup meeting started with a presentation by Vincent Giele,Hospital Solutions Director for Northeast Europe in Medtronic.Medtronic is the world’s largest medical technology company,offering innovative therapies to fulfil a mission of alleviatingpain, restoring health and extending life. Their medical therapiestreat cardiac and vascular diseases, diabetes, and neurologicaland musculoskeletal conditions. The second expert presentationwas given by former Swedish minister, Bo Könberg, on his reporton closer healthcare cooperation in the Nordic countries overthe next 5-10 years. The report was submitted on 11 June 2014and it contains 14 proposals.The BSPC Working Group on Innovation in Social- and Health-care also had a study trip to the HUNT research institution on5-6 March 2015. The Nord-Trøndelag Health Study (TheHUNT Study) is one of the largest health studies ever per-formed. It is a unique database of personal and family medicalhistories collected during three intensive studies. The4. WG Composition and Activities 41HUNT Research Facilityfundamental strategy is to earn and maintain the confidence ofthe population we work in and with as is necessary for any suc-cessful population study. This strategy has been successful andhas resulted in extraordinarily high participation rates. There isenthusiastic public and political support for HUNT and for theHUNT Research Centre. This has created a good basis for fur-ther health surveys in the county and an excellent research envi-ronment. The WG also visited Levanger municipality to hearabout the municipal sector’s plan for health and welfare services,the Municipal Master Plan as a strategic tool to promote publichealth and health equity, and the new Norwegian CompetenceCentre for Arts and Health. Levanger aims to include the healthperspective in all local policies.The BSPC Working Group on Innovation in Social- and Health-care held its fifth meeting in Tampere on 16-17 March 2015. Themeeting itself was preceded by a study tour of the Vaccine Re-search Centre and the Tampere University Central Hospital. TheWorking Group was briefed by Auli Pölönen, Clinical Nutrition-ist at Pirkanmaa Hospital District, on the Prevention of Diabetesand Cardiovascular Diseases. The second briefing was given byMaarit Varjonen-Toivonen, Chief Physician at the Centre of Gener-al Practice in Pirkanmaa Hospital District, on electronic reporting42 4. WG Composition and ActivitiesThe WG in Tampere, Finlandlinked to Operations Planning & Budgeting on the CommunalLevel. At Tampere University Hospital the WG members received abriefing on the hospital and were then informed about diabetes re-search and vaccine development against type 1 diabetes by VesnaBlazević, Head of Laboratory, and Heikki Hyöty, Professor at Tam-pere University Hospital.The BSPC Working Group on Innovation in Social- and Health-care held its sixth meeting on the Åland Islands on 11-12 June 2015.The meeting itself was preceded by a study tour of Healthcare Clin-ic Medimar and Åland Central Hospital. The Working Group wasbriefed by MD Mathias Grunér, CEO Bimelix, on the Bimelix Lab-oratory and the Medimar Borrelia Clinic. Bimelix Biomedical Lab-oratory is based in Åland and provides laboratory services in micro-biology for healthcare in Finland and other Nordic countries. Mostimportantly, it possesses unique expertise in tick-related diseasesand specialises in Lyme disease. Prof. Dag Nyman from Medimarfollowed up with a presentation on lyme borreliosis.It is the most common vector-borne infectious disease in northernEurope. At the Åland Central Hospital MD Katarina Dahlmanspoke about challenges with a hospital on a small island. The hospi-tal is responsible for all public healthcare on the Åland Islands. Doc-tor of Infections, Marika Nordberg, followed with a presentation on4. WG Composition and Activities 43The WG after the final two-day debate on its Final Report on the isleof Silverskär, Åland Islandstick-borne encephalitis (TBE) on the Åland Islands. Associate Pro-fessor of Surgery, Mr Haile Mahteme, shared his thoughts with theWG members on why he believes health professionals on Ålandcare more about their patients’ well-being than elsewhere. Finally,the Åland Minister for Health, Ms Carina Aaltonen, spoke aboutPublic Health on the island.Finally, the members of the Working Group have conducted threesets of homework on the general nature of public strategies andmeasures of ISHC, the ethical aspects of ISHC, as well as the de-mographic perspectives and the mobility of elderly. The home-work was conducted to get an overall view of the issues at hand,prepare upcoming WG meetings and questions for experts, as wellas to provide input and inspiration to the political recommenda-tions of the WG.A summary of the homework follows below under section 4.3. Boththe complete answers to the homework as well as the WG meetingprogrammes and the slides of the expert presentations can be foundin Volume II of this report, published on the BSPC website.Further information about the Working Group and its activities canbe retrieved from the WG homepage at http://www.bspc.net/page/show/69444 4. WG Composition and Activities4.3 WG homeworkAs noted above, the following section summarises responses by theWG members to three sets of homework on the general nature ofpublic strategies and measures of ISHC, the ethical aspects of ISHC,as well as the demographic perspectives and the mobility of elderly.4.3.1 Homework assignment 1The member states offer their perspective on the main challengesfaced by social- and healthcare now and in the future.By far the widest concern is expressed over the consequences of thedemocratic shift that will occur in the Baltic Sea Region over thenext fifty years. The growing share of elderly within the populationsof the member states will result in a higher demand of social- andhealthcare and a more limited supply, since the workforce willshrink significantly and costs will go up. Existing care structures willhave to bear more pressure, both practically and financially.One of the results of an older population is the disease landscape.Lifestyle diseases, cardio-vascular diseases and cancer will requiremore attention in the future, as will the rise of multi-resistant bac-teria. The percentage of multi-morbidity will amount to more in-tensive and complex care for a larger part of the populations.A significant share of the responding members expresses uncertain-ty about the future of the workforce in healthcare. The percentageof the population willing to be active as healthcare professionals de-clines due to unattractive work conditions and poor payment. Thisonly increases the pressure on the existing professionals.Access, especially socio-economical, is a concern of almost all re-sponding member states and regions. An increasing pressure on pen-sion funds and climbing costs for patients may prove to be prohibit-ing when it comes to access, especially to those with a weaker so-cio-economic background. Member states and regions with sparselypopulated areas, such as Estonia, Mecklenburg-Vorpommern, andSchleswig-Holstein express concern about the physical access to care.The lack of physicians in rural areas ensures that patients have to trav-el longer distances in order to receive necessary care.4. WG Composition and Activities 45In order to improve the current situation and make healthcare con-tinuously available to all in need in the future, the responding mem-ber states and regions agree that the care system needs restructuringin order to keep being effective. An important example is the shiftfrom inpatient to outpatient care, and the consequential increase ofhome care. A great majority of the responding member states fur-ther agree that medical innovation is necessary in order to deal withrising and changing challenges. At the same time, they agree that re-structuring and innovation will increase the financial burden, andthat a balance has to be found in moving the quality of healthcareforward, while keeping an eye on the costs.A number of responding member states also recognises the increas-ing burden on local government, which in many member states islargely responsible for the delivery of healthcare as well as social ser-vices. Concerns about the ability to further deliver such services toa growing group of recipients as well as the increasing financial bur-den they will face can be gleaned from a number of responses.The changing demographic is indicated as an important challengefor the future, perhaps because it has a direct effect on the unani-mously addressed result: costs. All member states indicate that thecost of innovation, the cost of restructuring and the cost of increasedemand will form perhaps the most significant challenge to suitablefuture healthcare.The member states reflect on the new public strategies and pro-grammes that have been launched for ISHC and on any planned ini-tiatives.Quite naturally, the answers to the second questions have been farmore diverse than the relative unanimity regarding the first ques-tion. The member states have reacted, and will react in many differ-ent ways to the challenges presented to ISHC. Nonetheless, somepatterns can be discovered.First, it must be noted that the member states are not only launch-ing new programmes and public strategies, but are making a fairconsideration if it is necessary to start a new programme, or if it ismore sensible to modernise existing structures and thereby makingthem newly equipped to conquer future challenges. An example canbe found in the widespread attempts to further support local gov-ernments in dealing with the increasing pressure on the servicesthey offer. Trainings and additional funding are assigned to allow46 4. WG Composition and Activitieslocal governments and care institutions to make highly informedand effective decisions. In some cases this is an attempt to level thequality of care between municipalities, since differences do occur.The local level is furthermore a testing ground for new models andinnovations. Municipalities around the Baltic Sea Region partici-pate in numerous trial projects, in order to assert which new pro-grammes are worth adopting nation-wide.Another common denominator in the responses to the question isthe new programmes involving the digitalisation of medicine.Member states are actively pursuing the opportunities offered byICT advancements in order to enable easier (digital) access for bothpatients and medical staff. A majority of the responding membersare now or soon will be actively involved in e-health or telemedi-cine.Furthermore, there are several member states that have started orwill start programmes for the advancement of human genome andbiological research. This is in an attempt to map personal risk, aswell as the ability to produce personalised medicine.A large number of the governments that reported have created pub-lic-private platforms in order for medical suppliers and innovators,the healthcare sector and government to come together and advanceefficient care. Such platforms stimulate demand-led innovation inthe healthcare and social care sectors, but also provide an opportu-nity to keep such new innovations affordable and hence imple-mentable. Government strategies regularly focus on solutions thatmake implementing the latest innovations affordable and managea-ble for local care institutions.In addition to these common themes, the member states have cre-ated a host of programmes focussing on regional health needs.These vary from healthy nutrition in schools (Latvia) and vaccina-tion programmes (Åland) to helpdesks and facilities for those deal-ing with dementia (Schleswig-Holstein).The member states reflect about public awareness campaigns thathave been launched or are planned, regarding ISHC.With regard to the raising of public awareness concerning ISHC, itis fair to say that in most member states this is in the early stages ofdevelopment.4. WG Composition and Activities 47In about a third of the responses, member states indicated that pub-lic awareness campaigns are not (yet) being realised or that they arenot at the top of the list of priorities.The respondents that have answered in the affirmative can be divid-ed into two categories. There are the member states that have (thusfar) decided to focus on informing the general public. Mecklen-burg-Vorpommern, for instance, has launched campaigns focussedon sexual health or alcohol prevention. Schleswig-Holstein’s cam-paign Land.Artz.Leben, attempts to interest physicians in settlingin rural areas.Then there are the member states that focus their attention withinthe healthcare community. Denmark for instance, has created so-called ‘healthcare promotion packages’, meant to help Danish mu-nicipal and healthcare decision makers set priorities and organisecare on a myriad of subjects, from alcohol and tobacco to good nu-trition and physical activity. Finland, in turn, awards prizes for in-novative solutions. The internal focus on awareness also results inadditional attempts to build networks between the different care ac-tors.The member states discuss the public economic support mechanismsfor ISHC that have been developed, such as dedicated funding, seenmoney or tax incentives.Economic support is granted to social- and healthcare in a numberof ways. It is rarely identical among the responding member states,mostly due to the fact that the legal structures for granting suchmoney (and which money to grant) are different between states. Taxincentives for instance, are offered by Finland to organisations thatinvest in R&D&I (Research and Development and Innovation),whereas options for offering tax incentives is relatively complicatedfor members such as Mecklenburg-Vorpommern and Schle-swig-Holstein, seeing that taxation is organised federally in Germa-ny.Although some governments argued that they don’t offer directfunding to any programme, there seems to be not one member statethat does not offer funds in one way or another. A relatively com-mon way of providing funding to social- and healthcare is throughsubsidies offered by local, regional or federal government, andthrough research grants offered by (national) foundations. In this48 4. WG Composition and Activitiesmanner, many member states are capable of steering the flow ofmoney and therefore the development of the social- and healthcareto the programmes they deem to be most vital and necessary at thetime. Examples of such recipients can be found across the board,from research initiatives to centres that counsel in case of abuse oraddiction or the strengthening of outpatient care.Public-(semi-)private cooperation is again a common phenomenonwhen it comes to funding innovation in social- and healthcare.States, for instance, seek the financial partnership with medical as-sociations or state-led insurance companies.These are the main obstacles in promoting and implementing ISHC.The following forms of political support and measures are conceiv-able to overcome these obstacles.A large majority of the member states have indicated that financialconstraints will form the most considerable obstacle to a successfulimplementation of ISHC. Many have pointed out that financial re-sources are already limited, and partially stem from the EuropeanUnion. These funds will be difficult for the member states to substi-tute from national sources, should the EU source discontinue. Thisis combined with the rising costs of providing high quality health-care, especially in the light of continued innovation and a higher de-mand on the healthcare systems across the Baltic Sea Region.Poor communication and prohibiting bureaucracy have been indi-cated as a further obstacle. Member states are confronted with thisin different ways. The delegations from Germany for instance, indi-cate that the strict separation between inpatient and outpatient careforms a barrier for those patients with complex medical require-ments, who are in need of different forms of care from different sec-tors. They often face significant hindrances when communicatingwith different providers across different sectors. Denmark on theother hand has indicated that a lack of clear communication to itspopulation forms a hindrance to a smooth implementation ofe-health. This results in a resistance to the digitalisation of medicinefor privacy reasons. Norway in turn has pointed out that communi-cations between different healthcare sectors, the government andthe research branch have been troubled, hampering its potentialpower in reforming its healthcare system.The member states are in the process of evaluating these obstacles inorder to remove them in the future. For example: in light of the4. WG Composition and Activities 49difficulty of procuring financial support, Estonia proposes a nation-al action plan to form financial support instruments. This way theyaim to provide stable and sustained financing for a time when EUfunds may run out.4.3.2 Homework assignment 2These are the major ethical issues and dilemmas caused by the prog-ress in medical and social treatment methods and therapies, accord-ing to the member states.Several responding member states have replied to this question bypointing out that although new innovation could give rise to signif-icant ethical dilemmas, it could also form the solution to currentethical issues.That said some ethical conundrums were highlighted in the re-sponses. Access to healthcare will continue to be a question, espe-cially in the light of rising costs. Each member state will have to de-termine whether it is ever acceptable to terminate treatment due tohigh costs, for instance when the treatment itself will only bringmoderate improvement, or if certain patients should be prioritisedconsidering potential success rates, for instance in the case of organtransplants.In the previous homework assignment, we have seen that severalmember states have started investigating the options of genome re-search, and the potential predictive capabilities it holds. That doesnot mean the ethical question is ignored. The member states havepointed out that being aware of someone’s potential illnesses shouldnot become a factor in the willingness to treat those illnesses. This isperhaps an example of the more general concern about data protec-tion, and which medical actor is permitted to access patient’s medi-cal information.Finally some member states wonder about the power of deci-sion-making. When illness, costs and perhaps lifestyle choices of apatient are weighed in the balance, politicians and even insurancecompanies might claim a role in the ultimate decision-making re-garding treatment options. Decisions, that can be argued, shouldstay with the medical experts.50These policies and methods have been applied or planned in order toguide the prioritising between different patient groups (differentkinds of diseases and ailments), in a situation where treatment poten-tials are growing by practical resources are scarce. The member statesanswer which body or person has the responsibility for setting andmaking priorities.A large majority of the responding governments have answered thatequal access for all patients is paramount and that prioritising mayin some cases even be unconstitutional.That said, most member states have indicated that it has govern-mental bodies that decide on what is medically and economicallynecessary and appropriate. Often, these boards are made up by across-section of the medical community and produce a set of guide-lines meant to improve effectiveness and stimulate evidence-basedmedical decisions. Depending on the member state, they also adviseon medical ethical issues, or make decisions regarding expensivetreatment.51In most cases, however, it is the medical professional that has the fi-nal say in the ultimate treatment of his or her patient.The member states weigh to what extent a patient’s lifestyle, behaviourand self-responsibility will influence the choice of treatment/therapyfor him/her, especially when it comes to new and more expensivetreatments.All responding member states agree about the fact that a patient’s life-style cannot play a role in the creation of a treatment plan. Although itis acknowledged that lifestyle and behavioural decisions can have a sig-nificant impact on the rise and development of an illness, it is believedthat one should not be treated differently because of it. An exception isonly made when such changes are required for medical reasons, for in-stance in the case where severe obesity or alcohol dependence have a realimpact on the treatment results.52 4. WG Composition and ActivitiesThe stance on equal healthcare despite negative lifestyle choicesdoes not stop the member states from trying to influence behaviourthat could lead to ill health. This approach is often many-fold. Ed-ucation of the general population on healthy living is the first logi-cal step in this attempt. However, most states aim to move beyondmere informing and hope to mould their population into a groupof empowered patients. This includes informing them on the possi-ble treatment plans, and involving them into the decision-making.This often stems from the belief that informed and involved pa-tients are more driven to take responsibility during the treatmentprocess, not just undergoing it.The member states disclose what steps (legal, regulatory, technicaletc.) are being taken or planned to ensure the patient’s safety and in-tegrity as patient records are increasingly digitised, and how is the pa-tient’s access to his or her own data safeguarded and regulated.A patient’s right to privacy of medical records is in most instancescovered under general privacy legislation. In a majority of the cases,acting medical professionals are only allowed to access the informa-tion in line with their care duties. It is not a free for all for the med-ical community, to browse as they please. A level of professional in-tegrity is expected from those employed in the medical professions.In most member states, a log is kept of the medical professionals ac-cessing it, and fines or even jail sentences attached to potentialabuse.The degree of digitalisation and access is varied among the memberstates. Some are still in the process of digitalising the medical infor-mation, whereas other have made the information available notonly to the medical community, but to the patients themselves. Theinhabitants of Finland and Denmark, for instance, are able to viewtheir medical records online, in an e-health environment. Most ofthe populations of the Baltic Sea Region, however, have a right totheir own medical information, even if it is not (yet) available withthe click on the home computer.Security is ensured in different ways, for instance by providing boththe physicians and the patients with a password or key card, whichunlocks the access to the files. How the files are protected against wil-ful attacks for e.g. hackers or what will be done in the case of a largerleak is not further specified in the respondents’ answers.4. WG Composition and Activities 53The member states illuminate to what extent ethical issues are taughtand incorporated in the education, training and continuing educa-tion of health workers.Ethical training is a valued section of each of the respondents’ med-ical training. It is either formed by a merely theoretical programmeor by a combination of theory and practice. Denmark, for instance,has formed a competence-based ethics section as part of itspost-graduate education, including amongst others “managementof professionalism in compliance with the Hippocratic Oath andlegislation” and “knowledge of conflict resolution”. Finland has in-creasingly focussed on sensitivity towards other cultures within themedical sphere.Generally speaking, broad parameters for ethical behaviour are setout by national governments. Most member states have a nationalbody that is involved with providing guidelines on ethical issues,like the National Advisory Board on Social Welfare and HealthcareEthics in Finland or the Centre for Medical Ethics in Norway.Often, however, they are built upon in detail by local government,institutions and higher education. This causes different professionalgroups or even different institutions to have varying guidelines onmedical ethical dilemmas.4.3.3 Homework assignment 3The member states shed light on the demographic perspectives in therespective countries.The responses from the member states are in a certain way difficultto compare because different statistics are used to demonstrate thedemographic perspectives for the different entities. What can be de-duced is that to a greater or lesser degree all member states are age-ing significantly, resulting in a reduced workforce and hence morepressure on the social- and healthcare structures.The peak of this ageing process is likely to strike different countriesin the Baltic Sea Region sometime between 2025 and 2040. Mem-ber states indicate that roughly a quarter of their population will beover 65 somewhere within this timeframe. Rural areas are generallymore vulnerable to ageing than urban areas. The countryside of54 4. WG Composition and ActivitiesMecklenburg-Vorpommern will have to face a population of which40 percent will be over 65. This compared to a percentage of 22-30percent in the rest of the state.In some member states however, it is not all grim. Norway’s popu-lation is currently rapidly ageing, but the country predicts that thistrend will flatten in the future, due to relatively positive birth ratesand a steady influx of young immigrants. Lithuania today is in agood shape when it comes to ageing, and has a relatively youngpopulation. This will face some change in the future, for instancedue to emigration rates.Nonetheless, the dependency rates of the population in the BalticSea Region will continue to rise in the coming decades.This is how the member states prepare for the approaching elderlyboom.Sweeping reforms are planned across the Baltic Sea Area, in order toconquer the demographic challenges. A large majority of the mem-ber states is currently preventing a further shrinking of its workforceby postponing the retirement age and incentivising healthy and en-ergetic elderly to keep working after the national retirement age, beit perhaps in an adapted form.Naturally, the healthcare sector will face reform. In several memberstates, hospitals and other healthcare institutions will be restruc-tured in order to accommodate the changing illnesses and needs.Often this will mean an increased focus on chronic diseases, cancerand cardio-vascular diseases. There will also be an attempt to inte-grate cure and care, and to make especially care options accessibleclose to home, if not in the home.Finally, there are multiple examples of member states that will notonly aim at prolonging life in a healthy fashion, but also keepingthose lives active and socially engaged, thus reducing the years ofdependency.This is how the mobility of elderly people, both at home and outsideof their homes, is organised in order to allow for a self-determinedlife.4. WG Composition and Activities 55The range of care options is the different member states are wide,from home care to complete institutionalised living. The memberstates are adamant to prolong independent home living in eachcountry. Being able to live at home is presumably most pleasant forthe populations, though the consideration is also largely financial.Supported home care is the more cost effective option when com-pared with care in a nursing home.In most member states, home care is organised and often financedby the municipal government. NGOs, private-for-profit organisa-tions or local governmental institutions offer a range of services thatcan be divided in practical care (grocery shopping, meal servicesand cleaning) and personal care (help with personal hygiene ornursing). In some states there is a reliance on informal care (provid-ed by the family), which is then supported and supplemented bypublic services.A relatively new aspect of home care is the virtual care services nowor soon to be offered by a number of the member states. Sweden of-fers its elderly citizens a range of digital solutions designed for userswith an advanced age, such as reminders to take medication andalarm units, but also mobile phones designed for elderly users andeven Nintendo WII sport for personal activity. It is likely that moreand more member states will rely on such digital advances in orderto further enable home care. It is also a step towards activating care,moving patients toward an active lifestyle, even if they require careoptions.In addition to home care there are options for (semi-) institutional-ised living. These options of long term, constant care are usually ex-clusively for those who have a medical necessity.The care options are paid for in different manners around the BalticSea Region. The Åland islands use a voucher system to pay for ser-vices rendered, while many other states financially subsidise theirpopulation in order to pay for home care. In some cases the health-care options are entirely free for the patients, in other cases a (small)amount has to be paid privately.56 4. WG Composition and Activities5. Political Recommendations 575. Political RecommendationsA diversity of supportive measures at different societal levels and ina broad range of sectors is necessary to address the challenges andpromote ISHC. Such measures could consist of, for example, polit-ical strategies and programmes for the benefit of ISHC, fiscal meas-ures to facilitate ISHC, information and awareness-raising cam-paigns, enabling legislation and removing legal obstacles, economicincentives, novel organisational and operational strategies for pro-viding social- and healthcare services, reform and re-thinking on so-cial- and healthcare practices, new concepts and methods of provid-ing medical treatment and social care, allocating resources to pro-mote research and education on ISHC, et cetera.5.1 Recommendations from the Midway report,23rd resolution and governmental reactionsSome political recommendations were already elaborated in theMidway report in 2014, a number of them was integrated in the23rd resolution of the BSPC (cf. 5.1.1 and 5.1.2). A part of them isreflected on in the follow-up reports by the Governments (5.1.3).5.1.1 Recommendations from the Midway reportThe WG Midway Report included the following political demands:The BSPC Working Group on Innovation in Social- and Health-care calls on the Governments, and where appropriate the Parlia-ments, of the Baltic Sea Region to:1. d evelop and implement strategies and action plans to promoteinnovations in social welfare and healthcare, based on a preven-tive philosophy and closely involving the health economy, andto integrate healthcare and social welfare issues in other growthstrategies;58 5. Political Recommendations2. p romote the development and deployment of new ways for theprovision of social welfare and healthcare services, including in-novative methods for treatment and therapies as well as organi-sational and structural reforms, and placing great weight on se-cure e-health solutions;3. p ut in place fiscal incentives to encourage and support entrepre-neurs, SMEs and business incubators in the health economy;4. s upport favourable financing conditions and models in thehealth economy, such as seed money, venture capital and foun-dations5. s upport competence centres as regards the transfer of scientificresults into commercial products and services in the area ofhealth promotion and prevention;6. u tilise and devise public procurement rules and procedures in away that favours smart and innovative social welfare and health-care services and products;7. e nsure that new solutions for social- and healthcare provisionare incorporated in the education, training and competence en-hancement of personnel;8. t ake strong measures to ensure equitably available healthcareand social welfare services, e.g. between urban and rural areasand between socio-economic groups;9. a gainst the background of the demographic shift, to work to-wards a greater focus on the needs of the elderly, including e.g.the promotion of qualified health tourism;10. s trengthen and systematise cooperation within the Baltic SeaRegion on social welfare and healthcare, promoting the ex-change of best practices among stakeholders and exploring thepossibilities of elaborating and implementing joint strategies forsocial welfare and healthcare;11. p rovide continued support to the Northern Dimension Part-nership in Public Health and Social Well-being.5. Political Recommendations 595.1.2 2 3rd resolution – recommendations from theMidway reportThe following compilation shows, in how far the recommendationsfrom the Midway report were implemented in the final resolutionof the 23rd BSPC:a) Recommendation 1 equals Call 23 from the 23rd resolution,changed wording is marked23. d evelop and implement strategies and action plans to promoteinnovation and entrepreneurship in social- and healthcare,based on a preventive philosophy and closely involving thehealth economy, and to consider the social welfare and healthcaredimension also in the innovative health economy when developinggrowth strategies;b) Recommendation 10 forms the first part of call 24 from the 23rdresolution, “promoting the exchange of best practices among stake-holders” is deleted;24. s trengthen and systematise cooperation within the Baltic SeaRegion on social welfare and healthcare, including e.g. the ex-ploration of the possibilities of elaborating and implementingjoint strategies for social welfare and healthcare,...c) Thoughts of Recommendations 2 and 6 are used in the secondpart of call 24 from the 23rd resolution24. ... transferable models for the provision of social welfare andhealthcare, public procurement models and quality standards,and joint research and development endeavours;d) Recommendation 8 forms the first part of call 25 from the 23rdresolution25. f urther strengthen measures to ensure equitably availablehealthcare services, e.g. between urban and rural areas and be-tween socio-economic groups;...e) Parts of Recommendations 2 and 6 form the second half of call25 from the 23rd resolution25. ... the development and application of modern communicationtechnologies such as telemedicine is especially relevant in thisregard;60 5. Political Recommendationsf) Recommendation 11 equals call 26 from the 23rd resolutiong) 26. provide continued support to the Northern Dimension Part-nership in Public Health and Social Well-being;5.1.3 Follow-upIn this passage the answers about the implementation of the 23rdresolution from the governments (as of 1 June 2015) with regard tothe recommendations on innovation in social- and healthcare arecompiled. They have been summarised in order to provide an over-view of the state of social-and healthcare in the Baltic Sea Region.The interested reader searching for the complete responses by themember states and regions is referred to the Volume II of this re-port, which contains the full-text reactions to the 23rd resolution bythe responding member states.In the responses to the 23rd BSPC resolution, a large number ofmember states have included extensive remarks on innovation in so-cial- and healthcare. Even if it is difficult make general remarksabout what can only be described as a wide array of policy propos-als and programmes currently being executed in the different mem-ber states. Nonetheless, the Working Group decided to develop asurvey of the different reports.A large theme in overcoming the significant challenges of a healthcaresystem under pressure is international cooperation. A majority of thegovernments that have reported sought partnerships either bilaterallyor multilaterally in the search for innovative solutions. This is oftenmany facetted, varying from practical cooperation on concrete pro-jects to the more theoretical cooperation regarding education andknowledge exchange. One of the often-mentioned vehicles for suchcooperation is the Northern Dimension Partnership in Public Healthand Social Well-being, currently chaired by Germany.22 The NDPHS, as a highly valued and innovative regional network, significantly contributes to theimprovement of peoples’ health and social well-being in the Northern Dimension area.5. Political Recommendations 61A large part of the healthcare tasks are usually delegated to the locallevel, referring to the different health systems of the countries with-in the Baltic Sea Region. However, national and regional govern-ments are actively involved in strengthening local institutions andgovernment and assisting them in performing their tasks under in-creasing duress. This involves providing the institutions with thescientific and practical information they need in order to use anddisseminate it, but also fostering relationships between different or-ganisations and actors in a region (e.g. public and private-for-prof-it) in an attempt to help them supplement each other. Estonia, forinstance, supports the creation of new social enterprises to servesuch a purpose.An important step in making the healthcare sector resistant and al-lowing it to continue to provide high quality services, is bringing itinto the digital age. Most governments implemented IT innova-tions in the social- and healthcare sectors in order to support its var-ious functions. Social- and healthcare benefit from such develop-ments by being able to monitor secure living, offering e-ambulanceservices and online medication prescription services. Telemedicine,however, is by far the most mentioned. The ability to monitor oreven diagnose patients from a distance is considered worth pursuingbecause it increases the efficiency of healthcare, but most of all be-cause it increases the access to healthcare, especially for those pa-tients either physically too far removed or incapacitated by poorhealth. It is understood, however, that telemedicine will remain ahelpful tool in distributing healthcare further, and will not becomea replacement for a face-to-face appointment with a physician.Another step into the future are the genome projects underway in anumber of member states. When successful, they will harness theability to forecast a person’s illnesses. This will have the benefit ofbeing much more proactive on a treatment path, even though per-haps some ethical and practical issues would have to be considered.Finally, the responses to the 23rd resolution involve many projects,both proposed and currently active, meant to battle different healththreats. Regular screenings for common (lifestyle related) diseasessuch as cardiovascular diseases and cancer are widely introduced, asare a number of vaccination programmes. Various member states at-tempt to reduce the intake and especially the abuse of alcoholic bev-erages and tobacco. This may include a stricter policy on advertise-ment and sales, but also on where and when use is allowed. Latviafor example goes beyond the restriction of smoking in public (whichis becoming the norm in many countries) and will consider restrict-ing smoking in private, for instance when children are present. It is62 5. Political Recommendationsalso taking an active stance on other aspects of healthy living, aim-ing to ban sugary, salty and other unhealthy foods from schools andhospitals.These are a selection of the many ways in which the member statespush their social- and healthcare systems towards higher adaptabil-ity to the challenges of the 21st century.5.2 Political recommendations for the 24th BalticSea Parliamentary ConferenceOn the basis of its mandate, the Baltic Sea Parliamentary Confer-ence Working Group on Innovation in Social- and Healthcare pro-poses the following political recommendations as a result of itswork. The recommendations also are a result of deliberations andproposals of the meetings of the Standing Committee of the BSPCin Brussels (21 January 2015 and Stralsund (29 May 2015) and in-clude the contribution of the BSPC to the 4th# Northern DimensionParliamentary Dialogue with regard to the Northern DimensionPartnership in Public Health and Social Well-being.These political recommendations will be conveyed to the 24th BSPCin Mecklenburg-Vorpommern on 30 August – 1 September 2015:The BSPC Working Group on Innovation in Social- and Health-care calls on the Governments, and where appropriate the Parlia-ments, of the Baltic Sea Region:5. Political Recommendations 63Regarding Cross-border Cooperation in Healthcare• to expand and deepen cross-border cooperation in healthcarein the Baltic Sea Region because of the common challenges allBaltic Sea Region countries face in the field of social- andhealthcare, and therefore• to support the Northern Dimension Partnership in PublicHealth and Social Well-being (NDPHS) as a highly valuedand innovative regional network, significantly contributing tothe improvement of peoples’ health and social well-being inthe Northern Dimension area, including its efforts to coordi-nate the new NDPHS 2020 Strategy and its Action Plan and• to launch and develop concrete cross-border healthcare initia-tives, such as ScanBalt or the WHO’s Healthy Cities project;• to improve the borderless cooperation and medical specialisa-tion in treatment of rare diseases, bearing in mind the cost-ef-fective usage of medical equipment;• to broaden the scope of the Könberg report to the entire BalticSea Region, in order to gain a comparable overview of the sta-tus of health and care in the Baltic Sea Region and• to intensify exchanges of experience and the cooperation withthe aim of fighting multi-resistant microbes and to implementresearch in this area;• to spread innovative practices throughout the Baltic Sea Re-gion to become a model region in healthcare and continue thedevelopment of the Baltic Sea Health Region;• to strive to introduce same standards in the treatment of con-tagious infectious diseases on a high level all around the BalticSea Region;Regarding Health Economy• to use synergies with existing strategies, such as the ScanBaltStrategy 2015-2018;• to improve the support for the development of innovations inhealthcare to undertake measures in order to prevent a braindrain;• to improve the conditions to support the development of in-novations in healthcare, especially in the fields of e-health andtelemedicine;• to improve early intervention to strengthen a good publichealth through social investment like vaccine programmes,and work towards a stronger alcohol, tobacco and illicit use ofdrugs prevention, diabetes and other lifestyle illnesses;64 5. Political Recommendations• to support the usage of cost-reducing methods for better lifequality, like cultural and physical health-related activities intreatment;• to foster the development of health-related services within thetourism strategies of the Baltic Sea Region countries;Regarding Sustainable and Accessible Social- and Healthcare• to ensure affordable healthcare for everybody and emphasisethe focus on the needs of the patient;• to raise the awareness of the people living in the Baltic Sea Re-gion to support approaches for more responsibilities of the pa-tients;• to take strong measures to ensure equitably available socialwelfare and healthcare services, e.g. between urban and ruralareas and between socio-economic groups;• to develop and strengthen strategies addressing the demo-graphic change, an important issue affecting all partner re-gions;• to carry out studies with the aim of developing preventionstrategies in healthcare, such as the North-Trøndelag HealthStudy (HUNT);• to create incentives to improve the conditions of the nursingand care professions;• to install geriatric healthcare centres and modify social rehabil-itation centres to ensure healthcare in rural areas as well as toimprove age-appropriate medicine;• to recognise that strong social partners in the social- andhealthcare professions exist, and to protect their activities;• to consider health in all policies;• to commission a regular report on the status of health in thecountries of the Baltic Sea Region.Baltic Sea Parliamentary Conference Secretariatwww.bspc.netBSPC Secretariatc/o Lennéstraße 119053 SchwerinGermanyPhone (+49) 385 525 2777