Final Report to 24th BSPC Volume II August 2015

Baltic Sea Parliamentary ConferenceThe BSPC Working Group onInnovation in Social- and HealthcareFinal Report - Volume IIPurpose of the ReportThe purpose of this extension of the report by the BSPC Working Group on Innovation in Social- andHealth Care (WG ISHC) is to provide an in-depth overview of the activities of the WG, the expert pres-entations received, and the homework it compiled in preparation of its meetings. This Volume II of the Fi-nal Report of the WG ISHC therefore has to be seen as a complementary addition to the actual report.ContentsI. WG meeting and study visit programmes and expert presentationsRiga, Latvia 3Tromsø, Norway 65Birštonas, Lithuania 132Copenhagen, Denmark 178Levanger, Norway 277Tampere, Finland 366Åland Islands 489II. WG homeworkHomework 1: general nature of public strategies and measures of ISHC 512Homework 2: ethical aspects of ISHC 577Homework 3: demographic perspectives and the mobility of elderly 628Baltic Sea Parliamentary ConferenceI.WG meeting programmes&expert presentations– 2 –Baltic Sea Parliamentary ConferenceI. WG meeting programmes and expertpresentationsRiga, Latvia, 4 November 20130930-1300 M eeting, including expert presentation by Mr Thomas Karopka, Project Manager ofScanBalt HealthPortThe BSPC Working Group on Innovation in Social- and Health Care (WG ISHC) held its inauguralmeeting in Riga on 4 November 2013. The meeting was led by the then WG Chairman Raimonds Vējonis.The meeting appointed Olaug Bollestad, Norway, and Wolfgang Waldmüller, Mecklenburg-Vorpommern,as vice Chairmen. An expert presentation on “Innovation in Social- and Healthcare - An Ecosystems Ap-proach” was delivered by Thomas Karopka, Project Manager of ScanBalt HealthPort. The meeting was pri-marily devoted to a reconfirmation of the WG mandate and deliberations over its scope of work, prioritiesand mode of work.– 3 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaInnovation in Health andSocial careAn „Ecosystems“ perspectiveInaugural MeetingWorking Group on Innovation in Social and Health CareBaltic Sea Parliamentary Conference(BSPC WG ISHC)Thomas Karopka, BioCon Valley GmbHRiga, 4th November 2013– 4 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaScanBalt organisation ~70 members Bottom up organisation with leanScanBalt fmba,central secretariat in Copenhagenfounded in august 2004 Regional offices and contactpoints in all Baltic sea statesNon profit member Decentralized and projectoriented mode of actionbased association Annual ScanBalt ForaTriple helix(academia – industry – authorities)Goals:Knowledge formation & educationCommercialisationForum for discussion onlife science – health – society impact2– 5 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaKey drivers in Life sciencesand HealthStable health care systemsaffecting a population ofapprox. 85 Mio. peopleMore than 5 Mio.Employees in health careand related industriesCritical mass of innovativeuniversities with world classbasic science with a generalstrong focus on life sciencesWell educated, skillful andmotived human ressourcesStrong health care/pharma/medtech industry with morethan 2.000 companiesPresentation Innovation Agenda | Brussels, 26.09.2013 © ScanBalt fmba · Copenhagen 3– 6 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhy Innovation?(e.g. Germany)– 7 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhy Innovation?Total expenditure on health per capita in the Nordic countries, 1998-2007– 8 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRegional challenges ...PPPPooooppppuuuullllaaaattttiiiioooonnnn DDDDeeeecccclllliiiinnnneeeeDDDDeeeemmmmooooggggrrrraaaapppphhhhiiiicccc cccchhhhaaaannnnggggeeeeCCoommppeettiittiivveenneessssWWoorrkkffoorrcceeSSoocciiaall CCoossttssRegionalRegional DevelopmentLabourHealth Caremarket6– 9 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka– 10 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaChallenges for theHealthcare systemObesity– 11 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaBehavioural Change?Source: http://en.wikipedia.org/wiki/File:Fettleibigkeit_in_Europa2.svg/Source: http://www.flickr.com/photos/robadob/88894048– 12 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhy Innovation?– 13 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaObtaining value per dollar– 14 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaTwo questions.....Among many others1) How do we address the healthrelated challenges ofdemographic change and non-communicable diseases (NCDs)?2) Is our health economy capable ofdeveloping cost effective, highquality products and services forthis new environment?– 15 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhat is Health Economy?Health Economy can be defined as:„The provision and commercialization ofgoods and services, in order tosupport the maintenance andrestoration of health“– 16 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhat is Social Innovation?Definition:“Social Innovation is about new ideas that work to addresspressing unmet needs. We simply describe it asinnovations that are both social in their ends and in theirmeans. Social innovations are new ideas (products,services and models) that simultaneously meet socialneeds (more effectively than alternatives) and create newsocial relationships or collaborations.”(European Commission 2010)Heinze and Naegele:“We speak of social innovations if there is an intentional,purposeful new configuration of social practices realisedby a certain group of stakeholders respectivelyconstellation of stakeholders.”– 17 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhat is Social Innovation?Heinze and Naegele:“We speak of social innovations if the followingpreconditions are fulfilled:• Orientation towards outstanding societal challenges / social issues• New solutions in the sense of a real understanding of newness• Specific new configurations of social practices/arrangements• Overcoming the traditional dichotomisation of technological and socialinnovations• Integration/collaboration of heterogeneous stakeholders that usually do not(have) co-operate• Integrated patterns of action• Reflexivity and interdisciplinary approaches• Orientation towards the key goal of societal usefulness• Sustainability of measures (in the sense of social practice/facts)• New growth potentials in terms of regular employment• Integration of the end-users (“user co-production”)Source: Heinze R, Naegele G. Social innovations in ageing societies. Callenge Social Innovation:Potential for Business, Social Entrepreneurship, Welfare and Civil Society. Springer; 2012. p. 153–67.– 18 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaHow about Innovation?What is Innovation?In a nutshell:Innovation is ideas putinto practice which thencreate value(Cited from Ideas Clinic Aalborg)Ideas can be completely new ones or existing ideas tunedor combined in new ways.Value can be heightened quality, improved economy orincreased safety– 19 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaHealth systems are patient centred ecosystemsThey are complex adaptive systemsWellnessResearchCollaborationInformation ExchangeProcesses Knowledge Managementare not Process Integrationlinear!DeliveryEducationSource: Joseph DalMolin, e-cology corp.– 20 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWe are witnessing a paradigm change inhealth care!Past FuturePresentThe individual The communityAcute diseases dominates More chronicillness/disabilityEpisodic care Continous careCure of disease Prevention of diseaseReactive ProspectivePhysician provider Teams of providersPaternalism Partnership with patientsProvider centered Patient/family centredParochial health threats Global health threatsCohen, 21st Century Challenges for Medical Education; 9th International Medical WorkforceConference; Melbourne, Australia; November 2005– 21 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaHealthPort visionA „health economy“ perspectiveStrengtheningcross-sectoral, collaborative, open innovationin health and life sciencesto promotesustainable, cost-efficient, citizen-centric healthsystems, strengthen regional economies andthus improve the health, wellbeing and prosperityin the Baltic Sea Region (BSR)– 22 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaPeople innovate,not systems• It is not possible to plan innovation –recognize, facilitate and foster it whenit emerges• Health care systems are complex –collaboration and partnership areessential to successfully market aproduct or service– 23 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaOpen InnovationSource: http://www.openinnovation.eu– 24 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaFrom „The lab is our world...– 25 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopkato „....the world is our lab!– 26 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaLead:HealthPortInnovationAgenda to openthe frameworksKey targets:Promote a MultidimensionalInnovation Ecosystem for healtheconomyPromote self-sustainable business Figure by Thomas Karopka, BioConValley, in ”Health and life sciences asinnovation support servicesdrivers for regional development andprosperity in the Baltic Sea Region”Wolfgang Blank, Peter Frank, ThomasKaropka, East-West Business, in press24– 27 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaInnovation Ecosystem forhealth economy– 28 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaWhy an Ecosystem?Hypothesis:An ecosystem is only in a „healthy“ state ifit is in equilibrium stage.A focus on only one aspect will not lead tosustainability and will have negativeeffects in the long runAn ecosystem approach allows toaddress the problems in a holistic way– 29 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(1) Scouting & Early EvaluationChallenges:Assess the potential of anRecommendation:idea to become an innovationSet up a platform / meeting point for youngentrepreneurs and experts for early evaluation andmentoring.Promote Innovation competitions to filter outinnovative ideasSet up user driven idea management platforms togenerate early feedback from potential users– 30 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(1) Scouting & Early EvaluationIdeas Competition: HealthPort Innovation AwardOxygen Soother– 31 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(1) Scouting & Early EvaluationIdea Management– 32 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(2) Business Support & FinancingChallenges:Recommendation: Access to capital especiallyfor early idea evaluationDevelop new forms of transnational financing e.g.crowdfunding or special transnationally availablefunds for health and life sciences.Promote successful models for SME support anddevelopment to cover the entire BSRDevelop a transnational, cross-sectoral mentoringsystem for SMEs in health and life sciences– 33 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(2) Business Support & FinancingCrowdfunding for Health & Life Sciences– 34 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(2) Business Support & FinancingA Baltic-Scandinavianelite acceleratorfor health sciencestartups– 35 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(3) Implementation & MarketingChallenges:Recommendation:Dissemination of Innovativeproducts and services in a trans-Provide a platform with national macro-regional contextmodular shared servicesfor SMEs that comprise marketing and dissemination offinal products or services, Organise platforms forcooperation between SMEs offering complementaryservicesProvide case specific support for transnational marketimplementation with a focus on BSR macro-regionSupport „strategic communication“ with all relevantactors for products and services from SME ́s– 36 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(3) Implementation & Marketing– 37 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(4) Education &Challenges:Qualification Lack of entrepreneurship skills inhealth and life sciences Lack of knowledge about regulation,certification and procurementRecommendations: Develop a platform of practical SME tailored courses onspecific topics for working individuals (post-education) upto hands on local coaching for SME consortia . Make working conditions innovation friendly ...Value working conditions and creativity ...Create room for innovation in the working environment(Improve working conditions, other skill mix (up-/down-skilling) ... change the climate to allow creativeness)– 38 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaScanBalt Educational PlatformRequirementsHealthPort Report – Major challenges for SME-s to be commerciallysuccessfulGrete Kuura and Boo Edgar, from University of Gothenburg, 2011.Method: 21 interviews with SME, cluster organizations, science parks andhospitals within the ScanBalt Health Region:ResultsNeed of knowledge in +Support fromEntrepreneural education withcluster organisationBioScience focusAcademic Courses Local Mentoring– 39 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaScanBalt Educational PlatformEducational Plan – PPootteennttiiaall CCoouurrsseessManagement ofProjectinnovation andManagemententrepreneurshipIdeaBusinessevaluationPlanand feasabilityScanBaltEducational PlatformClinical verification(Pharmaceuticals/ComplementaryBiomaterials,CoursesMedicalSales &TechnologyProcurementVenture(legal andFinancingregionally adapted)All with BioScience-Focus!– 40 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(5) Regulation & ProcurementThe public sector has a dual role inrespect to innovation. The public sectoracts as regulator and as procurer.In the Nordic countries 80 – 85% ofhealth spending is funded by publicsources.There is a huge potential to stimulateinnovation through public procurement.– 41 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka(5) Regulation &ProcurementChallenges:It is increasingly difficult to conductclinical trials.Recommendations: It is increasingly important to proofthe efficacy and cost- effectiveness of Understanding new products and services Late stage failure rate and time toodifferencesmarket extremely longin regulation andprocurement (governance) in BSR and makeentrepreneurs work with them Support initiatives to coordinate clinical trials in the BSRand offer SME support measures Support the installation of early HTA expertise as a parallelprocess to product development Support in certification and other formal requirements withrespect to international markets Support PPI and PCP in the health care sector and furtherwork on harmonizing and minimizing (deregulation)regulations on the EU-level– 42 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRegulation & Procurement PCP to steer the development of solutions towards concretepublic sector needs, whilst comparing/validating alternativesolution approaches from various vendors PPI to act as launching customer / early adopter / first buyer ofinnovative commercial end-solutions newly arriving on themarketR&D / Pre-commercial Procurement (PCP)Phase 0 Phase 1 Phase 2 Phase 3 Phase 4Curiosity Solution design Prototype Original development Deployment of commercialDriven of limited volume end-productsdevelopmentResearch of first test products / Diffusion of newly developedSupplier Aservices products / servicesSupplier BSupplier BSupplier B Supplier(s)Supplier CA,B,C,DSupplier CSupplier D and/or XSupplier DSupplier D...... iinn lliinnee wwiitthh WWTTOO pprroocc.. rruulleess,, EEUU TTrreeaattyy,, SSttaattee aaiidd ffrreeee– 43 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkHigh Level Group on Innovation PolicyManagementEffective innovation requires a set of 7 key activities:• Optimize the embryonic European innovation ecosystem• Improve policy coherence• Reduce regulatory complexity and rigidity• Eliminate obstacles and provide new funding to innovation• Facilitate industrial cooperation and re-interpretation of competition law• Take an encompassing and inclusive view of intellectual property• Increase the innovation potential through user and consumer driveSource: High Level Group on Innovation Policy Management, Report & Recommendations, 2013, p.13– 44 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkConceptualising and creating a global learning healthsystemCharles Friedman and Michael Rigby• “In any nation, the health sector, ....., in fact operates more on the level ofseperated islands of information.”• “There are, in short, no systematic means for the national or global healthsystem to learn rapidly from its experience”• “A further result of this lack of learning is that it reportedly takes 17 years beforea new element o validated clinical knowledge finds its way into routine clinicalpractice in the United States.”• “In summary, the learning health system – nationally, regionally and globally –can be seen as an ethically required public good. Indeed, given the increasingperformance and economic pressures on every national health system, such anapproach can be seen as essential.”Source: Charles Friedman and Michael Rigby: Conceptualising and creating a global learning health system,International Journal of Medical Informatics 82 (2013), e63-e71– 45 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkThe OECD Innovation Strategy: Getting a head start onTommorrow• “Innovation drives growth and helps address social challenges.”• “Action on innovation must be a priority for emerging from the crisis.”• “Policies need to reflect innovation as it occurs today.”• “People should be empowered to innovate.”• “Innovation in firms must be unleashed”• “The creation, diffusion and application of knowledge is critical.”• “Innovation can be applied to address global and social challenges.”• “The governance and measurement of policies for innovation should beimproved.”Source: The OECD Innovation Strategy: Getting a head start on tomorrow, OECD 2011– 46 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaCreating shared ValuePorter M.E. and Kramer M.R.: Creating Shared Value – How to reinvent capitalism – and unleash awave of innovation and growth, Harward Business Review, Jan-Feb 2011– 47 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkCreating Shared ValueHow to reinvent capitalism – and unleash a wave of innovation andgrowth by Michael E. Porter and Mark R.Kramer• “The solution lies in the principle of shared value, which involvescreating economic value in a way that also creates value for society byaddressing its needs and challenges. Business must reconnectcompany success with social progress.”• “A big part of the problem lies with companies themselves, whichremain trapped in an outdated approach to value creation that hasemerged over the past few decades. They continue to view valuecreation narrowly, optimizing short-term financial performance in abubble while missing the most important customer needs and ignoringthe broader influences that determine their long-term success”.• “Social needs, not just conventional economic needs, define markets,and social harms can create internal costs for firms”.Porter M.E. and Kramer M.R.: Creating Shared Value – How to reinvent capitalism – and unleash awave of innovation and growth, Harward Business Review, Jan-Feb 2011– 48 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkSocial care informatics and holistic health careThe members of the European Science Foundation ExploratoryWorkshop declare the fundamental importance of:providing harmonised health and social care services that meetthe extended needs of the individual, taking into account diversityin need, preferences, ability and support; and also recognisingthe concurrent resultant rights and needs of informal carers asindividual citizens;• focussing these services on the individual citizen as thebeneficiary, including the pattern of delivery they find mosteffective;• and to this end, utilising modern Information and CommunicationTechnologies as enabling services, as part of a wider health andsocial care toolkit;• whilst recognising the importance of e-services being anappropriate enabling mechanism, and not an inappropriatereplacement for necessary inter-personal interactionRigby M. OECD-NSF WORKSHOP: BUILDING A SMARTER HEALTH AND WELLNESS FUTURENational Science Foundation, Washington, D.C., USA, 15-16 February 2011– 49 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkEuropean Research and Innovation Area Board (ERIAB)Recommendations:• Smart regional policies going beyond smart specialisationThere is a need for a radical rethinking of regional policies going beyond thecurrent notions of smart specialisation, but including new concepts and notionssuch as:• Smart public sector specialisation• Smart university and higher education specialisation prioritizing e.g. science andtechnology studies with a strong innovation / entrepreneurship dimension• Smart mobility including double career programmes, etc.• The increasing fragmentation of value chains and the increasing heterogeneityof required knowledge inputs require strong international cooperation inresearch and a stronger focus on the deployment of ICT based technologies.Source: 1st Position paper of the European Research and Innovation Area Board (ERIAB): „Stress-test“ of theInnovation Union, November 2012– 50 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkCommunity-led local development (CLLD)Main aims of community-led local development:• encourage local communities to develop integrated bottom-up approaches incircumstances where there is a need to respond to territorial and localchallenges calling for structural change;• build community capacity and stimmulate innovation (including socialinnovation), entrepreneurship and capacity for change by encouraging thedevelopment and discovery of untapped potential from within communities andterritories;• promote community ownership by increasing participation within communitiesand build the sense of involvement and ownership that can increase theeffectiveness of EU policies; and• assist multi-level governance by providing a route for local communities to fullytake part in shaping the implementation of EU objectives in all areas.Source: Community-Led local development: Cohesion policy 2014-2020, Factsheet, EC 2012– 51 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkErnst & Young: Progressions 2012 – Health careeverywhereCompanies need to significantly extend their businessmodels to be:Data-centric: to harness and monetize insights from dataobtained from sensors, devices, social media threads, etc.Behaviorally savvy: to better understand and influencepatient behaviors.Experience-focused: with personalization, masscustomization and an increased focus on industrial design.Holistic: with approaches that encompass the cycle ofcare and the life cycle of the patient.Revenue-flexible: as companies capture value in differentways, reflecting the changing ways in which they arecreating and delivering value.Source: Ernst & Young: Progressions 2012 – Health care everywhere – Creatively disrupting business models– 52 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkSource: Ernst & Young, Progressions: Building Pharma 3.0– 53 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated workCenter for Integration of Medicine and Innovative Technology– 54 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaRelated WorkCenter for Integration of Medicine and InnovativeTechnologyCIMIT accelerates the healthcare innovation cycle by facilitatingcollaboration among clinicians, healthcare managers, technologists,engineers and entrepreneurs through the development andimplementation of novel products, services and procedures to improvepatient care.CIMIT AT–A–GLANCE• Founded: 1998 • Peer-Reviewed Publications: 500+• Member Institutions: 13 • Invention Disclosures: 200+• Industry Partners: 60+ • Patent Applications: 200+• Projects Funded: 550+ • Patents Issued: 30+• Active Projects: 76 • Licenses: 10+• Principal Investigators: 310+ • Companies Formed: 15+Source: http://www.cimit.org– 55 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaConclusionsProduct (service)development takesplace at a global leveltoFrom„....the world„The lab is ouris our lab!“world ...“Health care deliverytakes place at theregional level53– 56 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaConclusions Focus on health outcomes We need technical AND process ANDorganizational AND social innovation Focus on demand- and user-driven innovation View innovations as part of a holistic system From „smart specialisation“ to „smartimplementation“ We need „smart investment“ (taking the value intoaccount and not only financial aspects) Creating shared value could be a good framework Collaboration is key in finding solutions forcommon challenges54– 57 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaConclusions cont.Keep the balance in the „Ecosystem“ !Focus on value!move to anevidence-based,outcomes focused,behaviour-drivenworld– 58 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaPartnersGöteborg University (SE)North Denmark Region (DK)Culminatum Innovation (FI)Entrepreneurship Development Centre forBiotechnology and Medicine (EE)BioCon Valley (GE)Turku Science Park (FI)InnoBaltica (PL)Institute of Biotechnology/Vilnius University(LT)ScanBalt (DK – Coordinator)15 associated partners– 59 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaLiteratureAccelerace Life. Available from: http://www.scanbalt.org/press/news+archive/view?id=3027Berwick, DM. Disseminating Innovations in Health Care“. JAMA: The Journal of the American Medical Association 289, 2003;15:1969 -1975.Blank W, Frank P, Karopka T. Health and Life Sciences as Drivers for Regional Development and Prosperity in the Baltic Sea Region.Journal of East-West Business. 2013;19(1-2):122–37.BSHR HealthPort. Available from: www.scanbalt.org/projects/scanbalt+health+region/bshr+healthportErnst & Young. Progressions -The third place: health care everywhere. 2012.Ernst & Young. New horizons: Collaboration, Health Care Provider Industry Report 2012, Available from:http://www.ey.com/Publication/vwLUAssets/New_Horizons_2012_health_care_provider_report/$FILE/New_horizons_2012_final_August_2.pdfEuropean Commission. The contribution of health to the economy in the European Union, Luxembourg: Office for Official Publications of theEuropean Communities, 2005, ISBN 92-894-9829-3European Commission. Health 2020: a European policy framework supporting action across government and society for health and well-being, Regional Committee for Europe, Malta, 10-13 September 2012, Available from:http://www.euro.who.int/__data/assets/pdf_file/0009/169803/RC62wd09-Eng.pdfEuropean Union. Open Innovation 2.0 Yearbook 2013, 2013; Available from: https://ec.europa.eu/digital-agenda/node/66129EUSBSR. Available from: http://www.balticsea-region-strategy.eu/Friedman C, Rigby M. Conceptualising and creating a global learning health system, International Journal of Medical Informatics 2013; e63e71.HealthClusterNet. The Liverpool Agenda –Regional health systems and health innovation markets working together for regionaldevelopment, 2008; Available from: http://healthclusternet.eu/media/attachment/HCN_Liverpool_Agenda_24052010.pdfHigh Level Group on Innovation Policy Mangement. Report & Recommendation. Brussels: HLG Secretariat, 2013; ISBN: 9789082089301Ideklinikken. Available from: http://ideklinikken.dk/iNNOVAHEALTH. Building and Open Innovation Ecosystem for Health Care in Europe, 2013; Available from:http://www.innovahealth.ws/material/presentations/iNNOVAHEALTH_Final_Report.pdfKASK Innovation. Available from: http://www.kask-innovation.eu– 60 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaLiteratureKuura G, Pihlakas P, Edgar B. BSHR HealthPort Report: Education to promote Innovation.Magnussen J, Vrangbaek K, Saltman RB. Nordic health care systems: Recent reforms and current challenges, McGraw Hill, OpenUniversity Press, 2009Moore JF. The Death of Competition: Leadership & Strategy in the Age of Business Ecosystems. New York: Harper Business; 1996Nordic Council of Ministers. Innovative Public Procurement and Health Care –Nordic Lighthouse Project, Copenhagen; 2011OECD/Statistical Office of the European Communities. Oslo Manual: Guidelines for Collecting and Interpreting Innovation Data.2005;3,162.OECD: Biomedicine and Health Innovation Synthesis Report, 2010; Available from http://www.oecd.org/dataoecd/42/56/46925602.pdfOmachonu, V. and Einspruch N. Innovation in Healthcare Delivery Systems: A Conceptual Framework, The Innovation Journal,2010;15(1).The Liverpool Agenda, Health Cluster Net, 2007http://www.healthclusternet.eu/media/attachment/HCN_Liverpool_Agenda_24052010.pdfThe OECD Innovation Strategy: Getting a Head Start on Tomorrow [Internet]. [cited 2013 Oct 22]. Available from:http://www.oecd.org/sti/theoecdinnovationstrategygettingaheadstartontomorrow.htmThe Northern Dimension Partnership in Public Health and Social Well-being: The EU Strategy for the Baltic Sea Region –Views of theNDPHS, 2009, Available:http://www.ndphs.org/?downloadpaper,53,NDPHS_contribution_to_public_consultation_on_the_EU_BSR_Strategy.pdfThe Northern Dimension Partnership in Public Health and Social Well-being. Raising the profile of health and social well-being,http://www.ndphs.org/internalfiles/File/Strategic%20political%20docs/Post-2013_European-Programmes--Raising_Profile_of_Health_and_Social_Well-being_%28NDPHS_position_paper%29.pdfParrish JA and Newbower RS. CIMIT: A Prototype Structure for Accelerating the Clinical Impact of Research on Novel Technologies.Available from: http://www.cimit.org/images/cimit-model.pdfPorter M, Kramer M. Creating Shared Value. Harvard Business Review. 2011 Feb;89(1/2):62–77.Rigby M, Koch S, Keeling D, Hill P. Developing a New Understanding of Enabling Health and Wellbeing in Europe. 2013.– 61 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas KaropkaLiteratureRolfstam M. Understanding Public Procurement of Innovation: Definitions, Innovation Types and Interaction Modes [Internet].Rochester, NY: Social Science Research Network; 2012 Feb. Report No.: ID 2011488. Available from:http://papers.ssrn.com/abstract=2011488.ScanBalt. Available from: http://www.scanbalt.org/ScanBalt, BridgeBSR: Smart Growth –Bridging Academia and SMEs in the Baltic Sea Region, 2009; Available from:http://www.scanbalt.org/files/graphics/ScanBalt%20member%20documents/Opinion%20Papers/Smart%20Growth%20-%20Bridging%20Academia%20and%20SMEs%20in%20the%20Baltic%20Sea%20Region.pdfScanBalt, ScanBalt Strategy: Smart Growth and Spezialisation on Top of Europe towards EU 2020. Available from:www.scanbalt.org/about+scanbalt/strategyScanBalt. EU Framework Programme 8 and the Role of Macro-Regions, 2011; Available from:http://www.scanbalt.org/files/graphics/ScanBalt%20member%20documents/Opinion%20Papers/ScanBalt%20PositionPaper%20FP%208%20Role%20of%20Macro%20regions.pdfScanBalt. EU Cohesion Policies and the Importance of macro-Regions and Regional Clusters for Smart Growth and SmartSpecialisation, March 2011, Available from:http://www.scanbalt.org/files/graphics/ScanBalt%20member%20documents/Opinion%20Papers/SB%20position%20paper%20EU%20Cohesion%20Policy.pdfWHO Europe. Gaining health –The European Strategy for the Prevention and Control of Noncommunicable Diseases, 2006; ISBN 92-890 2179 9, Available from: http://www.euro.who.int/__data/assets/pdf_file/0008/76526/E89306.pdf– 62 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka„The significant problems we facecannot be solved at the same level ofthinking we were at when we createdthem“Albert Einstein– 63 –I. WG meeting programmes and expert presentations | 1. Riga, Latvia – Thomas Karopka„It is hard to learn from experience,But it is even harder not to learn fromexperience“Anonymous– 64 –Baltic Sea Parliamentary ConferenceTromsø, Norway, 27-28 March 2014Thursday 27 March1430-1800 W G meeting, including expert presentation by Ms Pille Kink, Standardisation Managerat the Estonian e-Health FoundationFriday 28 March0900-1115 N ational Centre for Telemedicine including expert presentation by Ms Magne Nicolaisen,Ms Kirsten Eriksen, Mr Per Hasvold1115-1200 WG meeting and summing-upThe BSPC Working Group on Innovation in Social- and Health Care held its second meeting in Tromsøon 27-28 March 2014. The meeting unanimously elected Ms Olaug Bollestad, Norway, to succeed Rai-monds Vējonis as Chair of the WG, since Vējonis had been appointed Minister of Defence of Latvia in Jan-uary 2014. An opening expert presentation was provided by Ms Pille Kink from the Estonian e-HealthFoundation. After the meeting, the WG made a study visit to the Norwegian Centre for Integrated Careand Telemedicine, where briefings were given on coordinated care and demographic challenges in rural are-as, telemedicine innovation and implementation, flexible e-learning in healthcare, homecare and preven-tion, and barriers and legal aspects of cross-border telemedicine.–– 6655 ––I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkeHealth in EstoniaPille KinkEstonian E‐Health Foundation– 66 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkFacts about EstoniaEstonia45 227 km2 area of Estonia1.29 mio inhabitants60 hospitals464 GPsHealthcare expenditures5.9% from GDP 20116.3% from GDP 20122– 67 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkEstonian information system platform3– 68 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkeHealth systems in Estonia• Health Information System• Digital Prescription• Health Insurance Information System• Administrative and Product Registries• Public Health and Quality Registries• Telemedicine Tools used in health sector• Service providers information systems4– 69 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkArchitectureX‐Road, ID‐card, State IS Service RegisterX‐ROAD GATEWAYSERVICENATION‐WIDEHEALTH PRESCRIPTIONPATIENT PORTAL INFORMATION CENTREEXCHANGE PLATFORM 2010 januaryPHARMACIES AND 2008 decemberFAMILY DOCTORS5– 70 –SENICIDEMFOYCNEGAETATSertneCgnidoC‐senicidemfosreldnaH‐DRAOBERACHTLAEHsredivorperachtlaeH‐slanoisseforphtlaeH‐stsimehcgnisnepsiD‐YRTSIGERNOITALUPOPYRTSIGERSSENISUBSLATIPSOHSROTCODYLIMAFSICAMRAHPSESRUNLOOHCSECIVRESLACIDEMYCNEGREMEI. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkSecurity and authentication– 71 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkHIE platform historyeHealthPlanning Project preparation Foundation eHealth Projectsinitiated (2003-2005) established (2006-2008)2000 2002 2004 2006 2008National HIEFunding decision by Ministryof Economic AffairsElectronic Health Digital DigitalDigital ImagesRecord Prescription Registration– 72 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkFunctionalities of healthinformation system:• Provide services to healthcare providers to simplifytheir every day work• Provide health information topatients• Central secure storage ofhealth data06.02.2013 8– 73 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkeHealth in numbersePrescription covers 97% of issued prescriptions.1.2 mio person have documents (93% of population) in centralsystem~ 97% of stationary case summaries have sent to the centralDB9– 74 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkNew Patient Portal released 01.07.201310– 75 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkNumber of patient queries11– 76 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkPossibilities for patientIn patient portal:• View and print out medical documents sent by health care providers tothe central system;• View information about their general practitioners and validity of healthinsurance;• Make informed consents;• Provide general information about themselves for health care providers;• Give authorisations for trustees;• Mask data for trustees and health care providers;• Monitor logsGet useful information and read explanations12– 77 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkSTANDARDS13– 78 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkStandards• HL7 and DICOM (Picture Archive)• International classification: ICD‐10, LOINC,NCSP, ATC• Estonian eHealth’s OID registry• Local eHealth classificators– Published in publishing centre– Classificators are regulated by government act14– 79 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkStandardization processHealthcareSpecialty Socialprovidersassotiations ministryHHeeaalltthhEeHFInsuranceTerminology standardizationFFuunnddexperts specialistsUML+HL7 HISexperts developersCreate data Formalize Approveset and merge and publishXMLUML model Changes in NHISschemasdocumentsDescriptionData set document regulatory actClassificatorsdocumentsOID‐s Examples Fixed version ofartifacts inStylesheets publishing centre15– 80 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkMajor architectural decisions of HIS• Integration through Central system (Opt‐out)• HL7 v3 (extended)• Documents are kept in XML format (HL7 CDA)• All structured data fields have OID‐s• Only final versions of clinical documents are sent into centralsystem• Reuse of national infrastructure– ID card for authentication and digital signature– Xroad for secure communication1166– 81 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkBenefits of eHealth Systems• Greater efficiency• Lower costs• Quality of care• Patient awareness about their health17– 82 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkLEARNINGPOINTS06.02.2013 18– 83 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille Kink• Resources were planned only for centraldevelopment.• Usability. Developing process has to includemedical competence – users• Data quality is important– Complete and quality data give value.• Balance between security and usability– PIN for every document ...19– 84 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Pille KinkThank you!20– 85 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenInteraction, competenceand demographyTromsø, Friday 28 March 2014.– 86 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenWhat’s important...?• "We do as we are told"– 87 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenWorlds best relay-team?– 88 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenPractice...?– 89 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenAre we good at this?– 90 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenPredictability and quality– 91 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne Nicolaisen– 92 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenEnsure quality and sustainabledevelopmentEnighet omutfordringsbildet;Vi må gjøreendringer!– 93 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenAging population– 94 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenDemographic trends TromsÅr 2010 2012 2015 2020 2025 2030Troms 156 494 161 185 168 466 171 594Over 67 19 849 23 177 30 237 33 029% endring 12,6% 14,4% 18% 19,2%– 95 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenExample TromsøÅr 2010 2012 2015 2020 2025 2030Tromsø 67 305 69 373 78 016 80 649Over 67 5 983 7 455 10 896 12 462% endring 8,9% 10,7% 14% 15,4%– 96 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenExample IbestadÅr 2010 2015 2020 2025 2030Ibestad 1 408 1 237 1 087 886Over 67 359 362 375 358% endring 25% 29% 34% 40%– 97 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenProductivity and skills I dag gårhver 6. elevfra ungdomsskolen inn ihelse- og omsorgsarbeid Med samme nivå påtjenestetilbudet,vil vi i 2025 ha behov for athver 4. elevfra ungdomsskolen blir helse- ogsosialarbeider .... og i 2035 måhver 3. elevvelge h/s utdanning....– 98 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne NicolaisenNeed for increase in society's workforcePerson i «yrkesaktivalder» per «eldre»1098,787654,24,9 5,0432,92,62102010 2020 2030 2040 2050 206019-67/>67 19-67/>75– 99 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Magne Nicolaisen– 100 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldself-management andpreventionPer Erlend Hasvold, MScSection Manager - Home-based services and personal health systemsper.hasvold@telemed.noNorwegian Centre for Integrated Care and Telemedicine - NSTUniversity Hospital of North Norway - UNN HF– 101 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldchallenges•Government white-paper:•today every 6th child in secondary schooltake a health or care related education•in 2035 every 3rd child must get a healthor care related education if we shalldeliver the same services to the sameparts of the population as todaythis is not sustainable!– 102 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldchallenges•a Danish colleague calculated the amountof time the worst COPD patients spentvisiting health services: 0,02%•i.e. more than 99,98% of the time seriouslyill patients spend alone, making all criticaldecisions that will affect their health– 103 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldchallenges•healthcare organizations are a complexsystems•healthcare organizations characterized byprofessional roles and ethics, and high rateof ad-hoc decisions•healthcare has been slow at making changes– 104 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldour objectivesto find ways of applying technology:•to deliver better care, using fewer resources•to support self-management•to motivate changes in lifestyle to a more healthyone•to prevent secondary disease•to reduce the risks leading to injury and healthproblems– 105 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvolda sociotechnicalperspectiveServiceTechnology Organization– 106 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldthe diabetes diary•result of 12 years of research•examples: bluetooth interface for blood glucose meters; SMSservice for parents of child with type 1 diabetes•user involvement in all aspects of development•focus on usability; supporting self-management•current version is available for free at Google Play and AppStore•features mechanism for analyzing data to find similar situations;seeing trends and patterns•future: tailoring; gamification; investigate gender differences– 107 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per HasvoldeRehabilitation•current projects:•COPD patients receive treadmill, pulse-oxymeter, iPad - follow up by physiotherapist•post cardiac surgery rehabilitation, tailoredsupport to encourage adherence to training•we achieve better adherence and compliance,improvements in quality of life, reduction ofreadmissions to hospital– 108 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldwelfare technology•participation in national networks on welfaretechnology•support of projects on municipality level on smarthomes for the frail•use of virtual presence robot - the Giraf•the serenity button: use of mHealth to connect theresources around the patient•discuss aspects of welfare technology and possibleconsequences– 109 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldmental health•apply eHealth to create low thresholdservices to reach people with mild mentalhealth problems•create models of care that gives morecitizen services with less use of resources– 110 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldapps and mHealthFitbit.comWhitings.com– 111 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldapps•apps are maturing•ecosystems of apps•integration with legacy systems•advanced data analysis (in phone or online)•dashboard interfaces•tailoring– 112 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldhealth information•apps and devices collect data about the user - morethan health professionals can deal with•using big-data and multivariate analysis we turn hugeamounts of data into useful information•important in terms of bridging the personal healthsystems to the professional health information systems•citizen services: erdusyk.no•real-time dashboard for infections in the region:snow.telemed.no– 113 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per HasvoldeHealth trends•national survey on use of eHealth and interaction withhealth care services through the net: 2000, 2001, 2003,2005, 2007, 2013•November 2013:•26% has used a foreign eHealth service•44% wants to be able to send email to GP•48% are worried that information will not beavailable in an emergency situation•41% are worried about health information privacy– 114 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per HasvoldHar erfaring med eHelse100 %90 %80 %70 %60 %50 %40 %30 %20 %10 %0 %15-18 19-25 26-35 36-50 51-66 67-80Aldersgruppe– 115 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvold– 116 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldtailored eHealth•slutta.no smoking cessation - part of thenational health portal•tailoring: feedback and type of follow updepends on psychological profile -stratification of user types•tailoring leads to better adherence andcompliance - i.e. better outcomes– 117 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvolduniversal access•privacy laws require use of BankID to log onto national portal helsenorge.no to accesspersonal information and services•however, if you are blind, you need someoneto help you with the BankID code generator- i.e. the assistant has full access to the healthinformation (as well as banking services)!•mHealth is a challenge in terms of UA– 118 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per HasvoldKnowledgeTrustSafety requires:Technology- Equipment must be made for the task- Equipment must be well maintained- Equipment must be used correctly– 119 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldgaming and gamification•gaming is used to award healthy behavior andto attract users to a health service•gaming used for activating people and tomeasure cognitive performance - might beuseful in diagnostic and monitoring•gamification is to build in the factors thatattract people to become active in games tomake people adhere to lifestyle changeprograms, and to educate: e.g. sjekkdeg.no– 120 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Per Hasvoldthank you!per.hasvold@telemed.no– 121 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten EriksenFlexible e-learning inhealthcareKirsten EriksenSection Managerhelsekompetanse.nokirsten.eriksen@telemed.no + 47 913 49 652– 122 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten Eriksen– 123 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten Eriksen– 124 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten Eriksen• Norwegian resource center for telemedicine• Research and development• Centre for Research-based Innovation – Tromsø Telemedicine Laboratory (TTL)• WHO collaborating center• European Space Agency ambassador platform– 125 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten EriksenNordic competencenetworkUsing VC - Disability:Norway, Iceland, theFaroe Islands andGreenland, Denmark,SwedenHow to treath rarediseases– 126 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten EriksenNordic course portal– 127 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten EriksenMedical Peace Work– 128 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten Eriksen– 129 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten EriksenGlobal learning for local impact– 130 –I. WG meeting programmes and expert presentations | 2. Tromsø, Norway – Kirsten Eriksen– 131 –Baltic Sea Parliamentary ConferenceBirštonas, Lithuania, 19-20 June 2014Thursday 19 June1430-1800 ExcursionFriday 20 June0900-1200 W G Meeting, including expert presentation by Ms Nijolė Dirginčienė, Mayor ofBirštonas and President of the Lithuanian Association of Resorts, and by Ms Jurgita Ka-zlauskienė, Vice President of European Spas Association (ESPA)The BPSC Working Group on Innovation in Social- and Health Care convened its third meeting inBirštonas, Lithuania, on 19-20 June 2014. The meeting itself was preceded by an extensive study tour ofthe balneological and rehabilitational resort of Birštonas, with several sanatoriums and a wide range ofhigh-quality recreational, rehabilitational and medical services (see www.visitbirstonas.lt). The WG meetingreceived initial greetings from the Mayor of Birštonas, Ms Nijole Dirginciene, who is also President of theLithuanian Association of Resorts. Her introduction was followed by a presentation on The Role of Resortsin the Baltic Health Tourism Sector by Ms Jurgita Kazlauskiene, Vice President of the European Spas As-sociation. The WG meeting primarily engaged in deliberations over the WG Mid-Way Report, to be pre-sented to the 23rd BSPC in Olsztyn on 24-26 August 2014, and its first set of political recommendations.– 132 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėRole of the Resorts in theBaltic Tourism SectorJURGITA KAZLAUSKIENĖVice President of EuropeanSpas Association (ESPA)– 133 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėContentI. The Role of the Spas in Europe.II. Trends in Health and Spa tourism.III. Potentials of Baltic Spa product.IV. Stakeholders of Lithuanian Spa Sector.– 134 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėThe role of the Spa and Health Tourism in Europe3 1.400 spa communities and health resorts in Europe; The industry employs direct and indirectly 750.000people; Annual turnover of 45 billion euro; Europe wide 180 million overnights.– 135 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėMore than Tourism:Spas and Health Resorts inEurope – Centres for Health– 136 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėSpas and Health Resorts in Europe – Centres forHealth Spas and health resorts - health centers with a highquality and complex value chain; Spas and health resorts in rural areas - health centers forthe local population; Increasing life expectancy and economic consequences ofdemographic change; National healthcare systems in Europe are required toensure good health services for the population; Cross border healthcare directive.– 137 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėElements of a European Spa community1. A natural remedy „of the soil, the seaor the climate2. Physicians in the community or in thehealth facility aquainted how to usethe remedies in therapies3. A place / hall to get the remedies4. Places for therapies (clinics, hotels,physical therapy with local remedies)5. House for the guests (communication,information, health training)6. A park, forest, walking trails7. Places for sport activities, kineso -therapy8. Places for cultural activities– 138 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėWhat does a spa Community distinguish from „normal“ communities?The use of natural remedies on site (ofthe soil, the sea or the climate)The knowledge about the bioclimaticconditionsThe special medical knowledge how touse the local natural remediesGood air quality, drinking water qualityNo stress due to noise, dangers,contamination.... a „small paradise“This USP should be more emphasized in future!– 139 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėThe misuse of the term Spa Today we must recognize, that we have an improper useof the term “spa” We learn terms like day spas, urban spas, city spas andcruise spas– when we will have night spas? Thanks to the Americans too hair spas and teen spas aretrendy– for me baby spas are still missing! The bottom line in this “new spa world” is, that localnatural remedies were separated from the spas.– 140 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėConsequences 1Consequences from this situation shouldbe a clear and simple positioning of ourspas and health resorts in Europe in twoways:First! There must be local naturalremedy/ies at the place andSecond! The communities/facilities(e.g. Balnearios, Medispas) must have amedical background.– 141 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėII. Trends in Health and Spa tourism. Thedemand of Baltic Spa product.– 142 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėII. Influences in market developmentof „New Health TourismPsychographic change:Demographic Change:- “health” as a pillar of a conscious- Increasing volume of demandlifestyle- Shifting of the age- Performance Optimization- Better responsiveness- Increased importance of new- Changing demands and needsindications and diseasesThe NewHealthTourismChange on supplier‘s side:Change of basic conditions:- Medical and technological- modified health systemdevelopment- withdrawal of social insurances- new networks, platforms and- boosting of self-pay demandpartnerships- specifity of layers- Changing supplier structuresŠaltinis: p. ClaudiaWager, Generalinė direktorė, FIT REISEN GmbH– 143 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėII.Megatrends New Lifestyle Health Slow down one's life Improve and maintain health Recover one's balance gets more important Looking for a new way of living Higher willingness to invest inthe own health Demographic Changes Relaxing and Recreation Number of Best Agers increases Enjoying peace and quiet Best Agers nowadays are Feeling relaxed, healthy andexperts in travellingbeautiful Affinity to wellness and health Being activecareThe future of the market is determined by four megatrends12Šaltinis: p. Claudia Wager, Generalinė direktorė, FIT REISEN GmbH– 144 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėSpa and Health Tourism Trends13 Shorter stays like one week, even in the traditional spas; Price is the most important indicator; All inclusive; Wellness – Ayurveda is still in the trend – 3 overnights; Individual services and value for money is the main pointfor the decision where to go; Slimming cure, Detox, Yoga, Anti-Stress stays are highlydemanded.– 145 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėFuture Health Tourism market: forecast 2020Mio.14 2002+105% 200712 2020+111%+48%108 +72% +88%6+84%420Health-Care Anti-Aging Wellness insg. Medical- Passiv- BeautyWellness WellnessQuelle: IFF: Gesundheitsstudie 2020; Veränderungswerte berechnet von 2007 auf 2020.– 146 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėIII. The potential ofthe Baltic Spa product– 147 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėCLASSIFICATION OF HEALT TOURISM (LT)SVEIKATOS TURIZMAS(Health & Wellness Tourism)SVEIKATINIMO TURIZMAS SVEIKATINGUMO TURIZMASarba (Wellness Tourism)MEDICINOS TURIZMAS(Medical Tourism)*MEDICINOS ODONTO‐ SLAUGOS SVEIKATN GROZIO FITNESO SVEIKATOS SVEIKOSLOGIJOS IR GLOBOS GUMO TURIZMAS TURIZMAS ŠVIETIMO MITYBOSTURIZMASTURIZMAS TURIZMAS SPA TURIZMAS TURIZMASTURIZMAS(Medical (Dental (Nursing &Tourism) Tourism) Caring (Sport & (Halth (HealthyTurism) (Wellness)(Beauty) Fitness) Education ) Nutrition )DIAGNOSTI REABILITA MEDICININIS‐KOS IR CIJOS SPASVEIKATOS TURIZMAS TURIZMASIŠTYRIMO (SANATORI‐TURIZMAS NISGYDYMAS)(Rehabilita‐(Diagnostic tion (Medical SPA& Health tourism Tourism)Check‐UpTourism)– 148 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėBaltic Spas one of thebests in Europe!!!– 149 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėBIRŠTONAS DRUSKININKAIPALANGANERINGA– 150 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėRecreational areasTRAKAIANYKŠČIAIНЕРИНГАIGNALINAZARASAI– 151 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėMedical Spa treatmentConference bureauwellnessleisuresports & fitnessFamily vacations– 152 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėTraditions more than 200 years– 153 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėEco-Fit– 154 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėA places worth visiting!– 155 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėUNESCO WORLD HERITAGE– 156 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėTraditional festivals of art and music– 157 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėTraditional food +Ecological and green products– 158 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėBaltic Amber in Tourism– 159 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėWhy is the Baltic Amber unique?• Found on the shore of the Baltic Sea;• 50 million years old;• Three elements are hidden in it: air,water and earth;• Contains 8% of amber acid that hashealing properties;• Protects against a bad eye;• Relieves pain, strengthens the immunesystem, helps to cope with commoncolds;• Is used to manufacture fascinatingjewellery;• Is used in SPA’s and in foods.– 160 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėUse of the Baltic AmberAmber JewelleryAmber in CulinaryAmber in CosmeticsAmber in DesignAmber in Medicine– 161 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėIV. Stakeholders of LithuanianSpa sectorSPA & WELLNESS RESORTSLEISURE AND RECREATIONAL SPASSPORT & FITNESS SERVICESBEAUTY TREATMENTS– 162 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėI. Stakeholders of Lithuanian Spa sector MEDICAL SPAS, SPA CLINICS,REHABILITATION CENTRES, DAY TIME SPACENTRES, HOTEL SPA CENTRES, HEALTHCENTRES, etc. MEDICAL SPA CENTRES – a licensed institutions,whose main goal is to provide medical care andrehabilitation services, using natural localremedies: mineral water, therapeutic mud, climate,Baltic sea water. The personnel working there havea medical background.– 163 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėI. Stakeholders of Lithuanian Spa sector Number of Medical Spas 22 Number of staff 2 799 Number of rooms 2 867 Number fo places over 6 thous. Annual turnover more than 206 mln.Lt. Overnights per year 1 271 185 Guests per year 113 17930 % - foreign guests.2010 m. IV ketvirčio ir 2011 m. trijų pirmųjų ketvirčių duomenys. Lietuvos statistikos departamentas– 164 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėI. Stakeholders of Lithuanian Spa sector The average of accomodation 70%Lithuanian 76%Foreign guests 24% The average income (per person) 1 398 Lt The average length of stay 11,88 dayLithuanian 11,03 dayForeign guests 15,24 day Hotels 1,91 day Šaltinis: Medicinos turizmo galimybių analizė, 2012 m.– 165 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėLithuanian medical Spa & wellness product• medical (health) SPA procedures, a wide choice of services, authenticity(amber therapy, herb therapy and so on.)• Natural local remedies (mineral water and therapeutic mud, sea water,climate);• doctors' consultations;• qualified medical personnel;• relatively large number of accommodation;• good value for money;• a good geographical location, the attractiveness of the Russian andScandinavian markets; Program length: 2-21 day; Price per day: starts from 130,- LT (37 EUR); Activities: Aero tourism, bicycle, water tourism, skiing, waterentertainment, bicycle, Nordic walking, yoga, entertainment clubs, cateringservices, etc.– 166 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėMedical Spa treatment– 167 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėNatural local remedies• Mineral Water• Therapeutic Mud• Climate• Local Herbs• Baltic sea (water, sandand sun)• Amber Therapy– 168 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėTraditions and new technologies– 169 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėMineral waterbaths– 170 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėSPA & wellness programs– 171 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėActive sports– 172 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėCycling routes770 kmTotal in Lithuania: more than450 kmMore the in Lithuanian Resorts– 173 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėActivities all year round– 174 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėResponsibility for our lives– 175 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėIRecognizing that one of the main goals of the EU-policieswill be the prevention of the people in the EU - the spasand health resorts in Europe should more emphasize theirrole as competence centres for healthand prevention.We should underline that our spas are “lighthouses”mostly situated on the country side of the regions in theEU.– 176 –I. WG meeting programmes and expert presentations | 3. Birštonas, Lithuania – Jurgita KazlauskienėThank you for yourattention!– 177 –Baltic Sea Parliamentary ConferenceCopenhagen, Denmark, 13-14 November 2014Thursday 13 November1430-1730 S tudy visit to Steno Diabetes Centre – focus on lifestyle-related diseases / diabetes and in-novationFriday 14 November0930-1015 M eeting with Hospital Solutions Director for Northeast Europe, Mr Vincent Giele,Medtronic – focus on innovation and cooperation between the public and private sector1030-1115 M eeting with former Swedish minister, Mr Bo Könberg, on his report on closer health-care cooperation in the Nordic countries1130-1300 WG meetingThe BSPC Working Group on Innovation in Social- and Health Care held its fourth meeting in Copenha-gen on 13-14 November 2014. The meeting itself was preceded by a visit to Steno Diabetes Center withthe focus on lifestyle-related diseases/diabetes and innovation. Steno Center is a world-leading institutionwithin diabetes care and prevention. It is owned by Novo Nordisk AS, and is a non-profit organisationworking in partnership with the Danish healthcare system. The Working Group meeting started with apresentation by Vincent Giele, Hospital Solutions Director for Northeast Europe in Medtronic. Medtronicis the world’s largest medical technology company, offering innovative therapies to fulfil a mission of allevi-ating pain, restoring health and extending life. Their medical therapies treat cardiac and vascular diseases,diabetes, and neurological and musculoskeletal conditions. The second expert presentation was given byformer Swedish minister, Bo Könberg, on his report on closer healthcare cooperation in the Nordic coun-tries over the next 5-10 years. The report was submitted on 11 June 2014 and it contains 14 proposals.– 178 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergNordic Council ofMinisters14 tangibleproposals forfuture co‐operationon health in theNordic regionBo KönbergBSPCCopenhagen114.November 2014– 179 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergIncrease in longevityDuring the last century Nordic longevity has increasedowith more than 25 YearsAnd those years are healthy years!o– 180 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo Könberg– 181 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergLungcancer– 182 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo Könberg1. Vigorous measures against 8. Greater co-operation ongrowing antibiotic resistance welfare technology2. Strong co-operation on 9. Greater co-operation on e-highly-specialised treatment Health3. Set up network on rare 10. Greater co-operation indiagnoses the psychiatric field4. Set up a virtual centre for 11. Greater mandate for co-register-based research operation in healthpreparedness5. Greater co-operation oninitiatives to improve public 12. Greater pharmaceuticalhealth co-operation to increasecost-effectiveness and safety6. Public health policyplatform to reduce inequality 13. New exchange of officialsin health14. Co-operation on national7. Patient mobility in the experts in the EU CommissionNordic regionNordisk samarbejde 5– 183 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 2: Highly-specialised treatmentSet up a Nordic review group at high level for highly-ospecialised treatments, with the aim of holding regulardialogue between the countries on the needs andopportunities for co-operation initiatives.– 184 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 3: Rare diagnosesSet up a Nordic network for co-operation on rareodiagnoses to strengthen existing and new joint initiatives,and to improve coordination of these.– 185 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 4: Register-based researchStrengthen research co-operation regarding dataoregisters, biobanks and clinical intervention studies.Introduce a model for mutual recognition of ethicaloreviews of Nordic research projects.Set up a Nordic virtual centre for register-based research.o– 186 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposals 5 and 6: Public healthIncreased co-operation on public healthoIncrease the exchange of information on public healthoSet up a public health policy platform for developingoproposals– 187 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 7: Patient mobilitywithin the Nordic region.Evaluate the effects, on patients, of the Nordic countries’orecently-adopted implementation of the EU patientmobility directive.Try to extend the right to care in another Nordic country.o– 188 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 8: Welfare technologyStrenghtened Co-operation on Welfare Technologyo– 189 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 9: E-healthExtended co-operation on e-healthoCo-operation on e-prescriptionsoCreate a Nordic health library onlineoDevelop a Nordic search tool "My patient"o– 190 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 12:Extended Nordic pharmaceutical co-operationGreater exchange of experiences on the conditions andoprices with purchasesExtend the exchange of experiences on implementation ofonew drugs– 191 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 12:Extended Nordic pharmaceutical co-operationGreater exchange of experiences on the conditions andoprices with purchasesExtend the exchange of experiences on implementation ofonew drugs– 192 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergProposal 1: The decrease in antibioticresistanceThe first invention was in 1930oUp to 1970, twenty new antibiotics were developedoBetween 1970 and 1987, two new antibiotics wereodevelopedSince then no new ones!oThis year some 50 000 persons in Europe and NorthoAmerica will die due to the increased reistance– 193 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo Könberg– 194 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergUse of antibiotics outside hospitals, 2012(ATC J01, DDD per 1 000 inhabitants per day)2522,320,12018,7 18,517,417,115,915 14,21050Island Finland Grönland Danmark Norge Färöarna Åland Sverige– 195 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergConcerted Nordic action againstantibiotic resistanceReduce consumption of antibiotics in the Nordic region to theolowest European level within five years.All countries in the world to adopt plans to reduce use ofoantibiotics.Prescription requirement in countries with developed healthosystems.Abolish bonus payments to doctors and veterinary surgeons.oMajor initiative (SEK 75 billion from rich countries for fiveoyears, of which 2.5 billion from the Nordic region) tostrengthen systems and rewards for developing newantibiotics.– 196 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergLongitude, by Dava Sobel– 197 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergActions since this springApril:oWHO warns of "the risks for a world without antibiotics"May:oWHO:s General Assembly orders the development of anaction plan for next springJune:oA British commitee proposes a Longitude Prize of 10million pounds for the development of a new antiobioticSeptember:oPresident Obama orders an action plan for next springandEU’s Veterinary Committee proposes a ban for veterinarybonuses on prescriptions of antibiotics– 198 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo Könberg“The next supermodel”– 199 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergThe report is part of theNordic Council of Ministersprogramme, SustainableNordic Welfarewww.norden.org/welfare– 200 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Bo KönbergNordic Council ofMinistersThe report can bedownloaded fromwww.norden.org/en/publications/publikationer/2014‐731(Language versions: Swedish, Finnish,Icelandic and English)23– 201 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Diabetes CenterBaltic areaParliamentary visit13 November 2014Martin Ridderstråle,Vice president andHead of Patient Care– 202 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre1Agenda14.30 Presentation of Steno Diabetes Center and Patient Care by VP Martin Ridderstråle- Private – Public partnership- Research and educational activities- Effectiveness and outcomes of diabetes management15.40 Presentation of Health Promotion Research by VP Bjarne Bruun-Jensen- Putting the patient in the centre in patient education- Community-based diabetes prevention16.10 Discussion and question session17.00 End of meeting or small tour of the Campus– 203 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreFounded in 1932 to improve clinical careof patients and to understand diabetes– 204 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreFour major areas at StenoResearch Health Promotion ResearchPatient Care Education– 205 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre4Steno ResearchPathophysiologySystems MedicineComplicationsEpidemiology– 206 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreOur vision is to become leaders in diabetescare and translational research with focus onearly disease and prevention– 207 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePublic Private Partnership– 208 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreStrategic Alliances– 209 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreWhy collaborate?• Denmark is a little country (Population of 5 million)• Allows us to concentrate on our competitive advantage• Develop competencies that may be even more widely relevant• Allows us to foster linkages which expand collaboration• Assist in developing an influence over policy• Increased mobility of scientists / Talent attraction– 210 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient Care– 211 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareA unique public-private partnership Collaborative Clinical Care for 5600 patients Screening for and treating Complications Team-based care delivery Education of patients One-stop shop– 212 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreDiabetes ComplicationsMicrovascular MacrovascularLeading causeof blindnessDiabetic Strokein working ageRetinopathyadultsDiabeticNephropathy CardiovascularDiseaseLeading causeof end-stage 2 to 4 foldrenal disease increase incardiovascularDiabeticmortalityNeuropathyand strokeLeading causeof non-traumaticlower extremity amputations– 213 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreCosts of complications: The Helsinki Study6000055057DKK50000424324000030000Without complications24x With Complications2000012x10000364422590Excess cost of Type 2 Excess cost of Type 1diabetes diabetes– 214 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareThe HbA level has never been this low – Type 1 Diabetes1c– 215 –)lom/lomm(AbHc1I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareThe HbA level has never been this low – Type 2 Diabetes1c100%90%SDC Baseline80%70% SDC After 9months **60%GP 201250%40%30%20%10%0%ABC* A1c Systolic BP Diastolic BP LDL<53 <140 mm <90 mmHg cholesterolmmol/mol Hg <2.6 mmol/lABC control: A1c<53 mmol/mol, BP<140/<90 and LDL <2.6 mmol/l.Data from GP not available. ** p<.0001.EASD 2014– 216 –)%(tnemniattalaoGI. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareAs easy as ABC...Safai N et al. EASD 2014– 217 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareAligning competencies– 218 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareAligning competencies– 219 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareInnovating Diabetes Care Delivery– 220 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient Care– 221 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient Care– 222 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareInnovating Diabetes Care DeliveryDocumentation“Den Gyldne Skalpel 2014”IKAS Akkreditering 2014ISO Akkreditering 2014Sundhedsstyrelsens tilsynsbesøg 2014– 223 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareCreating a value adding even flowSpecialistAmbulatory Day HospitalAmbulatory– 224 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareSpecial attention to special needsType 2Clinic24 hr PhoneFoot ClinicServiceHomeEye ClinicServicePregnancy AdolescentClinic ClinicInsulin PumpClinic– 225 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareSpecial attention to special needsEye Clinic– 226 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareEye Clinic– 227 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareSpecial attention to special needsThree podiatristsOrthopedic consultant weeklyAssessments of risk patientsOrthopedic foot wareTreatment of ulcersObservation, examination and education– 228 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CareFoot Therapist of the Year!– 229 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyReduction in Diabetes Morbidities– 230 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyReduction in Diabetes MorbiditiesT1 diabetes T2 diabetesCardiovascular- 12 % - 30 %DiseaseMajor amputations -70 % - 82 %Severe retinopathy - 18 % -34 %– 231 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyReduction in Diabetes Mortality– 232 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyReduction in Diabetes MortalityT1DNon-DMT1D T2Dwithout(DK)nephropathyMen 4.6 % 8.6 % 5.1 % 2.5 %Women 2.5 % 3.5 % 2.6 % 1.8 %Published: Diabetologia, 16 August 2013Time trends in mortality rates in type 1 diabetes from 2002 to 2011,Marit E. Jørgensen, Thomas P. Almdal and Bendix Carstensen– 233 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CarePatient Satisfaction– 234 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient CarePatient Satisfaction“Safe taking home”“Good overall impression”“Informed about life style”– 235 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreInnovating Diabetes CareDiabetesLifeLab TechnologyPlatform– 236 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreInnovating Diabetes Care– 237 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreInnovating Diabetes CareEuropean Diabetes Technology Course– 238 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - Epidemiology– 239 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreInnovating Diabetes CareLifeLab – personalising evidence based medicine– 240 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreInnovating Diabetes CareHealthy person Pre-diab. Diabetes Complicated– 241 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyThe Addition-Pro Study: Progression to diabetesADDITION-PRO Follow-up 2009-1011Screening status Non-NGT iIFG iIGT IFG+IGT SDM KDM Total2001-2006 classifiablen % N % N % N % N % N % N % NLow risk 11 5.7 149 76.8 18 9.3 5 2.6 3 1.6 5 2.6 3 1.6 194Normoglycaemia 21 1.9 741 67.4 109 9.9 77 7.0 52 4.7 60 5.5 40 3.6 1100iIFG 0 0 101 28.0 84 23.3 13 3.6 29 8.0 29 8.0 105 29.1 361iIGT 3 1.2 60 23.5 13 5.1 39 13.3 36 14.1 37 14.5 67 26.2 255IFG+IGT 3 1.6 20 10.9 8 4.3 11 6.0 22 12.0 25 13.7 94 51.4 18338 1071 232 145 142 156 309 2093– 242 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyWhitehall II study: Latent class trajectory analysisVistisen et al. PLOS Medicine 2014– 243 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - EpidemiologyGreenland studies: genetic riskMoltke et al. Nature 2014– 244 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - PathophysiologyLuleåUmeåOsloStockholmEarly No majorcomplications complications GothenburgGentofteMalmöDuration 5-15 years Duration >30 years– protective genes in diabetic complicationsP R L N Gand longevity– 245 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - Complications50% age adjusted reduction in mortality1983-2002P<0.052000-2010G Andrésdóttir et al Diabetes Care, 2014cJun;37(6):1660-7– 246 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - ComplicationsExisting markersNew markerEarly and robust– 247 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research - ComplicationsMass SpectrometryCapillary ElectrophoresisIonizationData StorageandEvaluationUrineSampleDisease specificDiagnosticBiomarker patternReport– 248 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreOMICS: from genes to metabolitesGENOME DNA What is possibleTRANSCRIPTOME mRNA What appears to behappeningPROTEOME PROTEINS What makes ithappenMETABOLOME METABOLITES What is happening– 249 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno Research – Systems Medicine– 250 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreEducation– 251 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre50Since 2000, the STAR programme has been the centraleducation platformThe goal of the programme isto increase knowledge aboutdiabetes in developingcountriesCourses are taught in China,India, the Middle East, South-East Asia and Latin AmericaMore than 8,000 HCPs havebeen trained through the STARprogrammeThe programme is funded bythe Novo Nordisk Foundation– 252 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre51With the REACH programme, Education aims tosignificantly scale up training of HCPsThe REACH programme will target approximately 9,200 HCPs annually, corresponding to reaching500,000 patients per daySteno Diabetes Center REACH ProgrammeDiabetes education for HCPs, training trainersCombines face-to-face training with e-learningStarts in South-East Asia and extends to LatinAmericaCreates a new network of Steno satellites– 253 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre52The SDC satellite will teach doctors and HCPs inMalaysia and nearby countriesMalaysia Satellite Target group Partners Kuala Lumpur Doctors Ministry of Health Satellite can also HCPs Academic institutionserve nearbycountries– 254 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSteno as global partner in Cities ChangingDiabetes“We will find solutions that will make a realdifference for people with diabetes and thosewho are at risk” Steno becomes global partner in Novo Nordisk’sCities Changing Diabetes project together with UCL We support the project with our experience andexpertise in fields such as Education Epidemiology Health Promotion The aim of the project is in line with our vision andstrategy to strengthen focus on prevention anddiabetes care– 255 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreHealth Promotion ResearchHead and professor Bjarne Bruun Jensen– 256 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreHealth Promotion ResearchHEALTHPROMOTION RESEARCHSecretariatVP + 2 PAPatient Education PreventionResearch Group Research Group11 fulltime academics 7 fulltime academics2 PhD students 3 PhD studentsMaster’s students and interns Master’s students and interns– 257 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient Education Research GroupPatient Education ResearchPsychosocial health,Innovative patient Diabetessocial supporteducation models and the workplaceand diabetes– 258 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePatient Education Research GroupNEED: Family DAWN 2: Diabetes andNext education interventions in Diabetes WP: RegisterT1D attitudes, wishes based studiesand needsEMMA:Empowerment,motivation andmedical adherencePsychosocial health,Innovative patient Diabetessocial supporteducation models and the workplaceDEEP: and diabetesDiet andeducation inethnic PakistanisABCDiabetes: Vulnerable Psychosocial Psychological AddressingPatient people with health and problems in diabetes amongeducation in T2 diabetes social support diabetes high risk groupsclinic, Steno in T1D consultations at workplace– 259 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePrevention Research GroupPrevention ResearchYoung people Family and Pre-diabetesand schools community health and risk groups– 260 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentrePrevention Research GroupTEACH-OUT: PULSE: Social network analysis:Physical activity Health promotion Prevention strategyat Danish exhibition targeting people at risk‘outdoor schools’ targeting familiesIMove:Promotingphysical activityamong childrenYoung people Family and Pre-diabetesand schools community health and risk groupsMEL:Move, Eat, Learnamong schoolchildrenHEPCOM: SOL/Supersetting: JOM MAMA:Promoting healthy Integrated community Prevention among younglifestyles among intervention at couples in Malaysiachildren in Europe Bornholm– 261 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreProfile with innovation in focus:“2+3+5”Field: Two focus areas• Patient education and PreventionR & D: Three criteria• Practice-orientation, Interdisciplinarity & CollaborationIntervention Paradigm: Five guiding principles• Participation and active involvement of the target group• Positive and broad concept of health• Action competence and empowerment• A ’Settings’ perspective• Equity in health– 262 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreNEED: Next Education– 263 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreNEED: Next Education- feasibility studyBackground• Participation and dialogue are core values in patient education• A participatory approach is a challenge for professionalsObjective• to examine if the toolbox enhances participation and dialogue bothamong patients and between patients and educatorsDesign• 45+ different settings throughout DK were involved• Questionnaire about educator experiences (n=432)• Observation of education sessions (n=19)• In-depth interviews with educators (n=18)– 264 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreNEED: Next Education- feasibility study– 265 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreNEED: Next Education- feasibility studyFour categories emerged• Icebreaker (educators and patients less shy/nervous)• Patient centeredness (patients defining the starting point)• Group interactivity (patients feeling inspired by each other)• Flexibility (enable educators to include new themes and tools)Conclusion• Toolkit efficient in facilitating participation and dialogueNext step• Effect evaluation (2014/2015)– 266 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreEMMA study at StenoEMMA: Empowerment, Motivation & MedicalAdherence - Dialogue tools for diabetesconsultationsStart at Steno:EMMA training 11⁄2 day, Sept./Oct. 2014Participants - 3 nurses and 1 physicianEMMA in outpatient – fidelity/feasibilityRCT (n=270) + qualitative evaluation– 267 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreTools for vulnerable people with diabetesGrant from Danish Ministry of HealthWith Danish Diabetes Association and Regionof Southern DenmarkFeasibility test finalised (80 HCPs)QuestionnairesObservationsInterviewsData analysis ongoing– 268 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreThe ‘Supersetting’ approach- a community prevention approach– 269 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreThe ‘Supersetting’ approachDay carePrimary schoolWorksitePrivate homeHospital Nursing home– 270 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreSUPERSETTING: BORNHOLMAim: To improve health and quality of life for familieswith small childrenThe intervention aims at facilitating synergy between:• Schools and daycare institutions• Media: Local TV (TV2 Bornholm)• SupermarketsAction research and co-creationOutcomes: local ownership, TV-watching, selling ofhealthy products, knowledge and attitudes etc.Control: Odsherred Municipality– 271 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre– 272 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes Centre– 273 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreExamples of newHealth Promotion conceptsThe Balancing PersonThe Health Educational JugglerSupersettingHealth Identity– 274 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreHealth Promotion Research– 275 –I. WG meeting programmes and expert presentations | 4. Copenhagen, Denmark – Steno Diabetes CentreThank you!– 276 –Baltic Sea Parliamentary ConferenceLevanger, Norway, 5-6 March 2015Thursday 5 March1615-1900 Study visit of Nord-Trøndelag Health Study FacilitiesFriday 6 March0900-0915 W elcome by municipal director in Levanger and Innherred, Mr Jon Ketil VongravenPresentation of all participants0915-0950 H ealth in all policies in a local context. The Municipal Master Plan as a strategic tool topromote public health and health equity by Ms Dina von Heimburg, Public Health Co-ordinator in Innherred district.0950-1030 E nabling inhabitants to cope with everyday life. Presentation of a municipal sector planfor health and welfare services by Mr Jon Ketil Vongraven, health director in Levangermunicipality.1045-1115 P resentation of Norwegian Competence Centre for Arts and Health in Levanger, directorMr Odd HåpnesThe BSPC Working Group on Innovation in Social and Health Care (BSPC WG ISHC) also had a study tripto the HUNT research institution on 5-6 March 2015. The Nord-Trøndelag Health Study (The HUNTStudy) is one of the largest health studies ever performed. It is a unique database of personal and family medi-cal histories collected during three intensive studies. The fundamental strategy is to earn and maintain the con-fidence of the population we work in and with as is necessary for any successful population study. This strategyhas been successful and has resulted in extraordinarily high participation rates. There is enthusiastic public andpolitical support for HUNT and for the HUNT Research Centre. This has created a good basis for furtherhealth surveys in the county and an excellent research environment. The WG also visited Levanger municipal-ity to hear about the municipal sector’s plan for health and welfare services, the Municipal Master Plan as astrategic tool to promote public health and health equity, and the new Norwegian Competence Centre forArts and Health. Levanger aims to include the health perspective in all local policies.– 277 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHealth in all policies in alocal contextThe Municipal Master Plan as a strategic toolto promote public health and health equityDina von Heimburg, Public Health Coordinator in Innherredsamkommune (joint municipality)1– 278 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgWHO Healty Cities» Euro Healthy Cities network» National network in Norway» Verdal and Levanger areproud members» «Laboratory»: Develop andshare «best practice» ofpublic health work at thelocal and regional level.– 279 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgSeminar in Estonia 2014– 280 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgStudy trip to Poland 2015– 281 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgProfessor Peter Goldblatt, UCL,Presentation in Levanger 2014– 282 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg– 283 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgPublic health in NorwayIn general, Norwegians have goodhealth, but we still face majorchallenges....1. Social inequalities inhealth is increasing Life expectancy – men by educational level2. Demographical changes 8684 univ/høgskole mennin the populationvideregående menn82 grunnskole menn803. Changes in lifestyle78caused by societal76structures74724. NCD’s and mental health707– 284 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThe «new» Public Health Act New challenges in public health Previous legislation had not workedout as intended «Bottom up» - public healthadvocacy from municipalities andcounties The coordination health reform of2012 points out the need forstrengthening health promotion andearly prevention in order to facilitatea sustainable development – locally,nationally and internationally8– 285 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg– 286 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgEmpowering communitiesthrough The Public Health ActMain objective:EvalueringOOvveerrvsiiekwt of public healthEv§a§lu3a0ti oong 5§5and health determinantsSocietaldevelopment inorder to promotepublic health andImplementation StratePgliacn sstorcaiteetagli planning:Tiltakof measures §6 førstereduce health §§ 4 og 7 overall goals and strategiesleddinequalitiesFastsettepolicymål i planand§ 6 andreactionleddplans2| 10– 287 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgSystematic public health workOverview of public healthEvaluationand health determinantsImplementation Strategic societal planning:of measuresoverall goals and strategiespolicyandactionplans– 288 –2I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgUnderpinning principles –Public Health ActHealth equity: Health inequities arise from the1.societal conditions in which people are born, grow, live,work and age – the social determinants of health.Social inequities in health form a pattern of a gradientthroughout society. Levelling up the gradient by actionon the social determinants of health is a core publichealth objective. A fair distribution of societal resourcesis good public health policy.Health in all policies: Equitable health systems are2.important to public health, but health inequities arisefrom societal factors beyond health care. Impact onhealth must be considered when policies and action aredeveloped and implemented in all sectors. Joined upgovernance and intersectoral action is key to reducehealth inequities.– 289 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgPrinciples of public health cont.Sustainable development: Sustainable development3.is development that meets the needs of the presentwithout compromising the ability of future generationsto meet their own needs. Public health work need to bebased on a long term perspectivePrecautionary principle: If an action or policy has a4.suspected risk of causing harm to the public or to theenvironment, the absence of scientific consensus thatthe action or policy is harmful, cannot justifypostponed action to prevent such harmParticipation: Public health work is about transparent,5.inclusive processes with participation by multiplestakeholders. Promotion of participation of civil societyis key to good public health policy development– 290 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHealth promotion requires systematic wiringHowever, organizing tons of wires to get themachinery working, is not an easy task...14– 291 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg3 Main messages from Verdaland Levanger: Public Health Strategy =Municipal Master Plan.A holistic approach to HiAP. Local knowledge andresearch-based argumentshave been extremelyimportant Sufficient anchoring in thepolitical and administrativeleadership has been crucialto success.15– 292 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg... Verdal and Levanger try our verybest to fulfill the systematic publichealth circle....– 293 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgCentral principles in Verdaland Levanger: Public health and equity are political choices.The Mayors are our «public health leaders», andthe chief of administration and all the rest of ussupport them in this task. We develop our work through processesanchored within the municipality organizationprior to loosely connected projects. Strategic development of services andcommunities with a focus on overall planning,co-creation and leadership17– 294 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg...Policy and governance must be conducted onthe basis of procedures that unites knowledge,goals, strategies, actions and priorities, so thatwe can deal with a complex world ...Yes!I have a plan(which handlescomplexity andwholeness!)Robert SvarvaMayor ISK– 295 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgAnnual reportFinancial reportonPlan forInternati-developmenteconomyonal,and strategic-nationalaimsBudgetandregionalguidelinesInquiriesprojectsEmpiricalknowledgePlanningstrategyPlans forstrategicMunicipalthemesmaster-(intersectorial)planMunicipal plan–physicalSector plans environment– 296 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgMunicipal plan – public health strategyProcess 2014Planning strategy 2013-2016Holistic solutions – Municipal plansChildhoodHealth Culture Buisiness CityeducationCentreRevision of public health strategyDevelopement of services and local communityDefining perspectivesExisting municipal plans– 297 –SENILEDIUGSEULAVEGDELWONKI. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgMunicipality of LevangerMunicipality of VerdalMunicipal Masterplan 2015-2030Vision: Quality of life and growthsustainable societies - a good start and coping throughout the lifespan - generous and robust life environments396– 298 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg22– 299 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgWhat are we really planning for??Health and well-being iscreated where peopleare born, play, learn,work, enjoy leisure, shop,and live24 hrs a day!– 300 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHealth in All Policies!24– 301 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg– 302 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgRedefine our perspectives:What creates health, well-beingand resilience?– 303 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgMike Grady, UCL/Marmot review team, 2014) What isWhat enhancesdetrimental tomy wellbeingmy wellbeingand healthand healthLack ofRecyclinginterestingfacilitiesactivitiesin winterGreenspaces thatI can use Poor localjobAffordableprospectshealthyfoodPoor streetAffordablelighting andtransportunevenpathwaysSpendingSoaringtime withfuel billsmyand poorneighboursinsulation– 304 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHalf full or half empty?http://www.abcdinstitute.org– 305 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgSocial inequalities inhealth is unfair andunavoidableI can get strong andresilient by carrying thisburden, but it basicallydepends on my socialconditions, and if Ilearn proper tecniquesto carry these stones onmy back...29– 306 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgLife course and generational perspective– 307 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHealthand QoLRose G (1985). Sick individuals and sick populations.31– 308 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg– 309 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg33– 310 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgEarly Childhood = investment34– 311 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgProportionateuniversialism35– 312 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgWHO Health 2020Health 2020 recognizes thatsuccessful governments canachieve real improvements inhealth if they work acrossgovernment to fulfill twolinked strategic objectives:• improving health for alland reducing healthinequalities• improving leadership andparticipatory governancefor health.– 313 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThe Trondheim Declaration (2014):Fair distribution of health and well-being - a political choiceControl of interactionEfforts to fundamentaland realcauses of health andimplementationwell-beingwillingnessSocially sustainableWide knowledgeand experience communities and healthyinflow community development– 314 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgLocal empirical data on populationhealth and determinants38– 315 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgUNG-HUNT 3: Social inequalities –loneliness amongst youth in Levanger– 316 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgUngdata 2012 – Levanger«feels like everything is a struggle» -Family economic resources2522,2 «Har familien dinhatt god eller dårlig20 råd/økonomi desiste to årene?»15God råd10,5Hverken god eller dårlig107,5 Dårlig råd50Andel ungdommer (%) som i løpet av siste uke har værtveldig mye plaget med følelsen av at alt er et slit40– 317 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgUngdata Verdal 2013Percentage of young peoplewho thrive very well in thecommunity – family economy– 318 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgParadigm shift???FROM DISEASE PREVENTION TOSOCIETAL DEVELOPMENT!42– 319 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThe power of definitionsand «framing»We chose the definition of health provided by Peter F. Hjort as the basis for thedevelopment of our goals and strategies:"Good health is what a personhas when he has the ability andthe capacity to cope with andadapt to life's inevitabledifficulties and day-to-dayHealthrequirements."and QoL43– 320 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgDefinitions and perspectivesprovided in the MMPPage 4 in the Municipal Master Plan44– 321 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgORGANIZING +MOBILIZING=SOLUTION– 322 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgCreating solutions togetherIt takes leadership andEqual participation.(we need to shut upand listen...)– 323 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg«Health in all policies»Process 2014Planning strategy 2013-2016Holistic solutions – Municipal plansHealth Childhood Culture Buisiness CityCentreRevision of public health strategyDevelopement of services and local communityDefining perspectivesExisting municipal plans– 324 –SENILEDIUGSEULAVEGDELWONKI. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgMunicipality of LevangerMunicipality of VerdalMunicipal Masterplan 2015-2030Vision: Quality of life and growthsustainable societies - a good start and coping throughout the lifespan - generous and robust life environments– 325 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgGOALSWe are working to achieve thefollowing objectives:• Our municipalities are goodcommunities to live in for a wholelifetime, and everyone feel as avalued part of the community• All children must be given the bestpossible start in life• All the inhabitants feel secure, theyhave control of their everyday lifeand they have added several activeyears of life with good health andwell-being• Our municipalities are a force fordevelopment in a sustainable androbust part of Central Norway– 326 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgA) ensure sustainablesocietiesB) give priority to a good startand coping throughout theSTRATEGIESlifespanIn order to achieve the objectives, the municipalities must A) ensure sustainable societies, B) give priority to a goodstart and coping throughout the lifespan and C) create generous and robust living environments. The blue text boxesC) create generous andexpand on some of the strategies.robust living environmentsA) Ensuring sustainable societies• Prioritising prevention and early intervention• Prioritising measures that benefit large sections of the population• Ensuring that municipal efforts are prioritised according to the citizens' needs• Arranging for an innovative and profitable working and business world and increased food production• Taking still clearer responsibility for environmental and climate challenges• Mobilising local community resources through transparency, the involvement of citizens and collaboration and allianceswith knowledge institutions, business, the cultural and the voluntary sector and public players• Ensuring holistic solutions, coordinated work processes and future-oriented and knowledge-based services• Reconciling policy and service provision through binding, coherent and economically sustainable planning• Contribute to a sustainable development in the region with emphasis on infrastructure, business and cooperation withother municipalities– 327 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburge...We need to evaluate our efforts ...valSocietalanalysis– 328 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgINDICATORS AND PERFORMANCE REVIEWThe target indicators shown below are assumed for the assessment of the results in the annual report. Theassessment is performed in the light of the municipal objectives and is intended to give an indication of whether thedevelopment is in line with them. Where possible, the assessment must be based on a breakdown by geography,age, gender and social status. It must presuppose an ambition for the situation to be improved for all and forinequality to be reduced.• Life Expectancy (Public Health Institute of Norway)• Self-reported health and quality of life (HUNT4 and UngData)• Years of life with good health (HUNT4)• Access to trusted friends/networks who can help in case of trouble (HUNT4 and UngData)A lot of public health-related• Participation in further education (County data)• Long-term unemployment (Nav) indicators!• Disability (Nav)• Households with persistent poverty/long-term recipients of social ben efits (SSB/Nav)• Participation in cultural activities/volunteerinWg (hHeUrNeT 4p aonsds iUbnlgeD, attha)e assessment must• Physical activity (bicycling and self-reported physical activity HUNT4/UngData)be sorted by geography, age, gender and• Infrastructure for walking and bicycling (new meters)social status. Ambition: improve• Traffic (number of passengers using public transport and car traffic counts)• Civil Index (The Civil Survey) situation for all and reduce inequality• Democracy Index (The Civil Survey)• The Municipal Barometer (Municipal Report)• Source Separation (Innherred Renovation)• The Industrial Index (Central Industrial Organisation)• Commercial Institutions (Innovation Norway)• Net and gross operating profit as a percentage of operating revenues (Municipal accounts)• Provision reserve as a percentage of operating income (Municipal accounts)– 329 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgDirect links between strategies,measures and (joint) budgeting– 330 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg...With a little help fromour friends....Vital to reach out for help (to our friends) in order to create theskills, the willingness and the abilities needed to implement andevaluate HiAP efforts and effects of interventions. People, neighbourhoods, NGOs, public and private organizations andbusinesses everyone that might contribute in the local community The Norwegian Healthy Cities Network (WHO) Partnership with University College of London/Marmot Review Team HUNT, University College of Nord Trøndelag, local hospital (HNT), KS, NTCounty government, National centre of arts and health Other local, regional, national and international resources54– 331 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg«How can it be organized?»Process 2014Planning strategy 2013-2016Holistic solutions – Municipal plansHealth Childhood Culture Buisiness CityCentreRevision of public health strategyDevelopement of services and local communityDefining perspectivesExisting municipal plans– 332 –SENILEDIUGSEULAVEGDELWONKI. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg3 Main messages from Verdaland Levanger: Public Health Strategy =Municipal Master Plan.A holistic approach to HiAP. Local knowledge andresearch-based argumentshave been extremelyimportant Sufficient anchoring in thepolitical and administrativeleadership has been crucialto success.56– 333 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHealth is a human rightDo somethingDo moreDo betterMichael MarmotPeter Goldblatt, 2014– 334 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThank you forlistening!!Contact information:Email: dihe@innherred-samkommune.noPhone: +47 93043714– 335 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThe HUNTStudy– 336 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgNord-Trøndelag County~ 135,000 citizens– 337 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgWhere people liveAntall bosatte per 1x1 km rute1 - 45 - 29Erik R. Sund30 - 199200 - 499500 - 2300±0 12.5 25 50Kilometer– 338 –Kartgrunnlag: Statistisk sentralbyrå og Statens kartverkI. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg1984-8688%1995-9770%2006-0860%– 339 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHealth data from120,000 individuals– 340 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgMeasuring health– 341 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg– 342 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg23 municipalities– 343 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHeight, weight– 344 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgBlood pressureLung function– 345 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgBone scan– 346 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg– 347 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgTransportation of blood samples,cooled, same day– 348 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHUNTResearch Centre,Nord-Trøndelag– 349 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHUNT 3:30 small tubes per person– 350 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgDNA storageCherrypicking at minus 20 Degree C– 351 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgCryo tubes at - 196oC– 352 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von Heimburg1,5 mill cryo tubes at - 196oC– 353 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgDNA-extractionGenotyping– 354 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHUNT 1 HUNT 2 HUNT 31984-86 1995-97 2006-08Key:The 11-digit personal identification number– 355 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgMedialBirth HUNT 1 HUNT 2 HUNT 3 REGISTRIESReg.• Cause of death1984-86 1995-97 2006-08• Cancer• Family registerKey: • Drug prescriptions• StrokeThe 11-digit personal identification number• Myocardial infarction• Venous trombosis• Dementia• Multiple sclerosis• Bipolar• Scizofrenia– 356 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgScientific papers:~ 60-70 each yearTotally ~ 700130 PhD degrees– 357 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgEuropeancollaboration– 358 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHUNT 1 HUNT 2 HUNT 3 HUNT4HUNT 31984-86 1995-97 2006-08 2017 --– 359 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgPolitical supportThe Norwegian governmentThe County CouncilThe 23 municipalities– 360 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgTRUST– 361 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgViking spirit– 362 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThe aim:Longer -and better lifehttp://www.ntnu.no/hunt– 363 –I. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgThe Nord-Trøndelag Health Study (HUNT) Contact information Selected publicationsHUNT is one of the largest and most comprehensive population-based health surveysHUNT Research Centre is part of the Close to 500 publications and 40 PhD’s, based on HUNT data, are an important part ofever performed. HUNT is a unique databank of personal and family medical histories, Faculty of Medicine at the Norwegian our scientific output.clinical measurements, exposure variables and biological material collected in three University of Science and Technology Dale AC, Vatten , Nilsen TI, Midthjell K, Wiseth R. Secular decline in mortality fromconsecutive studies from 1984–2008. In total, more than 100,000 persons from the ( RN eT sN eaU r) c, hT r Co en nd th ree i im s , l oN co ar tw eda y in. H VU erN dT a l in c 1o ;3r 3o 7n :a ar 2y 3 h 6e .art disease in adults with diabetes mellitus: cohort study. BMJ. 2008 JulCounty of Nord-Trøndelag in Norway have participated. the County of Nord-Trøndelag. Rayjean J. Hung, James D. McKay, Valerie Gaborieau, et al. A genome-wide a ssociationRead more: www.hunt.ntnu.no study identifies a susceptibility locus for lung cancer encompassing nicotine acetylcholine receptor subunit genes at 15q25. Nature. 2008 Apr 3;452(7187):633-7HUNT collaborates with national and international research groups on some of T Fe al x: : + +4 47 7 7 74 4 0 07 7 5 51 1 8 80 1 E Til ae nft lh ee Hri ua , Z Pe ag ug l i In Wi, L da eu Br aa k J k S erc o et tt , a R l .i c Mha e tS aa nx ae lyn sa is, B oe f n gj ea nm oi mn eF - wVo idig eh at, s J so on cia at th ioa nn dL a M taa arc nh di nit ch ae n cm eo r,s mt i um sp co ur lota sn kt e h lee ta al lt h d ic sh ea al sl ee ,n mge es n f ta ac l i in llg n eo su sr , w mo ir gl rd a t inod e,a py, r os su tc ah t ea s p rd oia bb lee mte ss ,, E D- irm eca til o: r h Hu Unt N@ Tm ste ud dis yi :n .ntnu.no l N Ja oar hg t aue nr- e ss sc G oa e nle n Ser t ,e i Rp csl ai c e4a d0t e,i o r6 n 3 H 8i ,d - Ee i6n d4t ei 5f i S e (2 ,s 0 M a 0 id 8 dd ) t. hi t P ji eo u ln b l a l Kil s ,n h He e vw d e eos mu ns l ic Kne e , p : S t 3 oib 0 vi i l kMit Oy a r ,l co Mhci o 2f lvo 0 er 0 n 8t y Ap ,e N 2 j ød li sa tb ae dt e Ps . . The Nord-Trøndelagurinary incontinence, reproduction, weight and cardiovascular disease. Ass. Professor Steinar Krokstad Studies in 3,523 Norwegians (HUNT2) and Meta-Analysis in 11,571 Subjects Indicate thatE-mail: Steinar.Krokstad@ntnu.no V Da iari ba en tt es s i .n 2 0th 0e 7 H DN ecF ;4 5A 6 (P 122 ) :R 3e 1g 1i 2o -n 7 .are Associated with Type 2 Diabetes in S candinavians. Health Study (HUNT),Director HUNT biobank:B Thu eil tfuo nndt ar mus etntal strategy of HUNT is to earn and maintain the confidence of theP E-ro mfe as ils : o Kr r K isr ti is at nia .Hn v H eeve me @m ntnu.no H kiMnia ddyl kn ilvla eiedn ytuufS au n, ln sA Ac :s,t Tit o Øo hnrveeB aHrn,l UadRnNo a dm Tl b SIu uI ,n mSDd ti aus n ht dua lyr d.Ai aAAS rw ,,cKA i ht ra h oIs nc ka ta sr er tøraddndi o KMSv, a, eK s Bdcv.je u e2n l r0a ki 0l r ed7msK eDo,terC Octo a,1r l Gi 0e t l;yso1h i z6n i7Jeo (.r2l A d N2s e),:s r2Ao 4v ac s9ri a0øy -t oi L6o u E.n n,g o Pefrri nce M. Norwaypopulation we work in and with. This strategy has been successful and has resulted in A population-based cohort study of the effect of common mental disorders on d isabilityextraordinarily high participation rates. There is enthusiastic public and political support pension awards. Am J Psychiatry. 2006 Aug;163(8):1412-8for HUNT and for the HUNT Research Centre. This has created a good basis for further Aegidius K, Zwart JA, Hagen K, Schei B, Stovner . Oral contraceptives and increasedheadache prevalence: the Head-HUNT Study. Neurology 2006; 66: 349-353health surveys in the County and an excellent research environment. Krokstad S, Westin S. Disability in society. Medical and non-medical determinantsfor disability pension in a Norwegian total county population study. Soc Sci MedExtensive data 2004;58:1837-48Romundstad S, Holmen J, Hallan H, Kvenild K, Ellekjaer H. Microalbuminuria andThe HUNT studies have compiled extensive medical, lifestyle and environmental data all-cause mortality in treated hypertensive individuals: does sex matter? The Nord- NTNUassociated with each biological sample, comprising in total about 800 exposure variables Trøndelag Health Study (HUNT), Norway. Circulation 2003; 108: 2783-2789and nearly 3000 different variables per individual. These datasets allow for p rospective Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Obesity and estrogen as risk factors Faculty of Medicinefor gastroesophageal reflux symptoms. JAMA 2003; 290: 66-72correlations to be made between genetic, epigenetic, lifestyle, environmental and health/ Rørtvet G, Daltveit AK, Hannestad YS, Hunsår S. Urinary incontinence after vaginaldisease profiles. Through an individual personal identifier (PIN) linkage to registries at delivery or cesarean section. N Eng J Med. 2003 Mar 6;348(10):900-7the national level can be established to access additional information. Particip ants haveprovided very detailed information through the HUNT surveys. This has been validated inseveral studies based on HUNT data and has greatly contributed to the overall value ofthe HUNT Biobank for research projects.HUNT Biobank in Levangerwww.hunt.ntnu.no 462– 364 –TNUH,ydutShtlaeHgalednørT-droNehTsosmaN,nesnahoJranietS :otoFsosmaN,nesnahoJranietS:otoFsosmaN,nesnahoJranietS:otoF8002kkyrttUripaT:kkyrtgo gnimroftUI. WG meeting programmes and expert presentations | 5. Levanger, Norway – Ms Dina von HeimburgHUNT 1-2-3 HUNT Biobank and the National CONOR Biobank HUNT phenotype, genotype and environmental data support R&D for majordisease areas such as:In 1984, a population-based health study was launched in the central Norwegian region HUNT Biobank is one of the most modern and extensive international biobanks, storingof Nord-Trøndelag. The study was intended to stimulate epidemiological research and whole blood and DNA from 200,000 individuals, serum and plasma samples from moreto provide a new basis for clinical and preventive medicine projects. The study was than 100,000 individuals as well as urine, RNA tubes, cells, buffy coat and Na-heparinnamed the HUNT Study. tubes for environmental analysis for as many as 50,000 individuals.The County of Nord-Trøndelag has a scattered rural population of about 130,000, which All bio-specimens from the HUNT surveys are collected, processed and stored at thecan be characterized as stable and homogeneous. Urban centres are small, with fewer HUNT Biobank in Levanger, which was officially opened in March 2007. 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Programme and its role in EU-funded health research is expected to be further extendedHUNT offers unique opportunities for longitudinal studies, in years to come. 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(cid:105)(cid:90) (cid:104)(cid:97)i (cid:90) (cid:100)(cid:21)(cid:90)n (cid:88)(cid:21) (cid:92)(cid:91)(cid:21) (cid:21)(cid:101) (cid:104)(cid:105)f (cid:92)(cid:103) (cid:105)(cid:90)(cid:106)o(cid:97) (cid:94)(cid:100)(cid:21)(cid:90)(cid:90) (cid:104)(cid:94) (cid:99)(cid:103)r (cid:99)(cid:98)(cid:99) (cid:104)(cid:104) (cid:90) (cid:100)m (cid:21) (cid:106)(cid:21)(cid:100) (cid:61)(cid:21) (cid:105)(cid:21)(cid:91) (cid:91)(cid:86) (cid:110)(cid:90)(cid:100)a (cid:105) (cid:100)(cid:74)(cid:110) (cid:101)(cid:99) (cid:104)(cid:103)t (cid:103)(cid:101)i (cid:94)(cid:21) (cid:67)(cid:21) (cid:21)(cid:21)o (cid:99)(cid:86) (cid:94) (cid:101)(cid:94) (cid:103)(cid:99)(cid:99)n (cid:90)(cid:73)(cid:99) (cid:92)(cid:100)(cid:88)(cid:92) (cid:101): (cid:21) (cid:21)(cid:86) (cid:104)(cid:57) (cid:91)(cid:103)(cid:21) (cid:97)(cid:97) (cid:86)(cid:104)(cid:103)(cid:90) (cid:94)(cid:110) (cid:86)(cid:90) (cid:88) (cid:94)(cid:88)(cid:86)(cid:104) (cid:87)(cid:105)(cid:86)(cid:104) (cid:94)(cid:104)(cid:94) (cid:86) (cid:97)(cid:97)(cid:104) (cid:105)(cid:106) (cid:94)(cid:90)(cid:94)(cid:87) (cid:105)(cid:94)(cid:99)(cid:97) (cid:100) (cid:21)(cid:110)(cid:86) (cid:107)(cid:105)(cid:92) (cid:21)(cid:99)(cid:104) (cid:94)(cid:104)(cid:21) (cid:86)(cid:21)(cid:21)(cid:99)(cid:90)(cid:104)(cid:108) (cid:21)(cid:88)(cid:106)(cid:21)(cid:105)(cid:94) (cid:106) (cid:97)(cid:97)(cid:98) (cid:94)(cid:97) (cid:89) (cid:99)(cid:21)(cid:87)(cid:87) (cid:94) (cid:94)(cid:90) (cid:88)(cid:90)(cid:90) (cid:104) (cid:86)(cid:21)(cid:103) (cid:21) (cid:97)(cid:21) (cid:21)(cid:21)HUNT Biosciences Ltd is the commercial arm of the HUNT Biobank and CONOR. HUNT Biosciences was established in 2007 in orderto offer a professional interface with industry and facilitate commercial use of HUNT data, without compromising the trust of thedonor population. HUNT Biosciences is publicly owned, and any profits made by the company will be returned to the community as afinancial basis for further research.Contact information: Neptunveien 1, N-7650 Verdal, Norway. Tel: + 47 74 07 51 80 Fax: +47 74 07 51 81 www.hunt.ntnu.nowww.hunt.ntnu.no 463– 365 –Baltic Sea Parliamentary ConferenceTampere, Finland, 16-17 March 2015Monday 16 March1700-1915 W G meeting, including expert presentations by Ms Auli Pölönen, Coordination Manag-er, M.Sc., Clinical Nutritionist, Pirkanmaa Hospital District, Prevention of Diabetes andCardiovascular Diseases, and Ms Maarit Varjonen-Toivonen, Chief Physician, Centre ofGeneral Practice, Pirkanmaa Hospital DistrictTuesday 17 March0900-0930 B rief introduction and words of welcome by Mr Rauno Ihalainen, Director of PirkanmaaHospital District0930-1030 V isit to the Vaccine Research Center accompanied by Ms Vesna Blazević, Head of Labo-ratory and Mr Heikki Hyöty, ProfessorThe BSPC Working Group on Innovation in Social and Health Care (BSPC WG ISHC) held its fifthmeeting in Tampere on 16-17 March 2015. The meeting itself was preceded by a study tour of the VaccineResearch Centre and the Tampere University Central Hospital. The Working Group was briefed by AuliPölönen, Clinical Nutritionist at Pirkanmaa Hospital District, on the Prevention of Diabetes and Cardio-vascular Diseases. The second briefing was given by Maarit Varjonen-Toivonen, Chief Physician at theCentre of General Practice in Pirkanmaa Hospital District, on electronic reporting linked to OperationsPlanning & Budgeting on the Communal Level. At Tampere University Hospital the WG members re-ceived a briefing on the hospital and were then informed about diabetes research and vaccine developmentagainst type 1 diabetes by Vesna Blazević, Head of Laboratory, and Heikki Hyöty, Professor at TampereUniversity Hospital.– 366 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenElectronic reporting linked toOperations Planning & Budgetingon the Communal LevelMs Maarit Varjonen-ToivonenChief Physician, Primary Health Care16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 367 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenIntroductionAbout organizationBackground to the development of electric welfarereportPresentation of the electric welfare reportLinkage to Planning and Budgeting on theCommunal level16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 368 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenTampere University Hospital`sspecial responsibility area 4 hospital districts 31 health centres16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 369 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 370 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 371 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenPrimary Health Care Chief Physician, Head of Centre Ms Doris Holmberg-Marttila Chief Physician (30 %), Professor of General Practice Ms EliseKosunen Chief Physician, coordination of Health Promotion Ms Maarit Varjonen-Toivonen Expert Physician Mr Mika Palvanen Expert nurse Ms Leena Kuusisto Expert nurse Ms Riitta Salunen Secretary Ms Teija Kvist-Sulin16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 372 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenThe Ottawa Charter for Health Promotion, 1986Definition of ”Health Promotion” Health promotion policy and management Living environments Cooperation and participation Competencies Services Monitoring and assessment of health promotion16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 373 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 374 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenHealth in all Policies, 2006 During the first Finnish presidency of the EU in 1999, a councilresolution was adopted to ensure health protection in all policies andactivities of the EU HiAP was launched more specifically in the EU during the secondFinnish EU Presidency in 2006 HiAP was made one of the key principles in EU health strategy Finland The Finnish Government programme 2007 -> The Health Care Act 2010: requires municipalities to prepare anddiscuss reports on their population groups’ well-being and healthand their major determinants within discussions of municipalities’strategic plans.16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 375 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 376 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 377 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 378 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen[THL 25.2.2015]16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 379 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenReducing Health Inequalities24 h/ day= 8 760h/ 365 daysMeeting health care professionals(example of person with many healthproblems)80 %20 % - physician 20min / week- nurses 40 min/ week80 %20 %= 52h/ 365 days= 0,006 % / 8 760hThe rest of the patient takescare of himselfPATIENTS COSTS ( € )16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 380 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenThe Health Care Act 1.5.2011 (1326/2010): new issues(cid:16178)Consideration of effects on health and welfare (11 )When planning and making decisions, local authorities and joint municipal authorities forhospital districts shall assess and take into consideration any effects that theirdecisions may have on the health and social welfare of residents.(cid:16178)Health and welfare promotion by local authorities (12 )* Local authorities shall monitor the health and welfare of their residents and anyunderlying factors per population group* Reports on the health and welfare of residents as well as any measures taken shall beproduced for the city or municipal council once a year* A more comprehensive review on welfare shall be produced for the city or municipalcouncil once during each term of office.* In their strategic plans, local authorities shall identify objectives for health and welfarepromotion by making use of local welfare and health indicators.* Local authorities shall assign coordinators for health and welfare promotion.* The various local authority departments shall work together in health and welfarepromotion.* Local authorities shall cooperate with other public organizations based in the localauthority as well as with private enterprises and non-profit organizations16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 381 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenNational Development Programme forSocial Welfare and Health Care (Kaste) A strategic steering tool that is used to manage and reform social andhealth policy. Kaste I 2008 – 2012, Kaste II 2012 – 2015 The Kaste Programme implements the Government Programme andthe Strategy of the Ministry of Social Affairs and Health. TheGovernment renewd the programme 2 January 2012. The targets of the Kaste programme are that1. Inequalities in wellbeing and health will be reduced2. Social welfare and health care structures and services will beorganised in a client-oriented and economically sustainable way16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 382 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenKASTE: sub-programmes1. Inequalities in wellbeing and health will be reduced Inclusion, wellbeing and health for risk groups More effective services for children, young and families with children Improved services for older people2. Social welfare and health care structures and services will beorganised in a client-oriented and economically sustainableway A new service structure and more effective primary services Information and data systems in support of clients and professionals Management will support the service structure and wellbeing at work16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 383 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenElectronic welfare reportSupport for local strategic managementKaste programme 2008 – 2011Kanerva-Kaste -> ”TEHO-tool”TerPS (The Healthy Northern Finland)Electric welfare report 0.1-> welfare report: cross-functionalElectric welfare report 0.2welfare leadership andpolitical decision-makingof local authorities.Kaste programme 2012 – 2015TerPS2 (2012 – 2014) Electric welfare report 0.3Suomen Kuntaliitto (the Association of Finnish Local and Regional Authorities)-> 2014 -> Publication of new releases (0.4) summer 201516.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 384 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 385 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenMunicipalities with credentials to the electronic welfare report toolFinland Pirkanmaa87 7 776 6 6 6 665 All municipalities544Municipalities3 with credentials3to the electronicwelfare reporttool2 Approvedwelfare reports1 1 1 1 of local1 authorities02 000 - 5 000 -10 000 -20 000 -100 0004 999 9 999 19 999 39 999 -the number of inhabitants in the municipality16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 386 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 387 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 388 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenWelfare report(The comprehensive review on welfare)Part One: The evaluation of the ending council term1. The evaluation of wellness information and measures Indicators, Summary, Conclusions2. The central doctrines to the next municipal council officePart two: Planning of the future council term3. Priorities of the municipal strategy4. Plans and programs that support health and welfare promotion National, Municipal, Regional5. Plan for health promotion and wellbeing during the council officePriorities and target Goals Measures Resources Assessmentfor development and toolsresponsibleparties6. Approved as a part of operating and financial plan of the municipal16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 389 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenIndicators of the electric welfare report 0.3Themes of wellbeingLifespanInclusion and influenceAll age groupsQuality of lifeMental well-being Children, young teens, families with childrenHealth and functional capacityAdolescentsSafety and youngadultsStudy and workMunicipal structures, budgets,vitality of the municipal People ofworking ageEquality and fairnessHousing and environmentElderlyLivelihoodResidents services16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 390 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenYear of information in Sotkanet16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 391 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenSotkanet:“Has no close friends,as % of all pupils in8th and 9th yearof comprehensive school “16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 392 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenConnected to Sotkanet (http://sotkanet.fi )16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 393 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 394 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 395 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenWelfare report linked linked to Operations Planning & Budgetingon the Communal LevelAPPROVES THEAPPROVE THEFINANCIALSTRATEGY AND APPROVE THE STATEMENTS ANDMUNICIPAL DECIDES PRIORITIES O F HP OPERATING THE EVALUATIONTHE (The comprehensive AND EPORT FOR THECOUNCIL INDICATORS welfare report) FOR FINANCIAL PREVIOUS YEAR ANDTHE TERM OF PLAN FOR THE THE ANNUALOFFICE NEXT YEAR WELFARE REPORTCOORDINATION ImplementationTHE MUNICIPAL HP- COORDINATIONMAKE A OF OPERATING and report ofMANAGEMENT AND PRIORITIESPROPOSAL AND FINANCIAL comprehensiveTEAM FORPROPOSALSPLANSwelfare reportANDTHE MUNICIPAL HP-OF THE OF STRATEGY RESOURCESCOLLABORATION INDICATORS AND HP +as a part ofTEAM RECRUITMENToperating andOF 3. SECTORINDICATORS OF EVERY YEAR:LOCAL AUTHORITY ACTION AND IMPLEMENTATIONDEPARTMENTS EXPLANATION OF AS A PART OF financial planTHEM OPERATING AND of allFINANCIAL PLAN OF departments AN EVALUATIONDEPARTMENT REPORT REVIEWINGTHE PREVIOUSYEAR ‘S OPERATINGTHE MUNICIPALITY AND FINANCIALAUDIT COMMITTEE IMPLEMENTATIONCooperation areaTHE HP-shall act as an expertCOLLABORATIONin any cooperation ofTEAM OF REGIONALthe various sectorsSOCIAL AND HEALTHCAREMVT 201516.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 396 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenAdvantages of electronic welfare report Helps to deliver the principles of good welfare leadership The challenges of welfare promotion are met together with thefinancial challenges The welfare perspective is included in local strategicmanagement and in the implementation of the municipalstrategy All administrative branches take more responsibility for thewelfare of residents.16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 397 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-Toivonen16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 398 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Maarit Varjonen-ToivonenThank YouMs Maarit Varjonen-ToivonenChief Physician (Health Promotion)maarit.varjonen-toivonen@pshp.fi16.3.2015 Pirkanmaa Hospital District Maarit Varjonen-Toivonen– 399 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenThe implementation of the nationaltype 2 diabetes prevention programme,FIN-D2D, in the Pirkanmaa HospitalDistrict – Lessons learned5th Meeting of the WG ISHC BSPCTampere, Finland, 16–17.3.2015Auli PölönenCoordination managerPirkanmaa Hospital District, Finland– 400 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenBackgroundFIN-D2D ProjectFIN-D2D model (high risk strategy)FIN-D2D in practiseExperiences and models developed in PirkanmaaResultsDiscussion2 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 401 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenBackgroundType 2 diabetes (T2D) and its co-morbidities are rapidlyincreasing health problems in Finland and worldwideRandomized trials have shown that lifestyle modification canpostpone T2D among individuals at high risk for T2D3 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 402 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDiabetes prevalence in FinlandNiemi, Winell: Diabetes Suomessa, Stakes 2005YearTotal T1D T2D DMType uncertain4 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 403 –rebmuNI. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDiabetes patients in dialysis in Finland 1965 - 2000Patients/year180T2D15012090T1D60300year-65 -70 -75 -80 -85 -90 -95 -00Finnish Registry for Kidney Diseases – Report 20005 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 404 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenCosts of diabetes care(on average, euros/person/year, Finland)T1D T2D24 x12 xComplications No complicationsKangas 20026 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 405 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenStudies:Risk factors of T2D and metabolic syndrome Obesity, central obesity and weight gainPhysical inactivity and sedentary lifestyle Diet: high fat and saturated fat intake Diet: low nutrient fiber intake Insulin resistance Family history of diabetes Ethnicity Increasing age Lifestyle modification and prevention? Trials7 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 406 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenEffects of diet and exercise in preventing NIDDM inpeople with impaired glucose tolerance.The Da Qing IGT and Diabetes Study, ChinaPan et al. 1997. Diabetes Care 20:537-544The cumulative incidence of diabetesRisk reductionat 6 yearsDiet 31 %Exercise 46 %Diet + exercise 42 %Control n=133Diet n=130Exercise n=141Diet + exc. n=1268 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 407 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenThe Finnish Diabetes Prevention Study (DPS)Tuomilehto et al. 2001. N Engl J Med 344:1343-1350522 overweight, middle-aged men and women with IGTRandomly allocated to:intensive lifestyle intervention or control groupIntervention goals:• Weight reduction > 5%• Moderate fat < 30 E%• Low saturated fat < 10 E%• High fibre >15g /1000 kcal• Physical activity > 30 min / day7 individual dietary counselling sessions (by dietitians)during the first year, every 3 months thereafter9 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 408 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDPS: Diabetes incidence was 58% loweramong the intervention group compared withthe control group after mean follow-up of 3.2 yearsHRWeight reduction > 5%Moderate fat < 30 E%Low saturated fat < 10 E%High fibre >15g/1000kcalPhysical activity > 30 min/dayN Engl J Med 2001; 344:1343-135010 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 409 –setebaidfoecnedicnievitalumuCI. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDPS: The more goals achieved, the lower the risk!10HR86Weight reduction > 5%4Moderate fat < 30 E%Low saturated fat < 10 E%2High fibre >15g/1000kcal0Physical activity > 30 min /day0 1 2 3 4 5Number of goals achievedGoals at year 3; incidence during 7 years follow-up11 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 410 –nosrep001repecnedicnIsraeyI. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDiabetes Prevention Program (DPP)N Engl J 2002, 346:393-403N = 3234 , IGT and elevated fP-glucControl/Placebo groupIntervention groups:MetforminLife styleWeight reduction (>7%)Lower fat ja energy intakeEnhanching physical activity(>150min/vko)Metformin intervention group riskfor diabetes decreased 31%Lifestyle intervention group:Risk for diabetes decreased 58%12 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 411 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli Pölönen13 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 412 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDPS (2001), DPP etc. evidence of the prevention of T2DImplementation Project of T2D Prevention ProgrammeFIN-D2D Project 2003 - 2007 and the Follow-up Project 2008 - 2010FIN-D2D: PartnersFour => Five hospital districtsFinnish Diabetes AssociationNational Institute for Health and WelfareTarget population 1.5 million people400 health care centres200 occupational health centres> 2000 health care professionals14 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 413 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D Funding 2003 - 2007Hospital districts 100 000 euros/year/districtFunding from the State 100 000 euros/year/districtFinnish Diabetes Association 450 000 euros/year(The Slot Machine Association of Finland)National Public Health Institute 100 000 euros/yearTotal: 8.4 million euros during the years 2003-2007Target population 1.5 million 1.1 euro/person/yearThe project had to apply for the funding every year (the State,the Slot Machine Association and municipalities separately)15 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 414 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D Project GoalsTo reduce the incidence and prevalence of T2Dand cardiovascular risk factorsTo identify individuals with T2DTo generate new models for the prevention of T2DTo evaluate the effectiveness, feasibility and thecost-effectiveness of the projectTo increase awarenessof T2D and its risk factors among the population16 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 415 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenThree strategies:Population Strategy:Prevention of obesity and T2D at population levelHigh-Risk Strategy:Screening of people with elevated risk (adults) andmanagement of risk factors by lifestyle counsellingEarly Diagnosis and Management Strategy:Appropriate treatment and prevention of complicationsamong newly diagnosed people with T2D17 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 416 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFINDRISC:Age, BMI, Waist,Physical activity, Nutrition,Hypertension, Family historyForm available:• On-line www.diabetes.fi• In pharmacies• At selected public events• In newspapers• Given by a health careprovider at a normal visit• As a part of routine healthcare check-ups• At self-service check-uppointsDiabetes Care 2003;26:725-31.18 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 417 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenAt high risk19 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 418 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D InterventionsPrimary health care or other service providers:Weight- Mental Alcohol usemanagement Exercise Healthy support management Peergroups groups cooking groups groups groups groupsIdentificationGroupas a high-riskinterventionpersonIndividual1. visit 2. visit (3. visit)intervention(nurse) (nurse) (GP) Annual follow-upsSelf-Height, Weight, BMI, Waist,initiatedBlood pressure,lifestyleOGTT, LipidschangesQuestionnaire on medical history,Smoking, Physical activity, Food habitsOtherRegularGlobal risk assessment interventionhealthformsReadiness to change habits care visits20 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 419 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D Project: Intervention goalsin life-style modificationRisk factor: Overweight (BMI > 25 kg/m2)Goal: 5 % reductionRisk factor: Low physical activityGoal: > 30 min/dayRisk factor: High saturated fat intakeGoal: < 10 E%Risk factor: High fat intakeGoal: < 30 E%Risk factor: Low fiber intakeGoal: > 15 g/1000 kcal21 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 420 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D Project interventionBased on:• Research evidence• Current Care Guidelines: Obesity, Hypertension, Dyslipidemias• Finnish Nutrition and Physical Activity Recommendations• FIN-D2D goalsLife-style modification as a long-term process, step by step:Stages of the changes - modelNew approach and methods for counselling - empowermentCustomer-oriented and target-oriented approachMultiprofessionality shared responsibities, experticeProtocols for screening and interventionValidated material for counsellingDocumentationEvaluation on individual and organisational levelsCollaboration networks:public and private primary health care, specialised caremunicipal actors, local organisations, associations etc.22 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 421 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D - basic questionnaire forhigh risk individualsHow Are You?Health statusSmokingPhysical activityDietWeight managementSleepAs a tool forintervention andcounselling follow ups23 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 422 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli Pölönen24 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 423 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenEveryday physical activityis beneficial as wellSmall changesyield big resultsExamples of daily one-hour motionopportunities:walkingfrom home to bus 5 minfrom bus to work 7 minto and from lunch restaurant 6 minfrom work to bus 7 minfrom bus to store 8 minfrom store to home 6 minusing stairs during the day 8 minclearing snow away 13 mintotal 60 min25 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 424 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFinnish Nutrition Recommendations26 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 425 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenEat well – You are well Proper foodBetter mood27 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 426 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenMaking the Food Choices VisibleEtelä-Pohjanmaan sairaanhoitopiiriJuotko vaiDEHKON 2D -hankesyötkö?400 kcalKummanOmenoita 3,6 kiloanapostelethuomaamatta?Iso karkkipussi(350 g)1600 kcal 600 kcalSaman verran energiaa (1230 kcal)28 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 427 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenThe Amount of Fat During Half a Year29 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 428 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenMedia CampaingsFIN-D2DLook at Your Belly Button A Small Decision a Day30 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 429 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D in Pirkanmaa Hospital District31 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 430 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenRRREEEGGGIIIOOONNNAAALLL LLLEEEVVVEEELLL FFFIIINNN---DDD222DDD PPPRRROOOJJJEEECCCTTT PPPIIIRRRKKKAAANNNMMMAAAAAA LLLOOOCCCAAALLL LLLEEEVVVEEELLLNNNEEETTTWWWOOORRRKKK AAANNNDDD CCCOOOLLLLLLAAABBBOOORRRAAATTTIIIOOONNNHHHeeeaaalllttthhh CCCaaarrreee CCCeeennntttrrreeesss MMMuuunnniiiccciiipppaaallllll GGGooovvveeerrrnnneeemmmeeennntttsssOOOccccccuuupppaaatttiiiooonnnaaalll HHHeeeaaalllttthhh CCCaaarrreee UUUnnniiitttsssHHHeeeaaalllttthhh CCCaaarrreee CCCeeennntttrrreeesssTTTaaammmpppeeerrreee UUUnnniiivvveeerrrsssiiitttyyy HHHooossspppiiitttaaalll aaannndddRRReeegggiiiooonnnaaalll HHHooossspppiiitttaaalllsss DDDD2222DDDD PPPPiiiirrrrkkkkaaaannnnmmmmaaaaaaaa AAAccctttooorrrsss iiinnn ttthhheee OOOttthhheeerrr MMMuuunnniiiccciiipppaaalllOOOrrrgggaaannnsssSSSStttteeeeeeeerrrriiiinnnngggg CCCCoooommmmmmmmiiiitttttttteeeeeeeeUUUnnniiivvveeerrrsssiiitttyyy ooofff TTTaaammmpppeeerrreee•••ssspppooorrrtttsss aaannnddd pppfffyyysssiiicccaaalll aaaccctttiiivvviiitttyyySSSccchhhoooooolll ooofff PPPuuubbbllliiiccc HHHeeeaaalllttthhh ssseeerrrvvviiiccceeesss•••sssoooccciiiaaalll ssseeerrrvvviiiccceeesssPPPiiirrrkkkaaannnmmmaaaaaa UUUnnniiivvveeerrrsssiiitttyyy ooofff AAAppppppllliiieeeddd DDDD2222DDDD PPPPrrrroooojjjjeeeecccctttt GGGGrrrroooouuuupppp•••cccaaattteeerrriiinnnggg ssseeerrrvvviiiccceeesssSSSccciiieeennnsssiiieeesss•••sssccchhhoooooolllsss aaannnddd cccuuullltttuuurrraaalll ssseeerrrvvviiiccceeesssUUUKKKKKK IIInnnssstttiiitttuuuttteeeOOOccccccuuupppaaatttiiiooonnnaaalll HHHeeeaaalllttthhh CCCaaarrreee SSSeeerrrvvviiiccceeesssDDDD2222DDDD PPPPrrrroooojjjjeeeeccccttttTTThhheee FFFiiinnnnnniiissshhh DDDiiiaaabbbeeettteeesssTTTTeeeeaaaammmmAAAssssssoooccciiiaaatttiiiooonnn,,, TTTaaammmpppeeerrreee DDDiiissstttrrriiicccttt PPPhhhaaarrrmmmaaaccciiieeesssTTThhheee FFFiiinnnnnniiissshhh HHHeeeaaarrrttt AAAssssssoooccciiiaaatttiiiooonnn,,,EEEExxxxppppeeeerrrrtttt GGGGrrrroooouuuupppp:::: EEEExxxxppppeeeerrrrtttt GGGGoooouuuupppp:::: CCCaaattteeerrriiinnnggg SSSeeerrrvvviiiccceeesss iiinnn ppprrriiivvvaaattteee ssseeeccctttooorrrPPPiiirrrkkkaaammmaaaaaa DDDiiissstttrrriiiccctttPPPPhhhhyyyyssssiiiiccccaaaallll aaaaccccttttiiiivvvviiiittttyyyy CCCChhhhiiiillllddddrrrreeeennnn’’’’ssss OOOObbbbeeeessssiiiittttyyyyLLLooocccaaalll BBBrrraaannnccchhheeesss ooofff ttthhheee DDDiiiaaabbbeeettteeesssTTThhheee FFFiiinnnnnniiissshhh SSSpppooorrrtttsss FFFeeedddeeerrraaatttiiiooonnn,,,aaannnddd ttthhheee HHHeeeaaarrrttt AAAssssssoooccciiiaaatttiiiooonnnsssHHHääämmmeeeTTThhheee AAAssssssoooccciiiaaatttiiiooonnnsss ooofff HHHeeeaaalllttthhh CCCaaarrreee,,, HHHeeeaaalllttthhh CCCaaarrreee aaannnddd OOOttthhheeerrrOOOccccccuuupppaaatttiiiooonnnaaalll HHHeeeaaalllttthhh CCCaaarrreee AAAssssssoooccciiiaaatttiiiooonnnsssPPPrrrooofffeeessssssiiiooonnnaaalllsss aaannnddd PPPhhhaaarrrmmmaaaccciiieeesssSSSpppooorrrtttsss aaannnddd PPPhhhyyysssiiicccaaalll AAAccctttiiivvviiitttyyy CCCllluuubbbsssTTThhheee NNNaaatttiiiooonnnaaalll RRReeessseeeaaarrrccchhh aaannndddDDDeeevvveeelllooopppmmmeeennnttt CCCeeennntttrrreee fffooorrr WWWeeellllllfffaaarrreeeaaannnddd HHHeeeaaalllttthhh MMMeeedddiiiaaa AAAddduuulllttt EEEddduuucccaaatttiiiooonnn CCCeeennntttrrreeesss Large variety of actors and professionalsin screening and life style modification32 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 431 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenVisits to every health care centerand occupational health care unitto chart resourcourses and needsfor the prevention of T2D, workingmethods, tools, materials, andneeds for education and traininglocal D2D multidisciplinaryteams, local D2D projects33 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 432 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenNetworksCollaborationMultidisciplinary workWorkshopsEduction and trainingDeveloping care chains, portocolsProjects plans and prosesses34 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 433 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenMultidisciplinary work,roles, and responsibilities in health care protocolsThe regional (Valkeakoski) protocol for the prevention and care of T2D in Pirkanmaa, 2008The protocol for the Pirkanmaa hospital district 201135 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 434 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDocumentation developed: food habits, physical activityData collection for FIN-D2D evaluation36 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 435 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenAnnual reports of localKEHITTÄMISSEMINAARITprojectsWorkshopsSharing experienciesPlanning further37 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 436 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenNew models for theoccupational health care38 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 437 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenCatering servicesGood opportunities forhealth promotion andcommunication39 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 438 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenPharmacies incollaboration40 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 439 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenSastamala board meeting: Seminars for men in Sastamala”Something for men?once a year - real successCompetitions, diet information,physical activities, celebrities...”Male personnel of the municipalityin charge of planning the seminar.> 300 participants/event41 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 440 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenCampaigns for decision-makers and personelSastamala: ”One cent out of your waist for the health” campaingVirrat: Checking the waistcircumference of the staffannuallyYlöjärvi: ”Light summercampaign” for the staffTays: Campaigns for the staff,well-being weeks, healthpromotion events42 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 441 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenParticipatingfairs togetherwithcollaborators43 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen AP PSHP 09– 442 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenHand in hand with the third sector44 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 443 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenActivating physically inactive men -An adventurous approach (SuomiMies seikkailee)FINNISH HEARTASSOCIATIONPIRKANMAAFINNISH SPORTSFEDERATION, HÄMED2D PIRKANMAAKKI-AWARD 2006 KKI product since 200745 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 444 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenConcern of the childrens’obesity problemMultidisciplinary work since 2004 Special project to improvechildrens’ nutrition education atday care 2011 - 2013 District care chain and servicenetwork 201346 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 445 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenInternationalReporting Days2006 and 2007WCPD 200847 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 446 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D De Plan Project and Image Project(EU) and toolkits48 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 447 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2DResults and Lessons Learned49 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 448 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D Survey 2004 (in three hospital districts):High prevalence of abnormal glucose tolerance in themiddle-aged Finnish population (age group 45-74 yrs.)Men (n = 1396) Women (n = 1500)Diagnosed type 2diabetes 7.1% 3.9%Screen-detected } 16.4% } 11.2%type 2 diabetes 9.3% 7.3%Impaired glucosetolerance 15.5% 17.0%Impaired fastingglucose 10.0% 5.2%__________Total*: 42.0% 33.4%* Age-adjustedSaaristo T et al. BMC Public Health 2008.8:42350 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 449 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli Pölönen200 000 - 250 000 screened for risk of T2Dduring FIN-D2DModerate riskcohort n = 9898Diagnostics,interventions andfollow-up inprimary healthcare as usualHigh risk cohort for evaluationn = 10176Evaluation, follow-up51 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 450 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenPerformed Oral Glucose Tolerance Testsin the Pirkanmaa Hospital District 2002-200790008000700060005000OGTT40003000 311 %2000100002002 2003 2004 2005 2006 200752 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 451 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D high risk cohort participantsNumber of participants 10 149 (33.4 % men)MeanAge 53.6 (10.9) yearsBMI, kg/m2 31.3 (4.7)BMI > 30 kg/m2 59.6 %Waist circumference 102.9 (13.1) cmFINDRISC score 17.2 (3.2)Saaristo T et al. Primary Care Diabetes 201053 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 452 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenIntervention visits in the high risk cohort of FIN-D2D%Number of visits Men (n = 3421) Women (n = 6845)At least one 45 47≥ 4 24 28Visit to physician 33 27Saaristo T et al. Primary Care Diabetes 201054 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 453 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenOGTT classification at the baseline andduring the one year follow-upin the FIN-D2D high risk men and womenMen (n = 926) Women (n = 1972)OGTT Baseline Follow-up Baseline Follow-upNormal 39 % 45 % 54 % 60 %IFG 30 % 23 % 18 % 16 %IGT 31 % 22 % 28 % 19 %DM 10 % 5 %Saaristo T et al. Primary Care Diabetes 201055 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 454 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenChange in risk factors in the FIN-D2D high-riskindividuals during the 1st year of intervention,all hospital districtsMen (n = 1492) Women (n = 3196)Baseline, Absolute Baseline, Absolutemean change mean changeWeight kg 96.5 -1.02 84.1 -0.88Waist cm 107.8 -1.06 99.8 -0.98BP syst mmHg 142.2 -0.75 138.9 -1.67BP diast mmHg 88.1 -1.30 85.5 -1.33Cholesterol mmol/l 5.1 -0.26 5.2 -0.12Saaristo T et al. Primary Care Diabetes 201056 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 455 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenDiabetes risk in one year follow-upaccording to weight change in FIN-D2DAdjusted to the age of 50+10 %8Ref76-29 %543 -69 %21Weight change0L>o5s%t > l a5 s%k u 2L,5o-s4t, 9% StaEbile G>a2i,n5e%d2la.5s-k4u.9 % mwueuitgohstt a n>o 2u.5s u%Diabetes Care 2010; 33: 2146-215157 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 456 –)%(setebaidfoecnedicnII. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenResults – practices and models (1)FINDRISC has proved out to be a practical toolfor screening and mini-intervention and a usefultool for the third sector.D2D questionnaire has proved out to be apractical tool when identifying, registering andevaluating customers’ habits. Shorter versionsdeveloped by Northern Savo and Pirkanmaa.New material for the preventive work developedby the FIN-D2D was necessary.The Model for the Stages of Change providesa practical model for understanding thecharacter of changes in habits.58 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 457 –The demand for nutrition therapy services has increased. Before the D2D Project only two health carecentres had an AN. Some AN services were purchased, but not focused on prevention. In 2007 fourmunicipalities consider establishing AN vacancies. In occupational health care there were no AN servicesThe deamvaaniladb foler. nNuotrwit io sne vtheeraral puyn istse rhvaicvees e hxapsr einscsreeda tsheedir. Bneeefodr efo trh Ae ND 2seDr vPicroejse.c t only two health carecentres had an AN. Some AN services were purchased, but not focused on prevention. In 2007 fourmunicipalities consider establishing AN vacancies. In occupational health care there were no AN servicesavailable. Now several units have expressed their need for AN services.I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D has shown the magnitude of the diabeticResults (2)epidemic in Finland.In 2004 the health care centres had no establishedpractices for high-risk intervention.During the project a multiprofessional local steeringgroup co-ordinated the work in most health centres.The D2D model has been adopted in most healthcare centres and some occupational health units forscreening and interventions.The FIN-D2D model has been included into the localand regional T2D prevention care protocols.The FIN-D2D model has been adopted also for theprevention of other noncommunicable diseases.Other prevention projects in Finland, De Plan, andImage Project in Europe have adopted the FIN-D2Dmodel as well.59 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 458 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenResults (3)The need for nutrition and physical activity educationbecame obvious. During the project health careprofessionals knowledge and skills of life style counsellingimproved.Public nurses got a central role in the prevention of T2D.Multiprofessional guidance and support was needed.Over 300 new models were documented.Occupational health care got a new role in the prevention ofT2D.District and local networks of heath care, third, and privatesector were established.At the population level the awareness of T2D and its riskfactors has increased.60 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 459 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenResults – National LevelThe Amount of diabetes patients based on reimbursementfor diabetes medication (103) in Finland 1986 – 2013The Social Incurance Institution of FinlandKela: Diabeetikoiden määrä (erityiskorvausoikeus 103) 1986–2013Suomen Diabetesliitto 201561 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 460 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenNew T2D Patiens in Finland 1997 - 2007Diabetesbarometri 201062 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 461 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D Survey 2004 and 2007Half of all T2D in the age group 45-74 are unidentifiedObesity trend in Finland seems to leveling off63 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 462 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFinnish Registry for Kidney Diseases – Report 201364 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 463 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenPublic awareness regarding T2D and itsprevention has been raised•Health communication and media visibility all overthe country: TV, radio, journals, newspapers•”Look at yourself” campaign•”A small decision every day” campaign•FIN-D2D exhibitions•A wide selection of training material for people at risk•Material for health care providers•Various local innovations for raising awarenessDiabetes mentioned in the media in Finland during 1980-20061980-1993 1300-15001994-1999 1800-23002000-2006 3700-6000Finnish Diabetes Association 200865 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 464 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenAwareness of the prevention ofdiabetes in the 2007 population surveyQuestion: Which action results in the prevention of type 2 diabetes?1008060%4020MenWomen0Normal weight 5-10% weight Reduced waist Increase fiberreduction intakeRisk factor66 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 465 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenFIN-D2D: Factors to overcome•Limited resources for prevention in primary health care.•Strong focus on treatment, not prevention and health promotion, inprimary health care.•Lack of knowledge and skills of the health care personnel concerninglife style modification.•Lack of long term approach to life style modification.•Lack of documentation and systematic follow-up of life style factors•Lack of tradition and practices of group counselling.•Lack of cross-sectional way of working in municipalities.•Strict job descriptions limited cross-sectional work.•FIN-D2D models and practices were seen as project work, notpermanent practice in many health care centers.•Physicians less committed to prevention work than other personnel.•Men less active than women in participating in T2D prevention activities.•Sedentary life style and unhealthy food habits as a counterforce to.prevention67 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 466 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenConclusionsLarge-scale screening and effective life style intervention for preventingT2D are possible in primary health care setting.There are plenty of interfering factors to overcome.Change of paradigm is necessary both in health care organisations andin other sectors of public services.Well-defined protocols for prevention and treatment, and systematicallyorganised professional services are needed.Local network and collaboration, and continuous multidisciplinary lifestyle education and training are prerequisites for success.Attention must be paid to the population strategy. The work mustinvolve the entire community.Politicians and other decision-makers are in a key role to realize theimpact potential of health promotion and prevention of non-communicable diseases.68 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 467 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenAcknowledgements•Pirkanmaa hospital district, health care centers, occupational health careHeikki Oksa, Rauno Ihalainen, Ritva Himanka, Olli A Mäkinen, Anneli Salminen, PirjoAromaa, Scott Yoder•South Ostrobothnia hospital district, health care centers, occupational healthcareEeva Korpi-Hyövälti, Jaakko Pihlajamäki, Arja Hyytiä, Hilpi Linjama, Riitta-Liisa Rekiaro,Elina Leikkainen, Hannu Puolijoki•Northern ostrobothnia hospital district, health care centers, occupationalhealth careSirkka Keinänen-Kiukaanniemi, Hannu Leskinen, Karita Pesonen, Jari Jokelainen, LeeaJärvi, Antero Kesäniemi, Liisa Hiltunen•Central Finland hospital district, health care centers, occupational health careJuha Saltevo, Mauno Vanhala, Timo Kunttu, Kaija Korpela, Jukka Puolakka, lIlkkaKunnamo, Marita Poskiparta, Nina Peränen, Tapani Kiminkinen, Urho Kujala•Northern Savo hospital district, health care centers, occupational health careLeo Niskanen, Matti Uusitupa, Matti Pulkkinen, Mervi Lehmusaho, Leena Moilanen,Annikki Sutinen, Markku Laakso•National Public Health InstituteMarkku Peltonen, Jaakko Tuomilehto, Jaana Lindström, Pekka Puska, Johan Eriksson,Vladislav Moltchanov•Finnish Diabetes AssociationLeena Etu-Seppälä, Jorma Huttunen, Satu Kiuru, Pirjo Ilanne-Parikka, Eliina Aro, EnnaBierganns, Jarmo Riihelä, Maria Aarne, Sari Koski, Tarja Sampo, Outi Himanen, KirsiHeinonen, Liisa Heinonen, Mervi Lyytinen, Juha Mattila•Other actorsJouko Saramies, Aino Myllyluoma, Harri Sintonen Tapani Melkas, Jarno Viikki. Reijo69 16.3K .20ä 15r kkäinen, Noel Barengo, P Pira kas nmi aA a Hr oo spn itae l Dn is, t riV ct i –r Ag uli i n Pöi löa n eM n attila, Robert Hollingsworth– 468 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli PölönenMore informationwww.diabetes.fi/en/finnish_diabetes_association/dehkowww.thl.fi (in English, på svenska, D2D)70 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 469 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Auli Pölönen71 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen– 470 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:55)(cid:75)(cid:72)(cid:3)(cid:37)(cid:54)(cid:51)(cid:38)(cid:3)(cid:58)(cid:82)(cid:85)(cid:78)(cid:76)(cid:81)(cid:74)(cid:3)(cid:42)(cid:85)(cid:82)(cid:88)(cid:83)(cid:3)(cid:82)(cid:81)(cid:3)(cid:44)(cid:81)(cid:81)(cid:82)(cid:89)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:76)(cid:81)(cid:3)(cid:54)(cid:82)(cid:70)(cid:76)(cid:68)(cid:79)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:43)(cid:72)(cid:68)(cid:79)(cid:87)(cid:75)(cid:3)(cid:38)(cid:68)(cid:85)(cid:72)(cid:57)(cid:53)(cid:38)(cid:15)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:15)(cid:3)(cid:20)(cid:26)(cid:3)(cid:48)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:21)(cid:19)(cid:20)(cid:24)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:11)(cid:57)(cid:53)(cid:38)(cid:12)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:55)(cid:85)(cid:76)(cid:68)(cid:79)(cid:3)(cid:49)(cid:72)(cid:87)(cid:90)(cid:82)(cid:85)(cid:78)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:56)(cid:81)(cid:76)(cid:89)(cid:72)(cid:85)(cid:86)(cid:76)(cid:87)(cid:92)(cid:3)(cid:82)(cid:73)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:15)(cid:3)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)(cid:39)(cid:85)(cid:17)(cid:3)(cid:57)(cid:72)(cid:86)(cid:81)(cid:68)(cid:3)(cid:37)(cid:79)(cid:68)(cid:93)(cid:72)(cid:89)(cid:76)(cid:70)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:56)(cid:81)(cid:76)(cid:89)(cid:72)(cid:85)(cid:86)(cid:76)(cid:87)(cid:92)(cid:3)(cid:82)(cid:73)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)– 471 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:68)(cid:81)(cid:71)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:55)(cid:85)(cid:76)(cid:68)(cid:79)(cid:3)(cid:49)(cid:72)(cid:87)(cid:90)(cid:82)(cid:85)(cid:78)(cid:39)(cid:76)(cid:85)(cid:72)(cid:70)(cid:87)(cid:82)(cid:85)(cid:55)(cid:76)(cid:80)(cid:82) (cid:57)(cid:72)(cid:86)(cid:76)(cid:78)(cid:68)(cid:85)(cid:76)(cid:15)(cid:3)(cid:48)(cid:39)(cid:15)(cid:3)(cid:51)(cid:85)(cid:82)(cid:73)(cid:17)(cid:47)(cid:72)(cid:68)(cid:71)(cid:3)(cid:44)(cid:81)(cid:89)(cid:72)(cid:86)(cid:87)(cid:76)(cid:74)(cid:68)(cid:87)(cid:82)(cid:85)(cid:50)(cid:73)(cid:73)(cid:76)(cid:70)(cid:72)(cid:3)(cid:86)(cid:87)(cid:68)(cid:73)(cid:73)(cid:29)(cid:3)(cid:20)(cid:19)(cid:38)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:55)(cid:85)(cid:76)(cid:68)(cid:79)(cid:3)(cid:56)(cid:81)(cid:76)(cid:87) (cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:39)(cid:72)(cid:89)(cid:72)(cid:79)(cid:82)(cid:83)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:56)(cid:81)(cid:76)(cid:87)(cid:43)(cid:72)(cid:68)(cid:71)(cid:29)(cid:3)(cid:36)(cid:76)(cid:81)(cid:82)(cid:3)(cid:41)(cid:82)(cid:85)(cid:86)(cid:87)(cid:112)(cid:81)(cid:15)(cid:3)(cid:48)(cid:39) (cid:43)(cid:72)(cid:68)(cid:71)(cid:29)(cid:3)(cid:57)(cid:72)(cid:86)(cid:81)(cid:68) (cid:37)(cid:79)(cid:68)(cid:93)(cid:72)(cid:89)(cid:76)(cid:70)(cid:15)(cid:3)(cid:51)(cid:75)(cid:17)(cid:39)(cid:17)(cid:54)(cid:87)(cid:68)(cid:73)(cid:73)(cid:29)(cid:3)(cid:25)(cid:19) (cid:54)(cid:87)(cid:68)(cid:73)(cid:73)(cid:29)(cid:3)(cid:20)(cid:22)(cid:90)(cid:90)(cid:90)(cid:17)(cid:85)(cid:82)(cid:78)(cid:82)(cid:87)(cid:72)(cid:87)(cid:88)(cid:87)(cid:78)(cid:76)(cid:80)(cid:88)(cid:86)(cid:17)(cid:73)(cid:76)(cid:48)(cid:68)(cid:76)(cid:81)(cid:3)(cid:82)(cid:73)(cid:73)(cid:76)(cid:70)(cid:72)(cid:37)(cid:76)(cid:82)(cid:78)(cid:68)(cid:87)(cid:88)(cid:3)(cid:20)(cid:19)(cid:22)(cid:22)(cid:24)(cid:21)(cid:19)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:15)(cid:3)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)– 472 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:16) (cid:38)(cid:82)(cid:81)(cid:70)(cid:72)(cid:83)(cid:87)(cid:40)(cid:86)(cid:87)(cid:68)(cid:69)(cid:79)(cid:76)(cid:86)(cid:75)(cid:72)(cid:71)(cid:3)(cid:76)(cid:81)(cid:3)(cid:21)(cid:19)(cid:19)(cid:23)(cid:3)(cid:36)(cid:79)(cid:79)(cid:3)(cid:82)(cid:83)(cid:72)(cid:85)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:76)(cid:81)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:73)(cid:85)(cid:68)(cid:80)(cid:72)(cid:90)(cid:82)(cid:85)(cid:78)(cid:3)(cid:82)(cid:73)(cid:3)(cid:56)(cid:81)(cid:76)(cid:89)(cid:72)(cid:85)(cid:86)(cid:76)(cid:87)(cid:92)(cid:3)(cid:82)(cid:73)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:135) (cid:51)(cid:88)(cid:69)(cid:79)(cid:76)(cid:70)(cid:3)(cid:76)(cid:81)(cid:86)(cid:87)(cid:76)(cid:87)(cid:88)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:69)(cid:88)(cid:87)(cid:3)(cid:81)(cid:82)(cid:87)(cid:3)(cid:70)(cid:82)(cid:81)(cid:81)(cid:72)(cid:70)(cid:87)(cid:72)(cid:71)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:85)(cid:72)(cid:70)(cid:82)(cid:80)(cid:80)(cid:72)(cid:81)(cid:71)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86)(cid:3)(cid:76)(cid:81)(cid:87)(cid:82)(cid:3)(cid:49)(cid:44)(cid:51)(cid:3)(cid:82)(cid:85)(cid:3)(cid:83)(cid:88)(cid:85)(cid:70)(cid:75)(cid:68)(cid:86)(cid:72)(cid:86)(cid:3)(cid:20)(cid:17)(cid:3)(cid:38)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:11)(cid:86)(cid:83)(cid:82)(cid:81)(cid:86)(cid:82)(cid:85)(cid:72)(cid:71)(cid:3)(cid:69)(cid:92)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:76)(cid:81)(cid:71)(cid:88)(cid:86)(cid:87)(cid:85)(cid:92)(cid:12)(cid:135) (cid:48)(cid:72)(cid:71)(cid:76)(cid:70)(cid:68)(cid:79)(cid:79)(cid:92)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:86)(cid:70)(cid:76)(cid:72)(cid:81)(cid:87)(cid:76)(cid:73)(cid:76)(cid:70)(cid:68)(cid:79)(cid:79)(cid:92)(cid:3)(cid:77)(cid:88)(cid:86)(cid:87)(cid:76)(cid:73)(cid:76)(cid:72)(cid:71)(cid:135) (cid:40)(cid:87)(cid:75)(cid:76)(cid:70)(cid:68)(cid:79)(cid:79)(cid:92)(cid:3)(cid:68)(cid:83)(cid:83)(cid:85)(cid:82)(cid:89)(cid:72)(cid:71)(cid:135) (cid:44)(cid:81)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:68)(cid:71)(cid:88)(cid:79)(cid:87)(cid:86)(cid:135) (cid:20)(cid:20)(cid:3)(cid:86)(cid:87)(cid:88)(cid:71)(cid:92)(cid:3)(cid:70)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:86)(cid:3)(cid:11)(cid:43)(cid:72)(cid:79)(cid:86)(cid:76)(cid:81)(cid:78)(cid:76)(cid:16)(cid:50)(cid:88)(cid:79)(cid:88)(cid:12)(cid:21)(cid:17) (cid:37)(cid:68)(cid:86)(cid:76)(cid:70)(cid:3)(cid:11)(cid:68)(cid:70)(cid:68)(cid:71)(cid:72)(cid:80)(cid:76)(cid:70)(cid:12)(cid:3)(cid:85)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:135) (cid:48)(cid:68)(cid:76)(cid:81)(cid:3)(cid:87)(cid:68)(cid:85)(cid:74)(cid:72)(cid:87)(cid:3)(cid:71)(cid:72)(cid:89)(cid:72)(cid:79)(cid:82)(cid:83)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:82)(cid:73)(cid:3)(cid:81)(cid:82)(cid:81)(cid:16)(cid:79)(cid:76)(cid:89)(cid:72)(cid:3)(cid:81)(cid:82)(cid:85)(cid:82)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:16)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:135) (cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:79)(cid:68)(cid:69)(cid:82)(cid:85)(cid:68)(cid:87)(cid:82)(cid:85)(cid:92)(cid:3)(cid:11)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:12)– 473 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:38)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:3)(cid:83)(cid:75)(cid:68)(cid:86)(cid:72)(cid:86)(cid:3)(cid:82)(cid:73)(cid:3)(cid:68)(cid:3)(cid:81)(cid:72)(cid:90)(cid:3)(cid:70)(cid:68)(cid:81)(cid:71)(cid:76)(cid:71)(cid:68)(cid:87)(cid:72)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:51)(cid:75)(cid:68)(cid:86)(cid:72)(cid:3)(cid:44)(cid:3)(cid:11)(cid:86)(cid:68)(cid:73)(cid:72)(cid:87)(cid:92)(cid:12)(cid:16) (cid:75)(cid:72)(cid:68)(cid:79)(cid:87)(cid:75)(cid:92)(cid:3)(cid:68)(cid:71)(cid:88)(cid:79)(cid:87)(cid:3)(cid:89)(cid:82)(cid:79)(cid:88)(cid:81)(cid:87)(cid:72)(cid:72)(cid:85)(cid:86)(cid:51)(cid:75)(cid:68)(cid:86)(cid:72)(cid:3)(cid:44)(cid:44)(cid:3)(cid:11)(cid:86)(cid:68)(cid:73)(cid:72)(cid:87)(cid:92)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:76)(cid:80)(cid:80)(cid:88)(cid:81)(cid:82)(cid:74)(cid:72)(cid:81)(cid:76)(cid:70)(cid:76)(cid:87)(cid:92)(cid:12)(cid:16) (cid:68)(cid:71)(cid:88)(cid:79)(cid:87)(cid:86)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:51)(cid:75)(cid:68)(cid:86)(cid:72)(cid:3)(cid:44)(cid:44)(cid:44)(cid:3)(cid:11)(cid:86)(cid:68)(cid:73)(cid:72)(cid:87)(cid:92)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:72)(cid:73)(cid:73)(cid:76)(cid:70)(cid:68)(cid:70)(cid:92)(cid:12)(cid:16) (cid:72)(cid:73)(cid:73)(cid:76)(cid:70)(cid:68)(cid:70)(cid:92)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:68)(cid:71)(cid:88)(cid:79)(cid:87)(cid:86)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:51)(cid:75)(cid:68)(cid:86)(cid:72)(cid:3)(cid:44)(cid:57)(cid:3)(cid:11)(cid:85)(cid:72)(cid:68)(cid:79)(cid:16)(cid:79)(cid:76)(cid:73)(cid:72)(cid:3)(cid:72)(cid:73)(cid:73)(cid:72)(cid:70)(cid:87)(cid:76)(cid:89)(cid:72)(cid:81)(cid:72)(cid:86)(cid:86)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:86)(cid:68)(cid:73)(cid:72)(cid:87)(cid:92)(cid:12)(cid:16) (cid:83)(cid:82)(cid:86)(cid:87)(cid:79)(cid:76)(cid:70)(cid:72)(cid:81)(cid:86)(cid:88)(cid:85)(cid:72) (cid:86)(cid:87)(cid:88)(cid:71)(cid:76)(cid:72)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:87)(cid:68)(cid:85)(cid:74)(cid:72)(cid:87)(cid:3)(cid:74)(cid:85)(cid:82)(cid:88)(cid:83)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:71)(cid:82)(cid:72)(cid:86)(cid:3)(cid:86)(cid:87)(cid:88)(cid:71)(cid:76)(cid:72)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:68)(cid:79)(cid:79)(cid:3)(cid:83)(cid:75)(cid:68)(cid:86)(cid:72)(cid:86)– 474 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:38)(cid:82)(cid:79)(cid:79)(cid:68)(cid:69)(cid:82)(cid:85)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:44)(cid:81)(cid:71)(cid:88)(cid:86)(cid:87)(cid:85)(cid:92)(cid:3)(cid:11)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:80)(cid:68)(cid:81)(cid:88)(cid:73)(cid:68)(cid:70)(cid:87)(cid:88)(cid:85)(cid:72)(cid:85)(cid:86)(cid:12)– 475 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:68)(cid:87)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:57)(cid:53)(cid:38)(cid:82) (cid:53)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:48)(cid:48)(cid:53)(cid:16)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:61)(cid:82)(cid:86)(cid:87)(cid:72)(cid:85) (cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:43)(cid:72)(cid:83)(cid:68)(cid:87)(cid:76)(cid:87)(cid:76)(cid:86) (cid:37)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:43)(cid:51)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:51)(cid:81)(cid:72)(cid:88)(cid:80)(cid:82)(cid:70)(cid:82)(cid:70)(cid:70)(cid:68)(cid:79) (cid:70)(cid:82)(cid:81)(cid:77)(cid:88)(cid:74)(cid:68)(cid:87)(cid:72) (cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:48)(cid:72)(cid:81)(cid:76)(cid:81)(cid:74)(cid:82)(cid:70)(cid:82)(cid:70)(cid:70)(cid:68)(cid:79) (cid:70)(cid:82)(cid:81)(cid:77)(cid:88)(cid:74)(cid:68)(cid:87)(cid:72) (cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:48)(cid:72)(cid:81)(cid:76)(cid:81)(cid:74)(cid:82)(cid:70)(cid:82)(cid:70)(cid:70)(cid:68)(cid:79)(cid:3)(cid:37)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:54)(cid:72)(cid:68)(cid:86)(cid:82)(cid:81)(cid:68)(cid:79)(cid:3)(cid:76)(cid:81)(cid:73)(cid:79)(cid:88)(cid:72)(cid:81)(cid:93)(cid:68)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:51)(cid:68)(cid:81)(cid:71)(cid:72)(cid:80)(cid:76)(cid:70)(cid:3)(cid:43)(cid:20)(cid:49)(cid:20)(cid:3)(cid:76)(cid:81)(cid:73)(cid:79)(cid:88)(cid:72)(cid:81)(cid:93)(cid:68)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:82) (cid:51)(cid:85)(cid:72)(cid:83)(cid:68)(cid:81)(cid:71)(cid:72)(cid:80)(cid:76)(cid:70) (cid:43)(cid:24)(cid:49)(cid:20)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:51)(cid:72)(cid:71)(cid:76)(cid:68)(cid:87)(cid:85)(cid:76)(cid:70) (cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81) (cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:82) (cid:38)(cid:17)(cid:71)(cid:76)(cid:73)(cid:73)(cid:76)(cid:70)(cid:76)(cid:79)(cid:72) (cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:16)(cid:70)(cid:82)(cid:81)(cid:71)(cid:68)(cid:70)(cid:87)(cid:72)(cid:71) (cid:33)(cid:27)(cid:19)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72) (cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)– 476 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:49)(cid:88)(cid:80)(cid:69)(cid:72)(cid:85)(cid:3)(cid:82)(cid:73)(cid:3)(cid:86)(cid:87)(cid:88)(cid:71)(cid:92)(cid:3)(cid:83)(cid:85)(cid:82)(cid:87)(cid:82)(cid:70)(cid:82)(cid:79)(cid:86)(cid:3)(cid:83)(cid:72)(cid:85)(cid:3)(cid:92)(cid:72)(cid:68)(cid:85)– 477 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:54)(cid:88)(cid:80)(cid:80)(cid:68)(cid:85)(cid:92)(cid:3)(cid:82)(cid:73)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:68)(cid:87)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:57)(cid:53)(cid:38)(cid:38)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:75)(cid:68)(cid:89)(cid:72)(cid:3)(cid:69)(cid:72)(cid:72)(cid:81)(cid:3)(cid:68)(cid:3)(cid:86)(cid:88)(cid:70)(cid:70)(cid:72)(cid:86)(cid:86)(cid:73)(cid:88)(cid:79)(cid:3)(cid:82)(cid:83)(cid:72)(cid:85)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:76)(cid:81)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:56)(cid:81)(cid:76)(cid:89)(cid:72)(cid:85)(cid:86)(cid:76)(cid:87)(cid:92)(cid:3)(cid:73)(cid:85)(cid:68)(cid:80)(cid:72)(cid:90)(cid:82)(cid:85)(cid:78)(cid:54)(cid:88)(cid:70)(cid:70)(cid:72)(cid:86)(cid:86)(cid:3)(cid:86)(cid:70)(cid:76)(cid:72)(cid:81)(cid:87)(cid:76)(cid:73)(cid:76)(cid:70)(cid:68)(cid:79)(cid:79)(cid:92)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:73)(cid:76)(cid:81)(cid:68)(cid:81)(cid:70)(cid:76)(cid:68)(cid:79)(cid:79)(cid:92)(cid:135)(cid:26)(cid:19)(cid:177)(cid:20)(cid:19)(cid:19)(cid:3)(cid:83)(cid:72)(cid:85)(cid:86)(cid:82)(cid:81)(cid:86)(cid:3)(cid:72)(cid:80)(cid:83)(cid:79)(cid:82)(cid:92)(cid:72)(cid:71)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:20)(cid:24)(cid:3)(cid:92)(cid:72)(cid:68)(cid:85)(cid:86)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:75)(cid:68)(cid:86)(cid:3)(cid:80)(cid:68)(cid:71)(cid:72)(cid:3)(cid:86)(cid:76)(cid:74)(cid:81)(cid:76)(cid:73)(cid:76)(cid:70)(cid:68)(cid:81)(cid:87)(cid:3)(cid:70)(cid:82)(cid:81)(cid:87)(cid:85)(cid:76)(cid:69)(cid:88)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86)(cid:3)(cid:87)(cid:82)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:79)(cid:76)(cid:70)(cid:72)(cid:81)(cid:86)(cid:88)(cid:85)(cid:72)(cid:3)(cid:82)(cid:73)(cid:3)(cid:86)(cid:72)(cid:89)(cid:72)(cid:85)(cid:68)(cid:79)(cid:3)(cid:76)(cid:80)(cid:83)(cid:82)(cid:85)(cid:87)(cid:68)(cid:81)(cid:87)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:29)(cid:135)(cid:47)(cid:76)(cid:89)(cid:72)(cid:3)(cid:82)(cid:85)(cid:68)(cid:79)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:135)(cid:47)(cid:76)(cid:89)(cid:72)(cid:3)(cid:76)(cid:81)(cid:87)(cid:85)(cid:68)(cid:81)(cid:68)(cid:86)(cid:68)(cid:79)(cid:3)(cid:76)(cid:81)(cid:73)(cid:79)(cid:88)(cid:72)(cid:81)(cid:93)(cid:68)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:135)(cid:48)(cid:72)(cid:81)(cid:76)(cid:81)(cid:74)(cid:82)(cid:70)(cid:82)(cid:70)(cid:70)(cid:68)(cid:79)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)– 478 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:47)(cid:76)(cid:89)(cid:72)(cid:3)(cid:82)(cid:85)(cid:68)(cid:79)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:3)(cid:55)(cid:90)(cid:82)(cid:3)(cid:79)(cid:76)(cid:89)(cid:72)(cid:3)(cid:82)(cid:85)(cid:68)(cid:79)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:3)(cid:79)(cid:76)(cid:70)(cid:72)(cid:81)(cid:86)(cid:72)(cid:71)(cid:3)(cid:76)(cid:81)(cid:3)(cid:21)(cid:19)(cid:19)(cid:25)(cid:53)(cid:82)(cid:87)(cid:68)(cid:85)(cid:76)(cid:91)(cid:140)(cid:3)(cid:11)(cid:42)(cid:54)(cid:46)(cid:12)(cid:30)(cid:3)(cid:179)(cid:53)(cid:57)(cid:20)(cid:180)(cid:47)(cid:76)(cid:89)(cid:72)(cid:3)(cid:68)(cid:87)(cid:87)(cid:72)(cid:81)(cid:88)(cid:68)(cid:87)(cid:72)(cid:71)(cid:3)(cid:75)(cid:88)(cid:80)(cid:68)(cid:81)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:11)(cid:73)(cid:76)(cid:85)(cid:86)(cid:87)(cid:3)(cid:70)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:71)(cid:82)(cid:81)(cid:72)(cid:3)(cid:76)(cid:81)(cid:3)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)(cid:12)(cid:53)(cid:82)(cid:87)(cid:68)(cid:55)(cid:72)(cid:84)(cid:140)(cid:3)(cid:11)(cid:54)(cid:51)(cid:3)(cid:48)(cid:54)(cid:39)(cid:12)(cid:30)(cid:3)(cid:179)(cid:53)(cid:57)(cid:24)(cid:180)(cid:37)(cid:82)(cid:89)(cid:76)(cid:81)(cid:72)(cid:16)(cid:75)(cid:88)(cid:80)(cid:68)(cid:81)(cid:3)(cid:85)(cid:72)(cid:68)(cid:86)(cid:86)(cid:82)(cid:85)(cid:87)(cid:68)(cid:81)(cid:87)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:40)(cid:81)(cid:85)(cid:82)(cid:79)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:76)(cid:81)(cid:3)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)(cid:3)(cid:21)(cid:22)(cid:17)(cid:23)(cid:21)(cid:28)(cid:47)(cid:76)(cid:89)(cid:72)(cid:3)(cid:53)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:3)(cid:75)(cid:68)(cid:89)(cid:72)(cid:3)(cid:86)(cid:75)(cid:82)(cid:90)(cid:81)(cid:3)(cid:87)(cid:75)(cid:68)(cid:87)(cid:3)(cid:53)(cid:57)(cid:3)(cid:74)(cid:68)(cid:86)(cid:87)(cid:85)(cid:82)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:76)(cid:87)(cid:76)(cid:86)(cid:3)(cid:70)(cid:68)(cid:81)(cid:3)(cid:69)(cid:72)(cid:3)(cid:83)(cid:85)(cid:72)(cid:89)(cid:72)(cid:81)(cid:87)(cid:72)(cid:71)(cid:3)(cid:69)(cid:92)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)– 479 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:68)(cid:81)(cid:71)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:55)(cid:85)(cid:76)(cid:68)(cid:79)(cid:3)(cid:49)(cid:72)(cid:87)(cid:90)(cid:82)(cid:85)(cid:78)(cid:53)(cid:72)(cid:70)(cid:72)(cid:81)(cid:87)(cid:3)(cid:70)(cid:75)(cid:68)(cid:79)(cid:79)(cid:72)(cid:81)(cid:74)(cid:72)(cid:86)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:3)(cid:69)(cid:72)(cid:76)(cid:81)(cid:74)(cid:3)(cid:70)(cid:82)(cid:81)(cid:71)(cid:88)(cid:70)(cid:87)(cid:72)(cid:71)(cid:3)(cid:80)(cid:82)(cid:85)(cid:72)(cid:3)(cid:76)(cid:81)(cid:87)(cid:72)(cid:85)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:68)(cid:79)(cid:79)(cid:92)(cid:15)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:86)(cid:75)(cid:68)(cid:85)(cid:72)(cid:3)(cid:82)(cid:73)(cid:3)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)(cid:3)(cid:69)(cid:72)(cid:70)(cid:82)(cid:80)(cid:76)(cid:81)(cid:74)(cid:3)(cid:86)(cid:80)(cid:68)(cid:79)(cid:79)(cid:72)(cid:85)(cid:135) (cid:49)(cid:36)(cid:53)(cid:38)(cid:50)(cid:47)(cid:40)(cid:51)(cid:54)(cid:60)(cid:3)(cid:70)(cid:68)(cid:86)(cid:72)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:41)(cid:76)(cid:81)(cid:79)(cid:68)(cid:81)(cid:71)(cid:3)(cid:68)(cid:73)(cid:87)(cid:72)(cid:85)(cid:3)(cid:83)(cid:68)(cid:81)(cid:71)(cid:72)(cid:80)(cid:76)(cid:70)(cid:3)(cid:76)(cid:81)(cid:73)(cid:79)(cid:88)(cid:72)(cid:81)(cid:93)(cid:68)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:43)(cid:20)(cid:49)(cid:20)(cid:3)(cid:11)(cid:51)(cid:68)(cid:81)(cid:71)(cid:72)(cid:80)(cid:85)(cid:76)(cid:91)(cid:138)(cid:12)(cid:3)(cid:85)(cid:72)(cid:71)(cid:88)(cid:70)(cid:76)(cid:81)(cid:74)(cid:3)(cid:85)(cid:72)(cid:70)(cid:85)(cid:88)(cid:76)(cid:87)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:76)(cid:81)(cid:87)(cid:82)(cid:3)(cid:68)(cid:79)(cid:79)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:87)(cid:85)(cid:76)(cid:68)(cid:79)(cid:86)(cid:48)(cid:50)(cid:53)(cid:40)(cid:3)(cid:44)(cid:49)(cid:41)(cid:50)(cid:53)(cid:48)(cid:36)(cid:55)(cid:44)(cid:50)(cid:49)(cid:3)(cid:36)(cid:49)(cid:39)(cid:3)(cid:38)(cid:50)(cid:49)(cid:41)(cid:44)(cid:39)(cid:40)(cid:49)(cid:38)(cid:40)(cid:3)(cid:37)(cid:56)(cid:44)(cid:47)(cid:39)(cid:44)(cid:49)(cid:42)(cid:29)(cid:3)(cid:58)(cid:72)(cid:69)(cid:3)(cid:83)(cid:68)(cid:74)(cid:72)(cid:15)(cid:3)(cid:69)(cid:85)(cid:82)(cid:70)(cid:75)(cid:88)(cid:85)(cid:72)(cid:86)(cid:15)(cid:3)(cid:41)(cid:68)(cid:70)(cid:72)(cid:69)(cid:82)(cid:82)(cid:78)– 480 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:71)(cid:72)(cid:89)(cid:72)(cid:79)(cid:82)(cid:83)(cid:80)(cid:72)(cid:81)(cid:87)(cid:29)(cid:3)(cid:38)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:72)(cid:71)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:68)(cid:74)(cid:68)(cid:76)(cid:81)(cid:86)(cid:87)(cid:3)(cid:81)(cid:82)(cid:85)(cid:82)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:11)(cid:49)(cid:82)(cid:57)(cid:12)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:11)(cid:53)(cid:57)(cid:12)(cid:3)(cid:50)(cid:85)(cid:76)(cid:74)(cid:76)(cid:81)(cid:68)(cid:79)(cid:3)(cid:70)(cid:82)(cid:81)(cid:70)(cid:72)(cid:83)(cid:87)(cid:15)(cid:3)(cid:86)(cid:76)(cid:81)(cid:70)(cid:72)(cid:3)(cid:21)(cid:19)(cid:19)(cid:28)(cid:29)(cid:16)(cid:57)(cid:51)(cid:25)(cid:3)(cid:69)(cid:68)(cid:86)(cid:72)(cid:71)(cid:3)(cid:75)(cid:72)(cid:87)(cid:72)(cid:85)(cid:82)(cid:79)(cid:82)(cid:74)(cid:82)(cid:88)(cid:86)(cid:3)(cid:83)(cid:85)(cid:82)(cid:87)(cid:72)(cid:70)(cid:87)(cid:76)(cid:89)(cid:72)(cid:3)(cid:76)(cid:80)(cid:80)(cid:88)(cid:81)(cid:76)(cid:87)(cid:92)(cid:16)(cid:75)(cid:92)(cid:83)(cid:82)(cid:87)(cid:75)(cid:72)(cid:86)(cid:76)(cid:86)(cid:3)(cid:87)(cid:75)(cid:68)(cid:87)(cid:3)(cid:57)(cid:51)(cid:25)(cid:3)(cid:68)(cid:70)(cid:87)(cid:86)(cid:3)(cid:68)(cid:86)(cid:3)(cid:68)(cid:81)(cid:3)(cid:68)(cid:71)(cid:77)(cid:88)(cid:89)(cid:68)(cid:81)(cid:87)(cid:3)(cid:87)(cid:82)(cid:3)(cid:49)(cid:82)(cid:57)(cid:3)(cid:57)(cid:47)(cid:51)(cid:182)(cid:86)(cid:49)(cid:82)(cid:81)(cid:16)(cid:79)(cid:76)(cid:89)(cid:72)(cid:3)(cid:85)(cid:72)(cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:68)(cid:81)(cid:87)(cid:3)(cid:86)(cid:88)(cid:69)(cid:88)(cid:81)(cid:76)(cid:87)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:16)(cid:33)(cid:3)(cid:49)(cid:82)(cid:57)(cid:3)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:79)(cid:76)(cid:78)(cid:72)(cid:16)(cid:83)(cid:68)(cid:85)(cid:87)(cid:76)(cid:70)(cid:79)(cid:72)(cid:86)(cid:3)(cid:11)(cid:57)(cid:47)(cid:51)(cid:86)(cid:12)(cid:3)(cid:14)(cid:3)(cid:53)(cid:57)(cid:3)(cid:57)(cid:51)(cid:25)(cid:49)(cid:82)(cid:57)(cid:3)(cid:42)(cid:44)(cid:44)(cid:16)(cid:23)(cid:3)(cid:57)(cid:47)(cid:51)(cid:86)(cid:53)(cid:57)(cid:3)(cid:85)(cid:57)(cid:51)(cid:25)(cid:49)(cid:82)(cid:57)(cid:3)(cid:42)(cid:44)(cid:16)(cid:22)(cid:3)(cid:53)(cid:72)(cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:68)(cid:81)(cid:87)(cid:3) (cid:57)(cid:47)(cid:51)(cid:86)(cid:37)(cid:57)(cid:72)(cid:91)(cid:83)(cid:85)(cid:72)(cid:86)(cid:86)(cid:76)(cid:82)(cid:81)(cid:86)(cid:92)(cid:86)(cid:87)(cid:72)(cid:80)(cid:53)(cid:57)(cid:3)(cid:57)(cid:51)(cid:25)– 481 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:53)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:68)(cid:79)(cid:72)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:68)(cid:3)(cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:72)(cid:71)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:68)(cid:74)(cid:68)(cid:76)(cid:81)(cid:86)(cid:87)(cid:3)(cid:49)(cid:82)(cid:57) (cid:68)(cid:81)(cid:71)(cid:3)(cid:53)(cid:57)(cid:3)(cid:74)(cid:68)(cid:86)(cid:87)(cid:85)(cid:82)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:76)(cid:87)(cid:76)(cid:86)(cid:3)(cid:11)(cid:42)(cid:40)(cid:12)(cid:3)(cid:135) (cid:55)(cid:90)(cid:82)(cid:3)(cid:80)(cid:82)(cid:86)(cid:87)(cid:3)(cid:76)(cid:80)(cid:83)(cid:82)(cid:85)(cid:87)(cid:68)(cid:81)(cid:87)(cid:3)(cid:70)(cid:68)(cid:88)(cid:86)(cid:68)(cid:87)(cid:76)(cid:89)(cid:72)(cid:3)(cid:68)(cid:74)(cid:72)(cid:81)(cid:87)(cid:86)(cid:3)(cid:82)(cid:73)(cid:3)(cid:68)(cid:70)(cid:88)(cid:87)(cid:72)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:75)(cid:82)(cid:82)(cid:71)(cid:3)(cid:42)(cid:40)(cid:3)(cid:74)(cid:79)(cid:82)(cid:69)(cid:68)(cid:79)(cid:79)(cid:92)(cid:135) (cid:36)(cid:81)(cid:81)(cid:88)(cid:68)(cid:79)(cid:3)(cid:71)(cid:72)(cid:68)(cid:87)(cid:75)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:3)(cid:31)(cid:24)(cid:92)(cid:29)(cid:3)(cid:23)(cid:24)(cid:19)(cid:17)(cid:19)(cid:19)(cid:19)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:53)(cid:57)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:21)(cid:19)(cid:19)(cid:17)(cid:19)(cid:19)(cid:19)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:49)(cid:82)(cid:57)(cid:135) (cid:54)(cid:68)(cid:80)(cid:72)(cid:3)(cid:87)(cid:68)(cid:85)(cid:74)(cid:72)(cid:87)(cid:3)(cid:68)(cid:74)(cid:72)(cid:3)(cid:74)(cid:85)(cid:82)(cid:88)(cid:83)(cid:3)(cid:73)(cid:85)(cid:82)(cid:80)(cid:3)(cid:31)(cid:25)(cid:3)(cid:80)(cid:82)(cid:81)(cid:87)(cid:75)(cid:86)(cid:3)(cid:87)(cid:82)(cid:3)(cid:24)(cid:3)(cid:92)(cid:72)(cid:68)(cid:85)(cid:86)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:69)(cid:82)(cid:87)(cid:75)(cid:3)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:72)(cid:86)(cid:135) (cid:36)(cid:81)(cid:3)(cid:72)(cid:73)(cid:73)(cid:72)(cid:70)(cid:87)(cid:76)(cid:89)(cid:72)(cid:3)(cid:49)(cid:82)(cid:57)(cid:3)(cid:14)(cid:3)(cid:53)(cid:57)(cid:3)(cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:90)(cid:82)(cid:88)(cid:79)(cid:71)(cid:3)(cid:72)(cid:79)(cid:76)(cid:80)(cid:76)(cid:81)(cid:68)(cid:87)(cid:72)(cid:3)(cid:80)(cid:82)(cid:86)(cid:87)(cid:3)(cid:82)(cid:73)(cid:3)(cid:86)(cid:72)(cid:89)(cid:72)(cid:85)(cid:72)(cid:3)(cid:68)(cid:70)(cid:88)(cid:87)(cid:72)(cid:3)(cid:42)(cid:40)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:3)(cid:76)(cid:81)(cid:3)(cid:71)(cid:72)(cid:89)(cid:72)(cid:79)(cid:82)(cid:83)(cid:72)(cid:71)(cid:3)(cid:70)(cid:82)(cid:88)(cid:81)(cid:87)(cid:85)(cid:76)(cid:72)(cid:86)(cid:135) (cid:49)(cid:82)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:68)(cid:89)(cid:68)(cid:76)(cid:79)(cid:68)(cid:69)(cid:79)(cid:72)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:49)(cid:82)(cid:57)(cid:3)(cid:11)(cid:70)(cid:82)(cid:81)(cid:86)(cid:87)(cid:85)(cid:68)(cid:76)(cid:81)(cid:29)(cid:3)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:71)(cid:82)(cid:72)(cid:86)(cid:3)(cid:81)(cid:82)(cid:87)(cid:3)(cid:74)(cid:85)(cid:82)(cid:90)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:72)(cid:79)(cid:79)(cid:3)(cid:70)(cid:88)(cid:79)(cid:87)(cid:88)(cid:85)(cid:72)(cid:12)(cid:135) (cid:47)(cid:76)(cid:89)(cid:72)(cid:3)(cid:82)(cid:85)(cid:68)(cid:79)(cid:3)(cid:53)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:3)(cid:72)(cid:91)(cid:76)(cid:86)(cid:87)(cid:16)(cid:33)(cid:3)(cid:81)(cid:82)(cid:81)(cid:16)(cid:79)(cid:76)(cid:89)(cid:72)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:86)(cid:3)(cid:68)(cid:85)(cid:72)(cid:3)(cid:69)(cid:72)(cid:76)(cid:81)(cid:74)(cid:3)(cid:70)(cid:82)(cid:81)(cid:86)(cid:76)(cid:71)(cid:72)(cid:85)(cid:72)(cid:71)(cid:3)(cid:11)(cid:83)(cid:82)(cid:82)(cid:85)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:72)(cid:73)(cid:73)(cid:76)(cid:70)(cid:68)(cid:70)(cid:92)(cid:3)(cid:76)(cid:81)(cid:3)(cid:71)(cid:72)(cid:89)(cid:72)(cid:79)(cid:82)(cid:83)(cid:76)(cid:81)(cid:74)(cid:3)(cid:70)(cid:82)(cid:88)(cid:81)(cid:87)(cid:85)(cid:76)(cid:72)(cid:86)(cid:12)(cid:38)(cid:82)(cid:81)(cid:73)(cid:76)(cid:71)(cid:72)(cid:81)(cid:87)(cid:76)(cid:68)(cid:79) (cid:20)(cid:21)– 482 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:49)(cid:82)(cid:85)(cid:82)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:74)(cid:68)(cid:86)(cid:87)(cid:85)(cid:82)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:76)(cid:87)(cid:76)(cid:86)(cid:20)(cid:17) (cid:40)(cid:81)(cid:71)(cid:72)(cid:80)(cid:76)(cid:70)(cid:3)(cid:11)(cid:179)(cid:86)(cid:83)(cid:82)(cid:85)(cid:68)(cid:71)(cid:76)(cid:70)(cid:180)(cid:12)(cid:3)(cid:49)(cid:82)(cid:57) (cid:42)(cid:40)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:21)(cid:17) (cid:55)(cid:75)(cid:72)(cid:3)(cid:79)(cid:72)(cid:68)(cid:71)(cid:76)(cid:81)(cid:74)(cid:3)(cid:70)(cid:68)(cid:88)(cid:86)(cid:72)(cid:3)(cid:82)(cid:73)(cid:3)(cid:73)(cid:82)(cid:82)(cid:71)(cid:16) (cid:68)(cid:81)(cid:71)(cid:3)(cid:90)(cid:68)(cid:87)(cid:72)(cid:85)(cid:16)(cid:69)(cid:82)(cid:85)(cid:81)(cid:72)(cid:3)(cid:82)(cid:88)(cid:87)(cid:69)(cid:85)(cid:72)(cid:68)(cid:78)(cid:3)(cid:85)(cid:72)(cid:79)(cid:68)(cid:87)(cid:72)(cid:71)(cid:3)(cid:49)(cid:82)(cid:57) (cid:42)(cid:40)(cid:3)(cid:76)(cid:81)(cid:3)(cid:68)(cid:79)(cid:79)(cid:3)(cid:68)(cid:74)(cid:72)(cid:3)(cid:74)(cid:85)(cid:82)(cid:88)(cid:83)(cid:86)(cid:16) (cid:80)(cid:76)(cid:79)(cid:76)(cid:87)(cid:68)(cid:85)(cid:92)(cid:16) (cid:70)(cid:85)(cid:88)(cid:76)(cid:86)(cid:72)(cid:3)(cid:86)(cid:75)(cid:76)(cid:83)(cid:86)(cid:16) (cid:86)(cid:70)(cid:75)(cid:82)(cid:82)(cid:79)(cid:86)(cid:16) (cid:87)(cid:75)(cid:72)(cid:3)(cid:72)(cid:79)(cid:71)(cid:72)(cid:85)(cid:79)(cid:92)(cid:3)(cid:76)(cid:81)(cid:3)(cid:81)(cid:88)(cid:85)(cid:86)(cid:76)(cid:81)(cid:74)(cid:3)(cid:75)(cid:82)(cid:80)(cid:72)(cid:86)(cid:55)(cid:75)(cid:72)(cid:3)(cid:86)(cid:68)(cid:80)(cid:72)(cid:3)(cid:68)(cid:85)(cid:72)(cid:3)(cid:83)(cid:82)(cid:87)(cid:72)(cid:81)(cid:87)(cid:76)(cid:68)(cid:79)(cid:3)(cid:87)(cid:68)(cid:85)(cid:74)(cid:72)(cid:87)(cid:86)(cid:3)(cid:82)(cid:73)(cid:3)(cid:49)(cid:82)(cid:57) (cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)– 483 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:49)(cid:82)(cid:85)(cid:82)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:74)(cid:68)(cid:86)(cid:87)(cid:85)(cid:82)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:76)(cid:87)(cid:76)(cid:86)(cid:3)(cid:76)(cid:81)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:3)(cid:56)(cid:81)(cid:76)(cid:89)(cid:72)(cid:85)(cid:86)(cid:76)(cid:87)(cid:92)(cid:3)(cid:43)(cid:82)(cid:86)(cid:83)(cid:76)(cid:87)(cid:68)(cid:79)(cid:53)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:76)(cid:81)(cid:3)(cid:49)(cid:44)(cid:51)(cid:21)(cid:19)(cid:19)(cid:25)(cid:177)(cid:21)(cid:19)(cid:19)(cid:27) (cid:21)(cid:19)(cid:19)(cid:28)(cid:177)(cid:21)(cid:19)(cid:20)(cid:20) (cid:21)(cid:19)(cid:20)(cid:21)(cid:177)(cid:21)(cid:19)(cid:20)(cid:23)(cid:21)(cid:23)(cid:8) (cid:22)(cid:23)(cid:8)(cid:3) (cid:21)(cid:26)(cid:8)(cid:3)(cid:198) (cid:49)(cid:82)(cid:85)(cid:82)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:75)(cid:68)(cid:86) (cid:69)(cid:72)(cid:70)(cid:68)(cid:80)(cid:72) (cid:87)(cid:75)(cid:72) (cid:79)(cid:72)(cid:68)(cid:71)(cid:76)(cid:81)(cid:74) (cid:70)(cid:68)(cid:88)(cid:86)(cid:72) (cid:82)(cid:73)(cid:3)(cid:36)(cid:42)(cid:40)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:43)(cid:72)(cid:80)(cid:80)(cid:76)(cid:81)(cid:74)(cid:3)(cid:72)(cid:87)(cid:3)(cid:68)(cid:79)(cid:17)(cid:3)(cid:21)(cid:19)(cid:20)(cid:23)(cid:86)(cid:72)(cid:72)(cid:81) (cid:76)(cid:81)(cid:3)(cid:75)(cid:82)(cid:86)(cid:83)(cid:76)(cid:87)(cid:68)(cid:79)– 484 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:36)(cid:83)(cid:83)(cid:79)(cid:76)(cid:70)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86)(cid:3)(cid:82)(cid:73)(cid:3)(cid:68)(cid:3)(cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:72)(cid:71)(cid:3)(cid:49)(cid:82)(cid:57)(cid:16)(cid:53)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:76)(cid:81)(cid:3)(cid:70)(cid:75)(cid:76)(cid:79)(cid:71)(cid:85)(cid:72)(cid:81)(cid:137) (cid:41)(cid:82)(cid:85)(cid:3)(cid:76)(cid:81)(cid:73)(cid:68)(cid:81)(cid:87)(cid:86)(cid:135) (cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86) (cid:69)(cid:72)(cid:73)(cid:82)(cid:85)(cid:72) (cid:87)(cid:75)(cid:72)(cid:3)(cid:68)(cid:74)(cid:72) (cid:82)(cid:73)(cid:3)(cid:25)(cid:3)(cid:80)(cid:82)(cid:81)(cid:87)(cid:75)(cid:86) (cid:68)(cid:81)(cid:71)(cid:3)(cid:68)(cid:87)(cid:3)(cid:20)(cid:21)(cid:3)(cid:80)(cid:82)(cid:81)(cid:87)(cid:75)(cid:86)(cid:190) (cid:51)(cid:85)(cid:76)(cid:80)(cid:68)(cid:85)(cid:92) (cid:68)(cid:81)(cid:71)(cid:3)(cid:69)(cid:82)(cid:82)(cid:86)(cid:87)(cid:72)(cid:85) (cid:76)(cid:80)(cid:80)(cid:88)(cid:81)(cid:76)(cid:93)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81) (cid:73)(cid:82)(cid:85)(cid:3)(cid:69)(cid:82)(cid:87)(cid:75) (cid:53)(cid:57)(cid:3)(cid:42)(cid:40)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:49)(cid:82)(cid:57) (cid:42)(cid:40)(cid:137) (cid:41)(cid:82)(cid:85)(cid:3)(cid:87)(cid:82)(cid:71)(cid:71)(cid:79)(cid:72)(cid:85)(cid:86)(cid:3)(cid:11)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:72)(cid:71)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:79)(cid:76)(cid:89)(cid:72)(cid:3)(cid:82)(cid:85)(cid:68)(cid:79)(cid:3)(cid:53)(cid:57)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:68)(cid:70)(cid:70)(cid:82)(cid:85)(cid:71)(cid:76)(cid:81)(cid:74)(cid:3)(cid:87)(cid:82)(cid:3)(cid:49)(cid:44)(cid:51)(cid:12)(cid:135) (cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86)(cid:3)(cid:68)(cid:87)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:68)(cid:74)(cid:72)(cid:3)(cid:20)(cid:21)(cid:16)(cid:20)(cid:27)(cid:3)(cid:80)(cid:82)(cid:81)(cid:87)(cid:75)(cid:86)(cid:190) (cid:51)(cid:85)(cid:76)(cid:80)(cid:68)(cid:85)(cid:92)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:68)(cid:74)(cid:68)(cid:76)(cid:81)(cid:86)(cid:87)(cid:3)(cid:49)(cid:82)(cid:57) (cid:42)(cid:40)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:69)(cid:82)(cid:82)(cid:86)(cid:87)(cid:72)(cid:85)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:68)(cid:74)(cid:68)(cid:76)(cid:81)(cid:86)(cid:87)(cid:3)(cid:53)(cid:57)(cid:3)(cid:42)(cid:40)(cid:38)(cid:82)(cid:81)(cid:73)(cid:76)(cid:71)(cid:72)(cid:81)(cid:87)(cid:76)(cid:68)(cid:79)– 485 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:51)(cid:68)(cid:87)(cid:72)(cid:81)(cid:87)(cid:3)(cid:73)(cid:68)(cid:80)(cid:76)(cid:79)(cid:92)(cid:3)(cid:82)(cid:73)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:76)(cid:81)(cid:89)(cid:72)(cid:81)(cid:87)(cid:76)(cid:82)(cid:81)(cid:179)(cid:49)(cid:82)(cid:85)(cid:82)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:70)(cid:68)(cid:83)(cid:86)(cid:76)(cid:71)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:85)(cid:82)(cid:87)(cid:68)(cid:89)(cid:76)(cid:85)(cid:88)(cid:86)(cid:3)(cid:57)(cid:51)(cid:25)(cid:3)(cid:83)(cid:85)(cid:82)(cid:87)(cid:72)(cid:76)(cid:81)(cid:3)(cid:73)(cid:82)(cid:85)(cid:3)(cid:88)(cid:86)(cid:72)(cid:3)(cid:68)(cid:86)(cid:3)(cid:70)(cid:82)(cid:80)(cid:69)(cid:76)(cid:81)(cid:72)(cid:71)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:179)(cid:18)(cid:381)(cid:437)(cid:374)(cid:410)(cid:396)(cid:455) (cid:4)(cid:393)(cid:393)(cid:367). 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(cid:1006)(cid:1004)(cid:1005)(cid:1004)(cid:1010)(cid:1004)(cid:1010)(cid:1011) (cid:1005)(cid:1009)(cid:856)(cid:1005)(cid:1004)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1004) (cid:39)(cid:42)(cid:396)(cid:85)(cid:258)(cid:68)(cid:374)(cid:81)(cid:410)(cid:87)(cid:286)(cid:72)(cid:282)(cid:71)(cid:47)(cid:374)(cid:282)(cid:349)(cid:258) (cid:1011)(cid:1006)(cid:1007)(cid:876)(cid:68)(cid:104)(cid:68)(cid:69)(cid:87)(cid:876)(cid:1006)(cid:1004)(cid:1005)(cid:1007) (cid:1005)(cid:1006)(cid:856)(cid:1008)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:910) (cid:87)(cid:286)(cid:374)(cid:282)(cid:349)(cid:374)(cid:336)(cid:58)(cid:258)(cid:393)(cid:258)(cid:374) (cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:882)(cid:1009)(cid:1007)(cid:1007)(cid:1006)(cid:1008)(cid:1013) (cid:1005)(cid:1006)(cid:856)(cid:1008)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:910) (cid:87)(cid:286)(cid:374)(cid:282)(cid:349)(cid:374)(cid:336)(cid:94)(cid:381)(cid:437)th (cid:60)(cid:381)(cid:396)(cid:286)(cid:258) (cid:1005)(cid:1004)(cid:882)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:882)(cid:1011)(cid:1004)(cid:1005)(cid:1006)(cid:1006)(cid:1005)(cid:1012) (cid:1005)(cid:1004)(cid:856)(cid:1009)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:910) (cid:87)(cid:286)(cid:374)(cid:282)(cid:349)(cid:374)(cid:336)(cid:68)(cid:286)(cid:454)(cid:349)(cid:272)(cid:381) (cid:68)(cid:121)(cid:876)(cid:4)(cid:876)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:876)(cid:1004)(cid:1004)(cid:1008)(cid:1005)(cid:1009)(cid:1013) (cid:1005)(cid:1006)(cid:856)(cid:1008)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:910) (cid:87)(cid:286)(cid:374)(cid:282)(cid:349)(cid:374)(cid:336)(cid:90)(cid:437)(cid:400)(cid:400)(cid:349)(cid:258) (cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:1005)(cid:1006)(cid:1005)(cid:1012)(cid:1005)(cid:1009) (cid:1005)(cid:1007)(cid:856)(cid:1009)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1007)(cid:910) 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(cid:1011)(cid:856)(cid:1005)(cid:1004)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1005) (cid:87)(cid:42)(cid:286)(cid:85)(cid:374)(cid:68)(cid:282)(cid:81)(cid:349)(cid:87)(cid:374)(cid:72)(cid:336)(cid:71)* (cid:271)(cid:258)(cid:400)(cid:286)d (cid:381)n (cid:349)(cid:374)(cid:410)(cid:286)(cid:396)(cid:374)(cid:258)(cid:410)(cid:349)(cid:381)(cid:374)(cid:258)l (cid:296)(cid:349)(cid:367)(cid:349)ng (cid:282)(cid:258)(cid:410)e (cid:381)f (cid:1005)(cid:1006)(cid:856)(cid:1005)(cid:1004)(cid:856)(cid:1006)(cid:1004)(cid:1005)(cid:1005)(cid:36)(cid:83)(cid:85)(cid:76)(cid:79)(cid:3)(cid:20)(cid:20)(cid:15)(cid:3)(cid:21)(cid:19)(cid:20)(cid:23)– 486 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic(cid:47)(cid:76)(cid:70)(cid:72)(cid:81)(cid:86)(cid:76)(cid:81)(cid:74)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:39)(cid:72)(cid:89)(cid:72)(cid:79)(cid:82)(cid:83)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:3)(cid:36)(cid:74)(cid:85)(cid:72)(cid:72)(cid:80)(cid:72)(cid:81)(cid:87)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:56)(cid:48)(cid:49)(cid:3)(cid:51)(cid:75)(cid:68)(cid:85)(cid:80)(cid:68)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:56)(cid:81)(cid:76)(cid:89)(cid:72)(cid:85)(cid:86)(cid:76)(cid:87)(cid:92)(cid:3)(cid:82)(cid:73)(cid:3)(cid:55)(cid:68)(cid:80)(cid:83)(cid:72)(cid:85)(cid:72)(cid:3)(cid:57)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:53)(cid:72)(cid:86)(cid:72)(cid:68)(cid:85)(cid:70)(cid:75)(cid:3)(cid:38)(cid:72)(cid:81)(cid:87)(cid:72)(cid:85)(cid:3)(cid:76)(cid:81)(cid:3)(cid:21)(cid:19)(cid:20)(cid:21)(cid:137) (cid:38)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:74)(cid:85)(cid:68)(cid:71)(cid:72)(cid:3)(cid:11)(cid:42)(cid:48)(cid:51)(cid:12)(cid:3)(cid:83)(cid:85)(cid:82)(cid:71)(cid:88)(cid:70)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:82)(cid:73)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:3)(cid:70)(cid:82)(cid:80)(cid:83)(cid:82)(cid:81)(cid:72)(cid:81)(cid:87)(cid:86)(cid:3)(cid:87)(cid:82)(cid:74)(cid:72)(cid:87)(cid:75)(cid:72)(cid:85)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:51)(cid:85)(cid:82)(cid:87)(cid:72)(cid:76)(cid:81)(cid:3)(cid:54)(cid:70)(cid:76)(cid:72)(cid:81)(cid:70)(cid:72)(cid:86)(cid:3)(cid:38)(cid:82)(cid:85)(cid:83)(cid:82)(cid:85)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:3)(cid:137) (cid:51)(cid:85)(cid:72)(cid:70)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:70)(cid:79)(cid:76)(cid:81)(cid:76)(cid:70)(cid:68)(cid:79)(cid:3)(cid:87)(cid:72)(cid:86)(cid:87)(cid:76)(cid:81)(cid:74)(cid:3)(cid:82)(cid:73)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:89)(cid:68)(cid:70)(cid:70)(cid:76)(cid:81)(cid:72)(cid:137) (cid:37)(cid:76)(cid:74)(cid:74)(cid:72)(cid:85)(cid:3)(cid:83)(cid:68)(cid:85)(cid:87)(cid:81)(cid:72)(cid:85)(cid:3)(cid:81)(cid:72)(cid:72)(cid:71)(cid:72)(cid:71)(cid:3)(cid:76)(cid:81)(cid:3)(cid:87)(cid:75)(cid:72)(cid:3)(cid:81)(cid:72)(cid:68)(cid:85)(cid:3)(cid:73)(cid:88)(cid:87)(cid:88)(cid:85)(cid:72)(cid:38)(cid:82)(cid:81)(cid:73)(cid:76)(cid:71)(cid:72)(cid:81)(cid:87)(cid:76)(cid:68)(cid:79)– 487 –I. WG meeting programmes and expert presentations | 6. Tampere, Finland – Vesna Blazevic– 488 –Baltic Sea Parliamentary ConferenceÅland 11-12 June 2015Thursday 11 June1220-1330 E xpert presentations by Professor Dag Nyman on the Clinic of Borellios Research, andby MD Mathias Grunér on the laboratory BIMEX1330-1500 E xpert presentations by Ålandic Minister of Health, Carina Aaltonen, Chief Medical OfficerFredrik Almqvist, Doctor of Infections Marika Nordberg, and MD Katarina Dahlman1700-1900 WG meeting and preparation of WG Final ReportFriday 12 June0900-1230 WG meeting and preparation of WG Final ReportThe BSPC Working Group on Innovation in Social and Health Care (BSPC WG ISHC) held its sixthmeeting on the Åland Islands on 11-12 June 2015. The meeting itself was preceded by a study tour ofHealth Care Clinic Medimar and Åland Central Hospital. The Working Group was briefed by MD Mathi-as Grunér, CEO Bimelix, on the Bimelix Laboratory and the Medimar Borrelia Clinic. Bimelix BiomedicalLaboratory is based in Åland and provides laboratory services in microbiology for health care in Finlandand other Nordic countries. It possesses unique expertise in tick-related diseases and specializes in Lyme dis-ease. Prof. Dag Nyman from Medimar followed up with a presentation on lyme borreliosis. It is the mostcommon vector-borne infectious disease in northern Europe. At the Åland Central Hospital MD KatarinaDahlman spoke about challenges with a hospital on a small island. The hospital is responsible for all publichealthcare on the Åland Islands. Doctor of Infections, Marika Nordberg, followed with a presentation ontick-borne encephalitis (TBE) on the Åland Islands. Associate Professor of Surgery, Mr Haile Mahteme,shared his thoughts with the WG members on why he believes health professionals on Åland care moreabout their patients’ well-being than elsewhere. Finally, the Åland Minister for Health, Ms Carina Aalto-nen, spoke about Public Health on the island.– 489 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanLyme BorreliosisDag NymanMedimar, Åland– 490 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanLyme Borreliosis is------• A multisystemic vector-borne, inflam-matory infectious disease• Caused by the immune-defence to spirochetes of theBorrelia burgdorferi s.l. complex• The most common vector-borne infectious disease inNorth-Europe– 491 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanBorrelia burgdorferi s.l. and others• B. b. sensu stricto• B. afzelii• B. garinii• B. bavariensis• B. spielmanii, valaisana• B. miyamotoi• Other – TBE, Anaplasma, Rickettsia SFG, Tularemia, CandidatusNeoehrlichia mikurensis– 492 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanTicks are the vectorsI. ricinus I. persulcatus– 493 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanWhy a borreliosis clinic?• Epidemiology• Diagnostics and differential diagnostics• Treatment• Chronic infection• Persisting symptoms– 494 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanTicks in EuropeECDC 2015– 495 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanReportedborreliosis2000-2011Serology based incidence!(IHW Finland)P-value <0.0001Incidence rate ratio 1.4495% CI for ratio 1,324 to 1,568– 496 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanClinical borreliosis 2000 -2012 Åland600Ca. 2000/100000/år500400300LB N2001000– 497 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanBorrelia prevalence and species in ticks, Åland IslandsNo.No. (%) of ticks containing Borreliaspecies determined by nucleotide sequencing(%) No. (%)Tick of ofstage ticks positive B. a B. g B. v B. b B. m B. s B. l Mixed UT178 24777 86 (48) 42 (24) 14 (8) 4 (2) 2 (1) 5 (3) -- 1(1)(23) (13)Adult 5--male (1)118 35 4Adult 10 (28) 11 (30) 5 (14) 3 (8) 1 (3) 1 (3)(15) (30) (11)female587 143 2076 (53) 31 (21) 9 (6) 1 (1) 1 (1) 4 (3) 1 (1)(74) (24) (14)Nymph67--(8)LarvaWilhelmsson 2013– 498 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanBorrelia in ticks from Estonia• Ixodes ricinus 8.2% (2293)• Ixodes persulcatus 9.7% (2833)• Total 4.7 - 24.2 % regional variation• The most prevalent genospecies was B. afzelii which was detected in53.5% of Borrelia-positive ticks, followed by B. garinii and B.valaisiana with 26.2% and 5.5%, respectively.Geller et al. Parasites & Vectors 2013 6:202– 499 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanBorreliosis in EuropeYear 2001 2002 2003 2004 2005Country Incidence [cases] Incidence [cases] Incidence [cases] Incidence [cases] Incidence [cases]Slovenia 163 [3232] 169 [3359] 177 [3524] 193 [3849] 206 [4123]Austria - - - - - - - - 135 -Netherlands 74 [12000] - - - - - - 103 [17000]Lithuania 33 [1153] 26 [894] 106 [3688] 50 [1740] 34 [1161]Finland 13 [691] 17 [884] 14 [753] 22 [1135] 24 [1236]Latvia 16 [379] 14 [328] 31 [714] 31 [710] 21 [493]Estonia 25 [342] 23 [319] 42 [562] 36 [480] 21 [281]– 500 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanDiagnosis• Clinical picture- early, late- localized, disseminated- organ involved• Laboratory verification- which test when- diagnostic performance– 501 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanBUILDING A DIAGNOSIS NBDiagnosticP NB 1.0 decision 0.95Treatment0.8decision0.640.60.470.40.20.170.0340.012Odds/LR+ 0.012 * 2.82 * 6.0 * 4.29 * 1.9 * 12.5Step Clinical I S-C6Ab Clinical II Csf-cells Csf-ABI Csf-CXCL13Nyman 2014– 502 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Dag NymanDo not be afraid of the nature!– 503 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias GrunérBimelix Laboratory andMedimar Borrelia clinic11.6.15 MedimarMathias Grunér, CEO Bimelix– 504 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias GrunérBimelix – unique competence in tick-related diseases, specialized in Borreliosis• Accredited EN ISO 15189, FINAS• The Bimelix test algorithm – a result of decades of research- Combines the best commercially available test systems- Developed after years of continuous in-house research- All possible outcomes for the patient are handled with minimum amount of re-visits– 505 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias GrunérMedimar Borrelia clinic• Connects clinic and laboratory‒ Medimar, Borrelia Team‒ Bimelix, specialized in Borrelia diagnostics• The fastest track to appropriate care– 506 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias GrunérBorrelia clinic – comprehensive care package.• Borrelia clinic offers a Borrelia Team:‒ Specialized physicians, nurses, physiotherapists and CBT therapist• Comprehensive care package:‒ Blood tests, treatment, rehabilitation, follow-up and furtherinvestigationsProf. Dag Nyman: ” we offer safe methods toefficiently rule out borreliosis and can also performfurther investigations and treatment plans forpossible other causes of observed symptoms. Anactive borreliosis can in most cases be diagnosedand treated accordingly”– 507 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias GrunérMathias GrunérBimelix/Medimar Borreliaklinikmathias.gruner@bimelix.axwww.borreliakliniken.axwww.bimelix.ax– 508 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias Grunér– 509 –I. WG meeting programmes and expert presentations | 7. Åland Islands – Mathias GrunérBorreliakliniken.ax– 510 –Baltic Sea Parliamentary ConferenceII.WG homework– 511 –Baltic Sea Parliamentary ConferenceII. WG homework 1The WG conducted three sets of homework on the general nature of public strategies and measures ofISHC, the ethical aspects of ISHC, as well as the demographic perspectives and the mobility of elderly. Thehomework was conducted to get an overall view of the issues at hand, prepare upcoming WG meetings andquestions for experts, as well as to provide input and inspiration to the political recommendations of theWG.Questions to the BSPC Member States on the general nature of public strategies and measures ofISHC1. W hat, from your perspective, are the main challenges facing social and health care today and in the fu-ture?2. H ave you launched any public strategies and programmes for ISHC? Are any new initiatives planned?What are your experiences and results so far concerning public programmes and measures to supportISHC?3. H ave you launched any public awareness campaigns concerning ISHC? Are any new initiativesplanned?4. H ave you launched any public economic support mechanisms for ISHC, such as dedicated funding,seed money or tax incentives? Are any new initiatives planned?5. I n general, what do you see as the main obstacles for promoting and implementing ISHC? What kindof political support and measures are conceivable to overcome the obstacles?– 512 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Denmark– 513 –II WG homework 1 – Answer from DenmarkBSPC Working Group on Innovation in Social and Health CareHomework 1Contribution from Denmark1. What, from your perspective, are the main challenges facing social and health caretoday and in the future?- To ensure sustainable healthcare in times of economic constraint and demographicpressure- To strengthen disease prevention and health promotion- To strengthen prevention and treatment of psychiatric conditions- To ensure high quality and evidence based treatment and care- To include patients in decision-making and to promote patient empowerment- To make patient pathways coherent and transitions smooth- To ensure equality in healthcare2. Have you launched any public strategies and programmes for ISHC? Are any newinitiatives planned? What are your experiences and results so far concerning publicprogrammes and measures to support ISHC?e-health strategy 2013-2017In June 2013, the Danish Government, Local Government Denmark [KommunernesLandsforening] and Danish Regions launched a new strategy for digitalization of the Danishhealthcare sector. The strategy sets the direction for the digitalization efforts in the health caresector till 2017.The title of the strategy is “making e-health work”. This is to emphasize that the main focus ofthe strategy is to ensure that we fully exploit the potential and benefits of existing digitalsolutions in the health care system.National action plan for dissemination of telemedicineIn august 2012, the Danish Government, Local Government Denmark and Danish Regionslaunched a national action plan for dissemination of telemedicine. The main aim of the plan isto speed up large scale spreading of telemedicine solutions that we know work.With the plan we have launched the biggest telemedicine initiatives in Denmark to dateincluding: Nationwide telemedical assessment of ulcers: By using telemedicine, the nurse in the localhome care together with the doctors at the hospital will be able to treat patients’ ulcers– 514 –II WG homework 1 – Answer from Denmarkmore efficiently and with greater patient satisfaction. We expect to reduce healing time by30 percent. Nearly 1,500 patients in Northern Jutland with severe or very severe C.O.P.D. [Chronicobstructive pulmonary disease] will have their disease monitored by the use oftelemedicine.Partnership for healthcare- and hospital innovationThe Market Development Fund (Markedsmodningsfonden) and the five Danish regions haveestablished a partnership for healthcare and hospital innovation. The purpose of thepartnership is to develop new and effective products and solutions for the new Danish hospitalsunder construction. The partnership has funded 14 new products where private companies andpublic hospitals collaborate to develop products in the areas of logistics, telemedicine andhygiene.Testing and adapting new products for healthcare and welfareThe Market Development Fund has granted funding for 40 projects where private businessesand public sector institutions together test new innovative solutions for either healthcare orwelfare. The projects are aiming to commercialize the tested products. The MarketDevelopment Fund has also granted funding for 12 public sector institutions that are workingin innovative ways to purchase new products that will enhance the public service in healthcareand welfare. These projects include pre-commercial procurement efforts and other innovativeprocedures for procurement.Total cost of ownership models for the health and welfare sectorDuring the next two years the Danish Ministry of Business and Growth will chair a workinggroup with participants from relevant ministries, municipalities and regions which will developtotal cost of ownership models for selected health and welfare areas. The aim of the initiativeis 1) to make it easier for public sector institutions to calculate total costs associated with thepurchase and procurement of innovative health and welfare sector solutions, and 2) tostimulate additional private sector development of innovative cost reducing products andservices with export market potential.Market development test projectsDuring 2014 the Danish Ministry of Business and Growth will chair a working group withparticipants from relevant ministries and regions which will select market development projectsrelated to the development of new hospitals. The aim of the initiative is to make it possible forprivate businesses to benefit from knowledge and competencies in the public health system, inorder to develop specific products and services that can be marketed internationally as well asacting as service operators within areas such as logistics, assistive technology solutions etc.Government strategy for intelligent public procurementThe strategy aims to promote efficient public procurement that supports innovative solutions,green public procurement and the use of total cost of ownership. The Strategy introducesseven guiding principles for intelligent public procurement, e.g. increased use of functionalrequirements in public tenders. To promote a differentiated approach to public procurementthe strategy comprises 29 different initiatives including a cross sectorial test programme forinnovative and pre-commercial procurement.– 515 –II WG homework 1 – Answer from Denmark3. Have you launched any public awareness campaigns concerning ISHC? Are anynew initiatives planned?Denmark has initiatives such as “the health promotion packages”. The purpose of the healthpromotion packages is to give the municipalities in Denmark an evidence-informed tool toassist municipal decision-makers and health planners in setting priorities, planning andorganizing local health promotion and disease prevention initiatives.Health promotion packages are prepared for significant risk factor areas withinwhich the municipalities are already active and that are expected to require considerablefocus in the coming years because of new evidence and developing societalnorms.Health promotion packages focusing on tobacco, alcohol, physical activity, mentalhealth, sexual health, sun protection, indoor climate in schools, hygiene, healthyfood and meals have been published, and packages on obesity and preventing drugabuse are underway.4. Have you launched any public economic support mechanisms for ISHC, such asdedicated funding, seed money or tax incentives? Are any new initiatives planned? As a part of the new e-health strategy 2013-2017 and the National action plan for thedissemination of telemedicine, DKK 155 million has been allocated to investments intelemedicine. Denmark has for a number of years funded a public, strategic health research programme.The funding is allocated by The Danish Council for Strategic Research. The councilannounces an open call on a yearly basis, and the funding is allocated as relatively largegrants. The research covers a broad range of health topics and is often carried out inpublic-private collaboration. The research aims at contributing to solving important societalchallenges within health, and contributes to innovation within public health service andorganization. For further information about the council: http://fivu.dk/en/research-and-innovation/councils-and-commissions/the-danish-council-for-strategic-research?set_language=en&cl=en The Council for Technology and Innovation has not funding dedicated to specific thematicareas. The council has – among other things - financed innovation activities within healthand welfare technology by drawing up performance contracts with the nine institutions inthe Advanced Technology Group (GTS institutions) in Denmark, especially Bioneer(medicine and biotechnology), Danish Technology Institute (medicine, biotechnology andwelfare technology) and DELTA (welfare technology and medical equipment). The councilhas also approved three Innovation Networks within the field of health and welfare thatspans from July 2014 to July 2018; two of which are new Innovation Networks withinwelfare technology and medico technology respectively. The thirds is a continuation of theestablished network Bio-people: an Innovations Network for Bio-health. For furtherinformation about the council: http://fivu.dk/en/research-and-innovation/councils-and-commissions/the-danish-council-for-technology-and-innovation?set_language=en&cl=en In 2011 The Danish Council for Strategic Research has - in collaboration with The DanishCouncil for Technology and Innovation - funded a strategic platform for research andinnovation regarding welfare technology. The platform is a public private collaboration with– 516 –II WG homework 1 – Answer from Denmark53 partners involved with a total budget of 190 m. DDK. The platform is aiming atdeveloping new welfare technology solutions for the benefit of patients, the health caresector and private enterprises in the social and healthcare sector. In 2014 Denmark will initiate a societal partnership on innovation regarding clinicalresearch. The funding for the partnership will be allocated by a new foundation called TheDanish National Innovation Foundation. The foundation is expected to be established byApril this year. The partnership will be a public-private collaboration aiming at makingDenmark the preferred country for conducting early stage clinical trials on new medicineswithin a number of disease areas and within a period of five years. The partnership is toestablish three to five pilot centers for experimental treatment and clinical proof of conceptstudies of a quality that can attract 10-20 studies of new medicines in the centers. Thecenter solutions developed are expected to be able to strengthen professionalcompetencies at hospitals through excellent research environments, boosting quality oftreatment and health service efficiency. At the same time the solutions will furtherstrengthen the strong Danish business cluster in the field. For further information about thepartnership: http://fivu.dk/en/publications/2013/inno-catalogue There are a number of other public councils and foundations within the field of researchand innovation supporting research and innovation activities regarding social andhealthcare topics. These bodies do not have dedicated funds for the topics. Danishuniversities and institutions of higher education also conduct research and innovationactivities within the social and healthcare areas within their non-dedicated public funds.5. In general, what do you see as the main obstacles for promoting andimplementing ISHC? What kind of political support and measures are conceivable toovercome the obstacles?One of the major challenges associated with promoting ISHC is the lack of knowledge andconsequently public, political and organizational resistance to many of the actions thatotherwise could be the solution to future health challenges. It is a challenge and an obstacleboth in terms of policy planning and adoption of technology solutions, as well as in the actualimplementation at the user level.There is no doubt that the introduction of technology solutions and healthcare IT, such astelemedicine, can have significant socio-economic benefits, as well as human potential tobetter care for patients and citizens. The big challenge is to spread knowledge about it andimplement it in a way that citizens and patients' organizations, etc. see as positive.Considerable knowledge sharing – including user studies documenting the positive effects – isnecessary. It is necessary that we also at the political level try to spread knowledge about bestpractices and communicate that it will lead to significantly improved quality of life for theindividual and at the same time be a socio-economic benefit, especially in an exportperspective.Close cooperation between relevant actors is necessary. Regions, municipalities, patient- anduser- organizations and politicians must work together to raise awareness and draw attentionto ISHC.– 517 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Estonia– 518 –II WG homework 1 – Answer from Estonia– 519 –II WG homework 1 – Answer from Estonia– 520 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Finland– 521 –II WG homework 1 – Answer from FinlandBSPC WG ISHC Homework 1 – Answers from Finland 19.2.20141. Main challenges:a. Age Structure of Population, aging society, need of services increases in social and healthcareb. Economic situation in national and public economyc. Structural changes on social and health care service delivery and funding2. Programsa. KASTE‐2‐program is national R&D&I‐program by the Ministry of Social Affairs and Health forstakeholders in development of welfare, health, and servicesb. TEM, and other Ministries made Agreement for growth with major citiesc. Finnish Innovation Center/Tekes has several programs to promote and support developmentof innovations eg.i. Innovations in Social and Health Care‐programii. Innovative Cities: Future Health ‐ programiii. Innovative procurement‐programd. ICT‐2015 ‐ national program to promote innovative development ict in Finlande. SITRA, Finnish Independence Fund: Health program support innovative project in social andhealth caref. planning of new programs:i. strategy for future health, 3 ministries togetherii. strategy for bio‐ and gene technologyiii. Strategy for national ICT‐development in social and health care: From data toknowledge ing. Innovillage ‐ new national open interactive innovation environment for welfare, health andsocial and health service3. Awareness campaigns:a. Prizes for Innovative solutionsi. Inno‐prize annually by Innovillageii. Prize for eHeatlh solutions, SITRAb. startups, SLUSH‐match making, Tekesc. open seminars and happenings4. New Support Mechanismsa. tax decrease for companies for R&D&I‐expensesb. Tekes has new tools and funds for capital investments to companies 1.1.2014‐c. see point 2. different programs to support ISCH5. Obstacles vary a lot depending of programs etc. However there are several evaluations available ofFinnish Innovation Ecosystem and programs.– 522 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Germany– 523 –II WG homework 1 – Answer from GermanyGerman BundestagLanguage Service- Translation -Franz Thönnes, MdBFormer Parliamentary State SecretaryDeputy Chairman of the Foreign Affairs CommitteeChair of the German-Nordic Parliamentary Friendship GroupMember of the BSPC Standing CommitteeFranz Thönnes MdB • Platz der Republik 1. 11011 BerlinMs Andrea Nahles, MdBFederal Minister of Labour andSocial AffairsWilhelmstr. 4910117 Berlin30 January 2014BSPC Working Group on Innovation in Social and Health Care (BSPC WG ISHG)Dear Minister,At the 22nd Baltic Sea Parliamentary Conference (BSPC) in August 2013 in Pärnu, the conferenceparticipants decided to form the Working Group mentioned above. In my function as a member ofthe German Bundestag's delegation, I am part of the working group.This working group deals with the issue of qualitative and equitably distributed social andmedical services for the citizens of the Baltic Sea Region. The Working Group's objectiveis to elaborate political positions and recommendations pertaining to innovation in socialand health care. These would be addressed to the national and regional governmentsconcerned. They would be an expression of the political views and positions ofparliamentarians from the Baltic Sea Region.In a first step, we aim to obtain a comprehensive picture of the challenges which exist andmeasures taken so far by the national and regional governments, and to collect a set of concreteexamples of projects. To this end, the Working Group has compiled the following list of questions forall the countries in the Baltic Sea Region:1. What, from the perspective of your ministry, are the main challenges facingsocial care today and in the future?2. Have you launched any national public strategies and programmes forinnovation in the area of social care? Are any new initiatives planned? What areyour experiences and results so far concerning public programmes andmeasures to support innovation in social care at federal level?3. Have you launched any public awareness campaigns concerning ISHC?– 524 –II WG homework 1 – Answer from Germany4. Has the Federal Government launched any public economic support mechanismsin the area of social care, such as dedicated funding, seed money or taxincentives? Are any new initiatives planned?5. In general, what do you see as the main obstacles for promoting andimplementing innovation in the area of social care? What kind of political supportand measures are conceivable to overcome the obstacles?Despite the short notice, I would be grateful if you could answer these questions on behalf of yourministry by 24 February 2014.Thank you very much in advance for your assistanceYours sincerely,Sgd. Franz ThönnesMember of the Bundestag2– 525 –II WG homework 1 – Answer from GermanyFederal Ministryof Labour and Social AffairsSeite 2 von 2Andrea NahlesMr Franz Thönnes Federal MinisterMember of the German Bundestag Member of the German Bundestag11011 Berlin OFFICE ADDRESS Wilhelmstraße 49, 10117 BerlinPOSTAL ADDRESS 10117 BerlinTEL +49 (0)30 18 527‐2323FAX +49 (0)30 18 527‐2328E‐MAIL ministerbuero@bmas.bund.de6 March 2014Dear Mr Thönnes, (m.p.) Dear Franz,Thank you for your letter of 30 January 2014. I am pleased to take this opportunity to answer thequestions from the 22nd Baltic Sea Parliamentary Conference (BSPC) Working Group onInnovation in Social and Health Care. My answers are set out in the annex to this letter.I should point out that from the perspective of the Federal Ministry of Labour and Social Affairs,not all the questions can be answered in full. Assuming that the terms “social care” and “healthcare” are defined as needs-based rather than contributory social welfare schemes, the followingsituation applies to Germany:In Germany, various benefits are provided to safeguard the sociocultural subsistence level undersocial law. They encompass a living allowance and health care provision in the absence of otherforms of cover, as well as provision for persons in need of long-term care, and assistance todeal with the effects of disability and other social difficulties and circumstances. These benefitsare provided under social assistance law and are governed by Book Twelve of the GermanSocial Code (SGB XII). The precondition for claiming these benefits is that recipients must lackthe requisite means and capacities to support themselves and are therefore dependent onassistance.The second major minimum income scheme is the basic provision for job-seekers under BookTwo of the German Social Code (SGB II). The passive benefits comprise a living allowance,health insurance and long-term care insurance.In light of this situation, programmes and initiatives are of secondary importance in Germany,where benefits are provided in accordance with the welfare principle pursuant to Books Two andTwelve of the Social Code. For certain groups who cannot be reached to an adequate extent orat all by state benefits or whose circumstances require that they be given special promotion orsupport, programmes and initiatives may provide additional assistance. “Additional”, in this– 526 –II WG homework 1 – Answer from Germanycontext, means that these services are provided as a supplement to, not as a substitute for, theirlegal entitlements.Social care, as a means of safeguarding a level of subsistence that is in line with human dignity,is enshrined in Germany’s constitution, the Basic Law. This states that Germany is a social stateunder the rule of law. As regards living allowances under Books Two and Twelve of the SocialCode, the German Federal Constitutional Court, in its judgment of 9 February 2010 on the levelof the standard benefits provided under SGB II, recognised the fundamental right to asubsistence minimum that is in line with human dignity. This fundamental right may not belimited solely to living allowance benefits and must be transposed into legal entitlements in(federal) legislation. Persons in need of assistance may only be referred to benefit schemesoperated by third parties when legal entitlements under these schemes take precedence.Among other things, this means that further developments in the field of social care largely takeplace through amendments to existing legislation or the adoption of new laws. A specificexample is the forthcoming reform, during this electoral term, of the current provisions onintegration assistance in Chapter Six of SGB XII. There is a need to take account of the newsocial understanding of disability assistance and develop integration assistance into a right ofparticipation that is appropriate for today’s society.Yours sincerely,2– 527 –II WG homework 1 – Answer from GermanyAnnexPreliminary remarks: Social care and health careThe minimum income schemes covered by Book Two of the Social Code (SGB II) and BookTwelve of the Social Code (SGB XII) comprise social care and health care. Persons entitled toclaim benefits under SGB II are generally provided with mandatory insurance cover understatutory health and long-term care insurance schemes, unless they have private health and careinsurance cover.Persons entitled to claim benefits under SGB XII are generally covered by statutory or privatehealth and long-term care insurance. In individual cases where this does not apply due tospecial circumstances, the social assistance system covers the costs of health care under the“Assistance for Health” provisions contained in Chapter Five of SGB XII, with the scope ofbenefits corresponding to those provided under statutory health insurance. There is thereforeno specific need for action on health care within the sphere of social care.Question 1:What, from the perspective of your ministry, are the main challenges facing social caretoday and in the future?Answer:The main challenges are as follows: Delimitation of the care schemes, as regards the scope of benefits and recipient groups, inrelation to the other branches of the social welfare system. Maintaining the efficiency of the care schemes in order to safeguard continued reliable provisionof the sociocultural subsistence level as regards the level of benefits and access for all persons inneed of assistance. This will require ongoing adaptation to changing social and economicconditions. The legal bases are established in federal law, but delivery largely takes place at themunicipal level, at least as far as social assistance is concerned. The financing of thebenefits is generally coupled to delivery, resulting in financial burdens for the municipalities.For that reason, the Federal Government has increasingly taken on financial commitmentsin the form of reimbursement of expenditure in some areas of social assistance (basicretirement pension, and pensions for persons with reduced earning capacity) and haspledged to ease the financial burden on the municipalities as part of the forthcoming reformof integration assistance.Question 2:Have you launched any national public strategies and programmes for innovation in thearea of social care? Are any new initiatives planned? What are your experiences and results– 528 –II WG homework 1 – Answer from Germanyso far concerning public programmes and measures to support innovation in social care atfederal level?Answer:No such national strategies and programmes exist in Germany beyond those set out by theFederal Government in national action plans, reports and the Coalition Agreement for the 18thelectoral term. Germany therefore has no experience that it can share in this area.Question 3:Have you launched any public awareness campaigns concerning ISHC?Answer:Please refer to the answer to Question 2.Question 4:Has the Federal Government launched any public economic support mechanisms in thearea of social care, such as dedicated funding, seed money or tax incentives? Are any newinitiatives planned?Answer:To the extent that this question relates to support for infrastructure, no information is available tothe Federal Government. The responsibility for infrastructural measures lies with themunicipalities or the federal states (Länder), as appropriate.Question 5:In general, what do you see as the main obstacles for promoting and implementinginnovation in the area of social care? What kind of political support and measures areconceivable to overcome the obstacles?Answer:As in all policy areas, the question of the ensuing additional costs and how they are to be fundedarises in relation to implementing innovation in the area of social care. Please also refer to theanswer to Question 1.2– 529 –II WG homework 1 – Answer from GermanyGerman BundestagLanguage Service- Translation -Franz Thönnes, MdBFormer Parliamentary State SecretaryDeputy Chairman of the Foreign Affairs CommitteeChair of the German-Nordic Parliamentary Friendship GroupMember of the BSPC Standing CommitteeFranz Thönnes MdB • Platz der Republik 1. 11011 BerlinMr Hermann Gröhe, MdBFederal Minister of HealthFriedrichstr. 10810117 Berlin30 January 2014BSPC Working Group on Innovation in Social and Health Care (BSPC WG ISHG)Dear Minister,At the 22nd Baltic Sea Parliamentary Conference (BSPC) in August 2013 in Pärnu, theconference participants decided to form the Working Group mentioned above. In my functionas a member of the German Bundestag's delegation, I am part of the working group.This working group deals with the issue of qualitative and equitably distributed socialand medical services for the citizens of the Baltic Sea Region. The Working Group'sobjective is to elaborate political positions and recommendations pertaining toinnovation in social and health care. These would be addressed to the national andregional governments concerned. They would be an expression of the political viewsand positions of parliamentarians from the Baltic Sea Region.In a first step, we aim to obtain a comprehensive picture of the challenges which exist andmeasures taken so far by the national and regional governments, and to collect a set of concreteexamples of projects. To this end, the Working Group has compiled the following list ofquestions for all the countries in the Baltic Sea Region:1. What, from the perspective of your ministry, are the main challenges facinghealth care today and in the future?2. Have you launched any national public strategies and programmes forinnovation in the area of health care? Are any new initiatives planned? Whatare your experiences and results so far concerning public programmes andmeasures to support innovation in health care at federal level?3. Have you launched any public awareness campaigns concerning ISHC?– 530 –II WG homework 1 – Answer from Germany4. Has the Federal Government launched any public economic supportmechanisms in the area of health care, such as dedicated funding, seedmoney or tax incentives? Are any new initiatives planned?5. In general, what do you see as the main obstacles for promoting andimplementing innovation in the area of health care? What kind of politicalsupport and measures are conceivable to overcome the obstacles?Despite the short notice, I would be grateful if you could answer these questions on behalf ofyour ministry by 24 February 2014.Thank you very much in advance for your assistanceYours sincerely,Sgd. Franz ThönnesMember of the Bundestag– 531 –II WG homework 1 – Answer from GermanyFederal Ministryof HealthPOSTAL ADDRESS Federal Ministry of Health, 53107 BonnHermann GröheMr Franz Thönnes Federal MinisterMember of the German Bundestag Member of the German Bundestag11011 Berlin OFFICE ADDRESS Rochusstraße 1, 53123 BonnPOSTAL ADDRESS 53107 BonnTEL +49 (0)228 99 441‐1003FAX +49 (0)228 99 441‐1193E‐MAIL poststelle@bmg.bund.de5 March 2014Dear colleague,Many thanks for your letter of 30 January and your interest in the subject of social and health care inthe Baltic Sea region. I regret that I was unable to reply earlier.In general, one major challenge in the field of health is inequality of access to health services andvariations in the quality of care in the Baltic Sea countries. This is partly due to the systemsconcerned, but in part it is also a consequence of the size and location of certain countries, parts ofwhose territory are located in the Arctic.The biggest health risks can be found in the following areas: HIV/AIDS in conjunction with co‐infections such as tuberculosis and hepatitis, resistance to antibiotics, and lifestyle diseases (obesity,heart diseases). Alcohol abuse also poses a challenge in some Baltic Sea states.No economic support mechanisms or campaigns exist at federal level. One key instrument for theregion, however, is the European Union Strategy for the Baltic Sea Region (EUSBSR). This strategyaims to intensify cooperation within the Baltic Sea region. As the EU’s first “macro‐regional strategy”,the EU Strategy for the Baltic Sea Region is a pilot project for a new form of cooperation between theEU and its neighbouring countries. The regional focus and indicators of these macro‐strategies fleshout the Europe 2020 targets. “Health” is one of the priority areas in the Strategy for the Baltic SeaRegion.This priority area of the EU strategy is coordinated by the Northern Dimension Partnership in PublicHealth and Social Wellbeing (NDPHS), in which Germany is actively involved. Along with the EU andWHO EURO, this partnership is the biggest stakeholder in the field of health in the Baltic Sea region.The partnership brings together all of the countries bordering the Baltic Sea, with the exception ofDenmark.I understand that the NDPHS and the Baltic Sea Parliamentary Conference are already cooperatingwith each other. I believe that it would be worthwhile for your new Working Group on Innovation inSocial and Health Care to work towards intensifying this cooperation.– 532 –II WG homework 1 – Answer from GermanyAs you are undoubtedly aware, last autumn Germany took over as Chair of the NDPHS for a two‐yearperiod. This work is being coordinated within my Ministry by the Global Health Policy Division (Z 23).Please do not hesitate to contact this Division at any time if you should have any further questions.In addition, the enclosed documents provide a good overview of health projects in the Baltic Searegion between 2007 and 2013.I hope that this information will be of assistance to you.Sincerely,Yours (m.p.)Sgd. Hermann Gröhe– 533 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Hamburg– 534 –II WG homework 1 – Answer from HamburgBaltic Sea Parliamentary Conference BSPCThe BSPC Working Group on Innovation in Social and Health Care9 December 2013/The WG SecretariatHomework 11. PurposeThis first homework of the BSPC Working Group on Innovation in Social and Health Care (WGISHC) addresses a number of questions of a general nature concerning the existence of publicstrategies and measures to support ISHC. It will also provide an indication of the level ofpolitical support for ISHC.At this stage, and as a basis for the subsequent orientation of the activities of the WG, it isimportant to obtain an overall picture of the situation and status of ISHC in the BSPC memberstates.Members of the WG are kindly requested to produce a concise response (a couple of pages) tothe questions below. The response should be submitted to the WG Secretariat no later than 26February 2014. The answers will be compiled and distributed to the WG before the next WGmeeting in Tromsø on 27-28 March 2014.The answers will also be used to amend and develop the WG Scope of Work and to provideinput and inspiration to the political recommendations of the WG.2. BackgroundThe preliminary interpretation of ISHC by the Working Group is that ISHC deals with the issueof securing the provision of qualitative and equitably distributed social and medical services tothe citizens in a situation of changing demographics, altering patterns of somatic and mentalailments, and constrained financial resources.The overarching objective of the WG is to elaborate political positions and recommendationspertaining to innovation in social and health care. The recommendations constitute anexpression of the political views and positions of parliamentarians from the entire Baltic SeaRegion. It is essential that the recommendations focus on the political added value thatparliamentarians can bring to the process of stimulating ISHC.In a first step, the WG should aim at obtaining a comprehensive picture of the challenges anddrivers of ISHC, as well as a representative overview of measures that have been applied topromote ISHC. The overview should also include examples of gaps and needs for new or otherforms of support for ISHC. In its follow-on work, the WG should i.a. collect and compile a setof representative practical examples of ISHC.3. Questions to the BSPC Member States on Strategies and Measures to SupportInnovation in Social and Health Care (ISHC)1. What, from your perspective, are the main challenges facing social and health care todayand in the future?– 535 –II WG homework 1 – Answer from Hamburg Helping long-term benefits claimants to get back into employment Reducing the risk of poverty, especially preventing poverty in old age Bringing social policies into line with demographic change Encouraging and making use of cultural diversity Increasing labour market participation Generationally just, adequate pension provision Quality-controlled, effective health and social care provision Reform of legislation on participation and inclusion (implementation of the UN Conventionon the Rights of Persons with Disabilities, reform of integration assistance, reform of BookIX of Social Security Code: SGB IX).The biggest challenge is demographic change. It is obvious that changes in the size andcomposition of the population have direct effects on morbidity (e.g. dementia, cancer,cardiovascular disease, metabolic diseases), on care requirements and on the state of health ofthe population in general. It must also be borne in mind that demographic change has an impact onthe number of people employed in the health professions, and that requirements here areprojected to increase. The structure, content and organisation of healthcare provision will have tobe adapted to meet the challenges. As far as healthcare structures are concerned, the relationshipbetween urban and peripheral regions presents a particular challenge. Regarding content, it shouldbe pointed out that the sensible goal, not just in view of demographic change, of avoiding theincidence of chronic illness in particular cannot be achieved through curative-based healthcarealone. It will be necessary to put prevention and health promotion on a firmer footing and tosupport them better.After demographic change, the second huge trend is the acceleration of technological progress,particular in the fields of communications and biosciences. ICT in the healthcare sector (e-health)is gaining greater acceptance. Biotechnology (genomics, proteomics, personalised medicine) canbe expected to play a greater role in healthcare provision as costs become competitive. Concretechallenges here are overcoming the difficulties of introducing and integrating new technology intoexisting care systems, on the one hand, and ethical aspects, funding and ensuring fair publicaccess to care on the other.2. Have you launched any public strategies and programmes for ISHC? Are any new initiativesplanned? What are your experiences and results so far concerning public programmes andmeasures to support ISHC?It will be less a question of developing new initiatives than organising better cooperation betweensystems. For instance better linkage between labour market programmes and local government services in thepsychosocial counselling area, or collaboration between the youth welfare service, Jobcenter (for long-term unemployed) andArbeitsagentur (employment agency for short-term unemployed) on an agency for youngjobseekers (Jugendberufsagentur: JBA) to ensure no young person is left behind, or Hamburg state action plan for implementing the UN Convention on the Rights of Personswith Disabilities; Confederation of Ministers for Labour and Social Affairs (ASMK) processto reform legislation on integration assistance and participation; federal reform of the caresector.3. Have you launched any public awareness campaigns concerning ISHC? Are any newinitiatives planned?– 536 –II WG homework 1 – Answer from Hamburg Hamburg’s JBA (see 2 above) is a model for the Federal Government which plans tointroduce it Germany-wide. The Hamburg action plan on the UN Convention on the Rights of Persons with Disabilitiesrepresents the start of a programme to implement it in all spheres of life.4. Have you launched any public economic support mechanisms for ISHC, such as dedicatedfunding, seed money or tax incentives? Are any new initiatives planned?see 2 above5. In general, what do you see as the main obstacles for promoting and implementing ISHC?What kind of political support and measures are conceivable to overcome the obstacles?see 2 above– 537 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Latvia– 538 –II WG homework 1 – Answer from LatviaIn response to your letter on 16 December 2013 No. 1/1113-214, please find attachedthe answers by the Ministry of Health of the Republic of Latvia to the questions ofthe Baltic Assembly and the Baltic Sea Parliamentary Conference Working Groupon Innovation in Social and Health Care1. What, from your perspective, are the main challenges facingsocial and health care today and in the future?In our perspective, the main challenges are:- to reduce premature mortality and morbidity of most common chronic non-communicable diseases - cardiovascular diseases, cancer, mental illness, perinataland neonatal period conditions;- to achieve increase of health care funding;- establishment of the new health care financing system, linking state funded healthcare delivery by paying taxes, while defining vulnerable groups who will receivestate funded health care, regardless of the fact of paying taxes;- e-health implementation and development;- health care workforce development.2. Have you launched any public strategies and programmes forInnovation in Social and Health Care (ISHC)? Are any newinitiatives planned? What are your experiences and results so farconcerning public programmes and measures to support ISHC?We have launched a number of policy planning documents concerning innovation inhealth care: There was developed and adopted medium term policy planning document The PublicHealth Strategy 2011 – 2017 in Latvia. The aim of this document is to prolong thehealthy life years of the Latvian population and to prevent untimely deaths, whilemaintaining, improving and restoring health. In order to improve maternal and child health in Latvia (including reduced perinatalmortality and maternal mortality) the Ministry of Health of the Republic of Latvia haselaborated and the Cabinet of Ministers has approved the Maternal and Child HealthImprovement Plan 2012 – 2014, which includes infertility treatment into a state-funded services that include assessment of the prevalence of infertility in Latvia bycollecting data. The Ministry of Health has developed and the Cabinet of Ministers has approvedAction Plan to Prevent Heart and Cardiovascular Diseases for 2013-2015. The aim ofthe Action Plan is to decrease the morbidity and mortality of heart and cardiovasculardiseases and to decrease their risk factors negative impact on the public health.– 539 –II WG homework 1 – Answer from Latvia2According to Action Plan the general practitioner nurse`s will carry out thecardiovascular risk screening once a year. The Cabinet of Ministers has approved the Action plan for Reduction of AlcoholConsumption and Restriction of Alcohol Addiction for 2012-2014. The aim of theAction Plan is to reduce alcohol related harm for public health, which is ensured byplanned, harmonized and coordinated actions. New amendments in Handling of Alcoholic Beverages Law have come into force inyear 2013. For example, the amendments define that alcoholic beverages cannot besold on the Internet; persons (aged 18 to 25) are obligated to show a personalidentification document when purchasing alcoholic beverages. At the end of 2013, theMinistry of Health has developed next draft on the advertising restrictions. Since 23 February 2013, new psychoactive substances are put under control bygeneric approach, which means that clusters of psychotropic drugs which evolve fromthe same basic chemical formula are banned in advance. The term "new psychoactivesubstance" is introduced in the law since 14 November 2013. In spite of a significant reduction of tobacco environmental smoking in workplaces,there is still high environmental smoking prevalence at homes. To reinforce civicawareness on tobacco harm and to limit smoking in the presence of children, therewas amended Law on Protection of Children Rights in the beginning of 2013. TheLaw states that smoking in the presence of a child is physical violence. After that,initiative to protect pregnant women from tobacco smoke was passed in Parliamentunder tobacco control law. In 2012, the Ministry of Health initiated new approach for organization of healthpromotion in municipalities. Local governments were encouraged to delegate acontact person from the municipality to the Ministry for cooperation in healthpromotion questions and for dissemination of actual information related to healthpromotion activities. At the end of 2012, the Ministry of Health together with Centre for Disease Preventionand Control (CDPC), WHO Country office in Latvia, Latvian Union of localgovernments and Riga Stradins University started development of new initiative“National Healthy Municipality Network” to coordinate activities of WHO“Healthy Cities” movement, to provide methodological support, to assistmunicipalities in developing health promoting programmes, to organize regularmeetings and training for contact persons etc. In order to involve more the municipalities in health promotion activities, the Ministryof Health has elaborated „Guidelines for Health Promotion in Municipalities”(approved with the Order of the Ministry of Health No.243 of 29 December 2011).The Guidelines provide municipalities with science-based information to implementhealth promotion (physical activities; nutrition; prevention of addiction-inducing– 540 –II WG homework 1 – Answer from Latvia3substances; family health, including safety promotion; injury prevention etc.) and toimprove the development of healthy behaviours and lifestyle of the local population. On 22 August 2006, Regulations of the Cabinet of Ministers were adopted with theaim to restrict the availability of soft drinks, sweets and salty snacks in educationinstitutions (schools and kindergartens). According to the Regulations, soft drinkswith added food additives (colours, sweeteners, preservatives), caffeine and aminoacids (i.e. energy drinks), sugar confectionery containing colours, sweeteners(candies, caramels), chewing gum containing colours, snacks containing 1.25g ormore salt per 100g or 0.5g or more sodium per 100g are not distributed in educationinstitutions. In March 2012 Regulations of the Cabinet of Ministers regarding dietary standardsin schools, kindergartens, long-term social care institutions and hospitals wereadopted. Regulations provide that the everyday menu of pupils and patients in theseinstitutions should include food products rich in complex carbohydrates; vegetablesand fruit, including fresh ones; food products rich in proteins. Following foodproducts should be excluded – French fries and similar products, margarine andconfectionery containing partially hydrogenated vegetable fats, instant soups andpotato mashes, oils from genetically modified ingredients etc. National Health Insurance Concept foresees establishment of the new health carefinancing system, linking state funded health care delivery by paying taxes, whiledefining vulnerable groups who will receive state funded health care, regardless ofthe fact of paying taxes. E-health Latvia is a policy planning document for more efficient use of informationand communication technology tools. The main objectives of e-health developmentare to: improve health, promote individual control of their health; reduce wasted timespend on patients contacts with medical institutions; increase the effectiveness of thehealth care, providing health care specialists with a quick access to necessary patienthealth data; reduce the amount of information that health care specialists need to enterinto the documents; increase the amount and usability of a structured information;increase effectiveness of medical institutions; increase health care data reliability andsecurity. In the Policy Document’s “Improvement of Inhabitants’ Mental Health for 2009-2014” Implementation Plan for 2013-2014 is planned to research the deploymentoptions and solutions of the „Mobile psychiatric team” (professionals, servicesprovided, recipients of services). Also if the necessary funding will be granted, it isplanned to introduce Emotional Support telephone services to the residents of Latvia116123. In 2006, the National population genome database was created. The use ofresources included in the database for human genome research, revealing the genetichealth risks, as well as creating of new medical preparations are essential for– 541 –II WG homework 1 – Answer from Latvia4forecasting of the progress of diseases, for prevention and initiating of appropriatetreatment thereby improving the welfare of the people. The Ministry of Health has prepared a short-term policy planning document “PrimaryHealth Care Development Plan for 2014-2016” with the aim to strengthen primaryhealth care as the most available, effective and comprehensive health care level, byincreasing the role of primary health care in prevention, diagnostics and treatment, aswell as to improve the quality of primary health care.Future initiatives: The Ministry of Health has developed a draft of legislation to reduce industriallyproduced trans fatty acids in food products. The proposal includes thedevelopment of a legal act to restrict the amount of trans fatty acids in food products. To develop legal regulation for defining energy drinks and to regulate themarketing and advertising of energy drinks. This year one Member of theParliament initiated that the use of energy drinks in Latvia should be restricted tochildren and he developed a draft of law for energy drinks in cooperation withMinistry of Health, Centre for Disease Prevention and Control and nutritionspecialists. This draft of law for energy drinks also includes restriction of trading,advertising and marketing of energy drink to persons who are younger than 18. There is a plan to develop legal framework for electronic cigarettes in Latvia.3. Have you launched any public awareness campaigns concerningICHC? Are any new initiatives planned?We have not launched any public awareness campaigns concerning ICHC.4. Have you launched any public economic support mechanisms forISHC, such as dedicated funding, seed money or tax incentives?Are any new initiatives planned?We have launched Action plan for Reduction of Alcohol Consumption andRestriction of Alcohol Addiction for 2012-2014 that provides for the Ministry ofFinance to develop an evaluation report to implement the optimum excise rate ofalcoholic beverages, taking into account the objectives of national fiscal and healthprotection.5. In general, what do you see as the main obstacles for promotingand implementing ISHC? What kind of political support andmeasures are conceivable to overcome the obstacles?– 542 –II WG homework 1 – Answer from Latvia5One of the barriers for promoting and implementing innovation in health care isinsufficient funding. In the most cases for the innovative activities in health care there isneed for additional funding. In order to introduce innovative activities or services notonly political support is needed, but also medical institutions and health worker support,adaption of infrastructure is needed.– 543 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Lithuania– 544 –II WG homework 1 – Answer from Lithuania– 545 –II WG homework 1 – Answer from Lithuania– 546 –II WG homework 1 – Answer from Lithuania– 547 –II WG homework 1 – Answer from Lithuania– 548 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Mecklenburg-Vorpommern– 549 –II WG homework 1 – Answer from Mecklenburg-Vorpommern– 550 –II WG homework 1 – Answer from Mecklenburg-VorpommernAppendix 1Response by the Ministry of Social Affairs to the BSPC questionnaire oninnovation in social and healthcare1. What, from your perspective, are the main challenges facing social andhealthcare today and in the future.Regarding healthcare:The main challenges for healthcare in Mecklenburg-Vorpommern are thedemographic shift in connection with sparsely populated areas and partiallydisadvantageous socio-economic structures.The demographic shift leads to an advance and shift of the burden of disease,especially among the group of elderly citizens. At the same time it also becomesmore difficult to ensure a comprehensive, high-quality provision for shrinkingpopulation groups, for instance children and youth.When factors such as an ageing society, low incomes, and sparsely populated ruralareas interact with the consequences of long distances to healthcare infrastructureas well as reduced public transport services, mobility and accessibility can becomethe central factors for the utilization of healthcare services.At the same time the demographic shift also impacts those who supply healthcareservices. Among others, the average age of, for instance, doctors, rises and itbecomes increasingly difficult to recruit new generations for the tasks of healthcareprovision.The financing of public health is furthermore seen as being problematic. Rising costsare increasingly a result of a rising need for treatment of the ageing population, butalso of medical progress.Taken together, the ageing and shrinking population shows a growing and changingneed for healthcare provision and prevention. Despite the shrinking population thereis an above-average need for treatment and care all the while major challenges insparsely populated rural areas and disadvantageous socio-demographic conditionsremain. This demand is linked with a rising shortage of skilled workers and fundingproblems.These challenges already exist and will become more problematic in the years tocome.Regarding social care:Also in the social domain the demographic shift poses major challenges. At thefederal level Volume II of the Social Code (SGB II) applies – which also regulatesmunicipal services (for instance costs for accommodation and heating as well aseducation and participation) – as well as Volume XII of the Social Code (SGB XII). InMecklenburg-Vorpommern especially the state law for the blind and the execution ofthe Pact for Education and Participation via the law governing the implementation ofSGB II apply.– 551 –II WG homework 1 – Answer from Mecklenburg-VorpommernFurthermore, the new coalition partners at the federal level have, among others,agreed that the integration assistance shall be developed into a modern participationlaw. The implementation of the participation of people with disabilities shall bereorganized in their favor. Against the background of the UN convention to protectthe rights of persons with disabilities it is no longer acceptable to refer people withdisabilities to the social security system. It is the goal to relieve the municipalities ofall states from € 5 billion per annum in integration assistance costs. A Benefits Actshall enter into force. Already before its adoption the municipalities shall be relievedof € 1 billion per annum. Furthermore, the introduction of a participation supplementat the federal level for people with disabilities shall be evaluated.The same demographic aspects, which apply in the case of healthcare, are relevantin the nursing sector. This is true both for the expected strong increase in the numberof elderly people with nursing needs and dementia patients as well as for the needfor well-educated nursing staff. At the same time it is imperative to structure andadapt the nursing structures in such a way they comply with the principle “outpatientrather than in-patient” both in urban and rural areas in line with what is asked for.This and the adaptation of the municipalities to the diverse needs in the work withand the care for elderly people, along with a strengthening of people’s individualresponsibility, are a prerequisite for keeping costs in the nursing sector in checkThe vast part of the population in Mecklenburg-Vorpommern above the age ofcurrently 65 years receives benefits from the public pension scheme. The currentacceptable general pension level cannot be maintained without effective andsustainable measures. Due to times of unemployment, incomplete full-time workinghours and low wages the number of retirees suffering from poverty will increase inthe future.Unemployment, on the one hand, and long distances to the work place, on the other,have proven to constitute factors which stand in the way of a strong civil society. Thegovernment of Mecklenburg-Vorpommern intends to improve the frameworkconditions for interested citizens of various backgrounds and with their individualabilities to assume responsibility for a democratic society. Voluntary civil engagementcontributes to political and social integration.2. Have you launched any strategies and programs for Innovation in Social andHealthcare (ISHC)? Are any new initiatives planned? What are your experiencesand results so far concerning public programs and measures to support ISHC?Regarding healthcare:The provision of healthcare lies first and foremost with the healthcare actors. Theassociation of statutory health insurance registered doctors – an institutionincorporated under public law – is responsible for the provision of outpatient care.The financing of outpatient care is organized via performance fees from the healthinsurance companies. The provision of hospital care is a task of general publicinterest for the state, the administrative districts and the urban municipalities. It isrealized by hospitals whose necessary investment costs are financed from the statebudget. The state carries 60 % and the administrative district and the urbanmunicipalities 40 % of the costs for the financial support of the hospitals. The– 552 –II WG homework 1 – Answer from Mecklenburg-Vorpommernoperating costs of the hospitals are financed through performance fees from thehealth insurance companies.The legal frameworks for healthcare are predominantly set at the federal level.Against this background, comprehensive strategies and programs to supportinnovation in healthcare are not a primary task of a federal state. Therefore, theinitiatives of the state mainly concentrate on bringing healthcare actors together, thuscontributing to solutions for the provision of healthcare.The Minister of Social Affairs is steering a concerted action group with the respectivehealthcare actors to deliberate questions on innovation in healthcare, especially theclose coordination of in-patient and outpatient care and regional healthcare provisionconcepts. The participants of the group usually meet twice a year.The following strategies have been developed with the involvement of the Ministry forSocial Affairs regarding individual aspects of healthcare provision and prevention: state geriatrics plan, plan for the further development of an integrated aid system for mentally illpeople in Mecklenburg-Vorpommern, a code of practice for the cooperation between child and youth welfare andchild and youth psychiatry in Mecklenburg-Vorpommern, a state action plan for the promotion of health and prevention child health goals action program on workplace health promotion .Generally, the experience gained from the implementation of such strategies showsthat this can only succeed with the inclusion and support of the relevant actors in thehealthcare sector and that regional circumstances play an important role.In the future, approaches to initiating regional healthcare provision concepts shall bepursued.Regarding social care:At the state level, strategic milestones for a care strategy in the context of a“Roundtable Care MV” are being developed. The following aspects are relevant: the development of a healthcare provision infrastructure that is tailored to suitactual needs the development of a personnel acquisition and skilled labor initiative for thehealth- und eldercare under the leadership of the healthcare sector the further development of quality management reform of the definition of the term “long-term care” at the state and federallevel improvement of the support for dependents, strengthening of individualresponsibility and further development of care center infrastructure improvement of prevention and rehabilitation extension of the municipal focus – strengthening of municipal responsibilityand structures definition and design of needs of rural areas inclusion of research and technology– 553 –II WG homework 1 – Answer from Mecklenburg-Vorpommern securing and expansion of financial basis.Furthermore, the “Report on the Situation of Nursing Professions in Mecklenburg-Vorpommern” is intended to contribute to the development of nursing professions inthe state. This report is currently being drafted by the Center for Social ResearchHalle on behalf of the Ministry of Social Affairs. The report focuses on the nursingstaff and companies with their working and framework conditions. The results shallcontribute to high-quality nursing in Mecklenburg-Vorpommern and shall yieldrecommendations from which concrete measures can be deduced, for instance inorder to attract skilled workers and to improve the image of nursing professions.The state program “Ageing in Mecklenburg-Vorpommern” intends to set an impetusfor politicians in the state to work with the older generation on the demographic shiftin order to design the societal parameters in such a way that the societal integrationof the older generation is promoted and that its specific participation prospects areimproved.Equally as part of the reporting on social issues, a study on the situation of peoplewith disabilities in Mecklenburg-Vorpommern was conducted between 2010 and2012 on behalf of the Ministry of Social Affairs. The study aimed at gaining a specificand valid scientific basis to evaluate the current situation of people with disabilities inthe state. The results were considered in the process of drafting a plan of action bythe state government on the implementation of the UN convention to protect therights of persons with disabilities, which became legally binding in Germany in March2009. With its action plan the state government provides an important and future-oriented contribution on the path towards an inclusive society.3. Have you launched any public awareness campaigns concerning ISHC? Are anynew initiatives planned?Regarding healthcare:Campaigns aimed at increasing public awareness are mainly conducted within thefield of prevention. This is predominantly achieved by the support of nationwidecampaigns, e.g. equity in health, sexual health and alcohol prevention.Regarding social care:The democratic participation especially of the elderly population in the lawmakingprocess of the state is emphasized through certain rights of participation in thatprocess.Networking between institutions and projects concerned with volunteer work and civilengagement is conducted and subsidized by the state government. Civil engagementis recognized by broad support and awards.Volunteerism and individual responsibility is also strengthened by restructuring partsof the social code, redesigning care support facilities as well as by supportingmunicipalities in their planning and organization of policies for elderly people andlong-term care.– 554 –II WG homework 1 – Answer from Mecklenburg-Vorpommern4. Have you launched any public economic support mechanism for ISHC such asdedicated funding, seed money or tax incentives? Are any initiatives planned?Regarding healthcare:Current support is granted by public means of the Federal State with regard to (co-)funding of substance abuse centers of the counties (co-)funding of contact- and information centers for self-help groups consultation aimed at prevention of sexually-transmitted diseases (STDs) bycharter institutions support of projects of institutions dedicated to health promotion and preventionThe funding is not explicitly focused on the creation of innovative approaches yetaims implicitly at it.One example for the funding of innovative approaches in health care is the project“Psychiatry on the case”, which focuses on advancing the care of mentally ill elderlypeople.Another small portion of funding of innovative approaches goes to projects dealingwith the challenges of demographic change in regards to health care. The fundingused to subsidize studies for pharmaceutical supply/ polypharmacy conducted withelderly/ chronically ill patients as well as evaluating job satisfaction of generalpractitioners. Funding of an innovative project relating to transition- and dischargemanagement (transition from inpatient to outpatient care) is planned for 2014.In the context of an action program to strengthen health promotion at the work placein Mecklenburg-Vorpommern innovative and high-quality projects with sustainableapproaches are promoted.Regarding social care:Current support granted by public funding of the Federal State with regard to funding of guardianship associations funding of social and professional integration as well the participation ofmigrants funding of universal counselling funding of crisis intervention (crisis line) funding of aid for people under onerous circumstances ( other outpatientmeasures) funding of debt counselling offices/ consumer insolvence advisory offices funding of outpatient measures dedicated to persons with disabilities funding of networks and senior representations funding of volunteer projects training and advanced training for volunteersAs an example the target plan of the Social Code II (SGB II) can be referenced. Inaccordance with § 48b SGBII target plans are agreed upon between the FederalMinistry of Labor and Social Affairs and the responsible state authority (in the case ofMecklenburg-Vorpommern: Ministry of Labor and Social Affairs) as well as betweenthe responsible state authority and the municipal agencies endorsed by the SGB II.– 555 –II WG homework 1 – Answer from Mecklenburg-VorpommernThis aims to reduce individual assistance requirements, to grant a professionalintegration, to avoid long-term benefit payments and to improve social participation.Besides the use of flagship project financing from the federal level as well as the swiftimplementation of the reform of the concept of care dependency, the federal state willcontinue its financial support especially in the following areas: funding of care facility centers as an instrument of consulting and developmentin the community funding of care planning and outpatient pilot projects in districts andadministratively independent towns funding of expansion of outpatient and semi-residential care funding of semi-residential care funding of expansion of offers of day and night care as well as short-term care funding of low threshold care5. In general, what do you see as the main obstacles for promoting andimplementing ISHC? What kind of political support and measures are conceivableto overcome the obstacles?Regarding healthcare:The separation between the health sectors obstructs the support and implementationof innovation in healthcare, particularly the separation between inpatient care(hospitals) and outpatient care (usually approved doctors) meant to be guaranteed byvarious actors and to be subsidized in line with various regulations. The term is alsorelated to the separation between medical treatment, rehabilitation and care.Especially the nexus between outpatient and inpatient care bears the risk ofinefficient care. Pharmaceutical supply serves as an example of communicationalproblems between inpatient and outpatient care as well as between generalpractitioners and medical specialists. This may lead to unintended doublemedication.Furthermore, as a consequence of the demographic shift the requirements for healthcare are changing. With the rising average age of patients the gravity and complexityof the status of health problems and requirements of patients increases as well.Therefore, a steady, continuous provision of healthcare needs to be ensured acrosshealthcare sectors.Especially with regard to a sparsely populated state as is Mecklenburg-Vorpommern,one has to consider that where certain health sectors may no longer be viable – forinstance with regard to the availability of general practitioners in the countryside – theboundaries of such sectors may have to be transcended. Healthcare in rural areas istherefore one central future project.Against this background, concepts of cross-sector care have lately been pursued.Volume V of the Social Code (SGB V) refers to the possibilities of integrated care(§ 140 a pp. SGB V) which is granted thanks to intertwinement between outpatientand inpatient care and rehabilitation as well as between medical and non-medical– 556 –II WG homework 1 – Answer from Mecklenburg-Vorpommernservice providers. This kind of care is suited for complex disease symptoms, whichare diagnosed by various service providers. Since the conclusion of contracts ofintegrated care takes place outside the system of collective contracts and the serviceguarantee of the association of statutory health insurance registered doctors,conflicts may arise more easily.The new Federal Coalition Agreement approves of the harmonization of legalframeworks and the abolishment of implementation obstacles with a view to theintegration of integrated and selective types of care. To his end the states haveagreed to the initiation of a working group, in which Mecklenburg-Vorpommern is alsorepresented.One major challenge concerns the extensive provision of high quality care in asparsely populated state. This encompasses the access to healthcare infrastructure,mobility and a minimum amount of patients that are necessary to provide adequatecare. Options for action include the establishment of centers for specializedhealthcare services, for instance with a view to cancer treatment, improved mobility,general medical treatment. Telemedicine can be seen as an additional importantpillar of extensive care.In the coalition agreement Mecklenburg-Vorpommern focuses on regional supplyconcepts and emphasizes the necessity of networking and interconnectedness withspecial regard to outpatient and inpatient offers. These issues are a frequent topic ofthe concerted action group, which the Minister of Social Affairs leads (see above).Further obstacles for innovation in healthcare are the division of labor, particularly inthe case of the medical and the nursing professions, and the working conditionsespecially in the nursing professions, which aggravates the shortage of skilled labor.New forms of division of labor might help improve the situation.Regarding social care:The deficient definition of connections between the sectors and their diverging formsas well as the funding issue all constitute obstacles to an adequate implementation ofcare. The reform at the federal level must go hand in hand with reforms at the statelevel.Finally, we refer to the report of the inter-ministerial working group on thedemographic shift which also deals with aspects of healthcare and social affairs. Thereport is currently in the departmental consultation and is going to be decided on bythe Cabinet by the end of the year.– 557 –II WG homework 1 – Answer from Mecklenburg-VorpommernResponse by the Ministry of Economic Affairs to the BSPC questionnaire oninnovation in social and healthcareThe paper drafted by the Secretariat of the Working Group constituted on December9, 2013 comprises five questions directed at BSPC member states about strategiesand measures on how to foster Innovation in Social and Health Care – ISHC.Additionally, item 2. – “Background” – describes in what way the Working Groupdefines and interprets innovation in social and health care. According to the WorkingGroup’s paper ISHC deals with the issue of securing the provision of qualitative andequitably distributed social and medical services to the citizens in a situation ofchanging demographics, altering patterns of somatic and mental ailments, andconstrained financial resources.Taking this definition as well as the introductory question of the survey into account,the survey primarily deals with classic aspects of social and health policy, which liewithin the competencies of the Ministry of Social Affairs.In that sense we also refer to the answer of the Ministry of Social affairs to thequestionnaire of the Working Group.The field of social and medical services naturally also incorporates economicopportunities and contributes as one part of the health economy to the overallnational economy. By now the issues of health, health economy and healthcare canno longer be regarded solely as cost factors but rather as a future growth sector. Inparticular, growth rates in employment, productivity and added value have beenachieved, which rely on the sustainable basis of the demographic development, themedical-technical advance as well as the rising conscience for health issues on thepart of the population.This claim is backed up by numbers from April 2013 published by the FederalMinistry of Economics and Technology on the state of health economy in a macro-economic context. According to these figures, the gross added value in 2020amounted to € 260 bn., or 11.1 % of the entire economy.This sector is an important contributor to employment. More than one in sevenemployees in Germany (4.5 million people) is occupied in the health economy. InMecklenburg-Vorpommern about 97,600 people are employed in this sector. Ofthese, 70 % work in in-inpatient, semi-residential and outpatient care. A smallerfraction works in medical engineering, health trade professions and administration.Between 2000 and 2010 employment grew by 24.3 % in Mecklenburg-Vorpommern.In contrast to that, total employment has decreased by 9.3%.The state government has identified the health economy as a strategic future marketand has undertaken several important steps in this regard.On the on hand, the Landtag has declared the health economy as an essentialdevelopment theme in an act of parliament from 2004 and has defined a frameworkfor action “Masterplan Health Economy 2010”, which was updated in 2011 on behalfof the Ministry of Economics until 2020.On the other hand, the „Board of Trustees Health Economy“ and its five affiliatedstrategy groups paved the way for a nationally unique „Health Parliament.“ This– 558 –II WG homework 1 – Answer from Mecklenburg-Vorpommernparliament allows for an integration of all decision-makers from science, economicsand politics into the overall context.One result of this process is the fact that over € 2 bn. have been invested in thevarious sectors of the health economy since 1990. Mecklenburg-Vorpommernfeatures 39 modern hospitals, including two university hospitals as well as 60prevention and rehabilitation facilities and 60 state-certified health resorts (top of anationwide ranking).Another part concerns the services sector, in particular health services. This fieldreceives particular attention. Within the framework of the “Board of Trustees HealthEconomy” a separate strategy group area is responsible for this thematic field anddeals with the updated Masterplan Health Economy. Its main themes arerehabilitation, prevention and high-performance medicine. As these are located at thecrossroads between the contributions-based healthcare system and the privatelyfinanced „health market” they also have to be regarded from an economic viewpoint.The modern high-performance medicine, above all, is of particular importance for thecontinued economic growth in the health economy in Mecklenburg-Vorpommern.Especially the link between science, medicine and the economy constitutes aninevitable precondition for innovation and value creation in Mecklenburg-Vorpommern.At this point the state government, and especially the Ministry of Economic Affairs,considers the funding of research, development and innovation as a high prioritysince international competitive products and services ensure future-orientatedemployment. By means of orientation towards this kind of employment we intend tosustainably increase value creation and the level of income in the state. Thetechnology policy especially aims to more effectively use the potential of science,benefitting the development of the regional economy.Promotion of research, development and innovationDuring the Funding Period 2007-2013 a total of € 155 m. from the European SocialFund (ESF) and the European Regional Development Fund (ERDF) could be usedand applied to promote research, development and innovation in Mecklenburg-Vorpommern. Until December 2013 € 151.3 m. could already be committed; 37.3 %of that to biotechnology and medical engineering. 808 projects are being funded withthe money. During the new Funding Period 2014-2020 an estimated € 137 m. will beavailable via the ERDF for the promotion of research, development and innovation.In principal two different funding schemes are available:a) Support through the allocation of venture capital currently via the TechnologyFund Mecklenburg-Vorpommern (TFM-V)The TFM-V invests venture capital in innovative, growth-oriented technologycompanies in Mecklenburg-Vorpommern. Small businesses in their seed-, start up-and first expansion phase receive financial support. The TFM-V invests, as far aspossible, in cooperation with private investors. The fund management of the TFM-Vhas bought Genius Venture Capital GmbH. The TFM-V investments comply with theinvestment principles according to the relevant EU official publication. The allocation– 559 –II WG homework 1 – Answer from Mecklenburg-Vorpommernoccurs via open capital interest (usually minority shareholding) or a combination ofopen and silent participation in incorporated enterprises.Emerging innovative technology companies that fulfil the following criteria receivefunding: companies with less than 50 employees and less than € 10 m. volume of salesor less than € 10 m. total, companies younger than 6 years, companies with a registered office or main commercial unit in Mecklenburg-Vorpommern.Capital ownership averages € 150,000 up to € 1.5 m. over a 12 months period.Co-Investments of private investors are sought and are required in case of expansioncapital and later-stage financing.b) Support through promotion of research, development and innovationDirective for the promotion of research, development and innovation (extended untilend of 2014)Measures of the directive:1. Scheme for research and development projects(a) single enterprise projects; b) joint research projects)2. Technical feasibility studies3. Commercial property law activities through SMEs4. Support of upcoming innovative companies5. Process- and business innovations in the services sector6. Innovation consulting services and innovation support services7. Loan of highly qualified personnel from research institutions or large enterprisesto SMEs8. Technology-oriented networksIn addition to 1a) Single Enterprise ProjectsSmall, medium and large enterprises are eligible for funding. The following aspectsare eligible for funding: labor costs including fixed costs (up to 25%), project-specificinstruments and equipment, research and technical knowledge expenses,miscellaneous expenses and material. The reimbursement rates vary according toproject and company size (industrial research/small enterprises up to 70%, mediumenterprises up to 60%, large enterprises up to 50%, experimental development/smallenterprises up to 45%, medium enterprises up to 35%, large enterprises up 25%).In addition to 1b) Joint Research- and Development ProjectsSmall, medium and large enterprises in cooperation with research institutes areeligible for funding. The following aspects are eligible for funding: labor costsincluding fixed costs (up to 25%), project-specific instruments and equipment,research and technical knowledge expenses, miscellaneous expenses and material.The reimbursement rates vary according to project and company size (industrialresearch/small enterprises up to 80%, medium enterprises up to 75%, largeenterprises up to 60%, experimental development/small enterprises up to 60%,– 560 –II WG homework 1 – Answer from Mecklenburg-Vorpommernmedium enterprises up to 50%, large enterprises up 40%). Joint research institutescan be supported with up to 100%.Successful examples of funded projects:- Miltenyi Biotech GmbH,- Cortronik GmbH,- IT Dr. Gambert GmbH,- Human Med AG,- DOT GmbH.– 561 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Norway– 562 –II WG homework 1 – Answer from NorwayFebruary 2014Homework 1 – NORWAY1. PurposeThis first homework of the BSPC Working Group on Innovation in Social and Health Care(WG ISHC) addresses a number of questions of a general nature concerning theexistence of public strategies and measures to support ISHC. It will also provide anindication of the level of political support for ISHC.At this stage, and as a basis for the subsequent orientation of the activities of the WG, itis important to obtain an overall picture of the situation and status of ISHC in the BSPCmember states.Members of the WG are kindly requested to produce a concise response (a couple ofpages) to the questions below. The response should be submitted to the WG Secretariatno later than 26 February 2014. The answers will be compiled and distributed to the WGbefore the next WG meeting in Tromsø on 27-28 March 2014.The answers will also be used to amend and develop the WG Scope of Work and toprovide input and inspiration to the political recommendations of the WG.2. BackgroundThe preliminary interpretation of ISHC by the Working Group is that ISHC deals with theissue of securing the provision of qualitative and equitably distributed social and medicalservices to the citizens in a situation of changing demographics, altering patterns ofsomatic and mental ailments, and constrained financial resources.The overarching objective of the WG is to elaborate political positions andrecommendations pertaining to innovation in social and health care. Therecommendations constitute an expression of the political views and positions ofparliamentarians from the entire Baltic Sea Region. It is essential that therecommendations focus on the political added value that parliamentarians can bring tothe process of stimulating ISHC.In a first step, the WG should aim at obtaining a comprehensive picture of the challengesand drivers of ISHC, as well as a representative overview of measures that have beenapplied to promote ISHC. The overview should also include examples of gaps and needsfor new or other forms of support for ISHC. In its follow-on work, the WG should i.a.collect and compile a set of representative practical examples of ISHC.3. Questions to the BSPC Member States on Strategies and Measures to SupportInnovation in Social and Health Care (ISHC)1. What, from your perspective, are the main challenges facing social and health caretoday and in the future?- Demographic changes: Due to population growth and population ageing theneed for health care and social services will increase. There is thus a risk ofshortage of manpower. A large number of people will live longer without anysevere health problems but many will also live longer with chronic diseases and acomplex clinical picture.– 563 –II WG homework 1 – Answer from Norway- Increased demands: The citizens have large expectations towards the healthsystem. They claim services to be quickly delivered, advanced methods oftreatment and a focused, efficient and individual treatment.- Growth in lifestyle illnesses; most of them also being widespread diseases.- Health inequality; both nationally and globally.2. Have you launched any public strategies and programmes for ISHC? Are any newinitiatives planned? What are your experiences and results so far concerning publicprogrammes and measures to support ISHC?Norway has several public strategies and programmes for ISHC. Two white papers andone official report have been made, and these constitute the basis for severalprogrammes directed towards researchers, business life, users, patients, municipalitiesand the state. The programmes intend to facilitate development of new technologicalproducts and services, and to improve processes and ways of organizing. The aim is toenhance quality and efficiency within the health sector, to improve satisfaction amongpatients, next of kin and employees, and finally, to establish more competitivebusinesses on the health market, both nationally and globally.Examples of programmes: Innovation for a better health- and care service (2007-2017)This programme concentrates on research and demand-led innovation andcommercialization. It includes elements as IT, medical technical equipment, publicprocurement, and it deals with challenges such as chronic diseases, ageing population,better interaction and cooperation between service levels. It facilitates meeting arenasfor the supplier industry, the health sector and the policy administration.Actors; regional health enterprises, Innovation Norway, the Norwegian ResearchCouncil, the Norwegian Association of Local and Regional Authorities, Directorate ofHealth and InnoMed. InnoMedInnoMed is a national competence network for need driven innovation in the healthsector. Our goal is to contribute to increased efficiency and quality in the health caresector through the development of new solutions. These are based upon national needsand have international market opportunities. The solutions are developed in closecollaboration between users in the health sector, Norwegian companies, reputablespecialists and funding agencies. Read more on http://www.innomed.no/en/ National program for developing and implementing welfare technology32 municipalities (out of 428) participate in this programme and will be testing differenttypes of welfare technology, f. ex. a variety of safety packages, GPS, electronical lockingsystems and other solutions enhancing safety for users and their relatives. The goal is tomake it possible for elderly people to live at home as long as possible. Health care 21A national process aiming to develop a strategy for research and innovation in thehealth- and care sector. This work is intersectorial and all relevant actors are welcome tocontribute and participate. Strategy for increased innovation effect of public procurements– 564 –II WG homework 1 – Answer from Norway3.What are the results and effects?It is too early to evaluate the effects of the strategies and programmes mentioned above.However, the first one (“Innovation for a better health- and care service 2007-2017”)was evaluated in 2011 and the results indicated it had played a considerable role inestablishing a common, national focus on innovation in the health sector. Further, it hascreated a common focus and frame for the ministries and the actors in the health sector.Nevertheless, the effects on the actual innovation activity in concrete projects remainuncertain.4. Have you launched any public awareness campaigns concerning ISHC? Are any newinitiatives planned?The public effort is focused on establishing networks and including different actorsthrough open processes. Public awareness campaigns have not been a priority. However,a yearly innovation conference is organized in order to inspire various actors to getinvolved with innovation in health and care. The conference presents real and concreteinnovation stories from Norway and other countries. Next conference will be in November2014.5. Have you launched any public economic support mechanisms for ISHC, such asdedicated funding, seed money or tax incentives? Are any new initiatives planned?Innovation Norway enhances companies’ competitive advantage and creates newdevelopment in the corporate sector and in the Norwegian rural districts. It has sixpriority areas, one of them being health, including development of new medicines,medical technology and health related IT. Innovation Norway thus offers three types ofgrants; installation, research- and development, and innovation loans.Further, some of the public programmes described in point 2 do also offer grants fortrying out new ideas and experiments. Some examples: The Directorate of Health has a subsidy scheme for municipalities wanting to tryout different kinds of technological safety systems for elderly people living athome (28 million NOK in 2014). The Norwegian Research Council distributes grants to different innovation projectsin the health-and care sector. One example is a grant programme supporting newbusinesses and commercial actors using results from publicly financed researchinstitutions in their activities.5. In general, what do you see as the main obstacles for promoting and implementingISHC? What kind of political support and measures are conceivable to overcome theobstacles? Few investor environments, financial as well as industrial. Lack of capital andfinancial support in the initial phase and in the long run. Limited cooperation between business- and research actors. A gap between the research institutions and the health service, in particular themunicipal one.Evaluations of different public efforts confirm these obstacles. Hospitals, municipalitiesand other practical orientated public institutions are not sufficiently involved indevelopment projects. Further, while public project owners claim that limited resources(time and economy) is the most important barrier to innovation, private project ownersblame the lack of financial sources outside their business.– 565 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from the Russian Federation– 566 –II WG homework 1 – Answer from the Russian FederationPublic policies and programs on social securityand health care in the Russian FederationIn the Russian Federation, the state program "Social support to citizens” is underimplementation till 2020 (the program was approved by the Russian government inDecember 2012).State program aimed at improving social support certain categories of citizens, familysupport, the development of an effective system of social services.The program focuses on four sub-programs:- development of social support certain categories of citizens- modernization and development of social services-improving social support for families and children-Improving the efficiency of state support for socially oriented non-profitorganizationsThe objectives of the program are: the creation of conditions for the growth of welfareof citizens of the recipient of social support, increasing the availability of socialservicesThe program solves the following problems:- fulfillment of the obligations of the state for social support of citizens- meet the needs of senior citizens, the disabled, families and children in social care- creation of favorable conditions for the family functioning of the institution of thefamily, the birth of children- increasing the role of non-state sector of commercial organizations to provideservices.Russian Government approved the Strategy for long-term development of thepension system, its implementation will ensure a decent level of pensions to citizenson the basis of the principle of social justice.Modernization of social services is constrained by budgetary constraints due toincreased instability, suited for the Russian economy.In Russia there is a road map "Improving the efficiency and quality of services in thesphere of social services in 2013 - 2018", it provides that the share of non-governmental organizations dealing with social services among the total number ofinstitutions of all forms of ownership will be 10%.The proposed comprehensive changes to legislation will create the necessaryconditions for the development of public-private partnerships and to attractinvestment in social services.The introduction of public-private partnership in social services will help overcomelimitations of federal, regional and municipal governments to finance investmentprojects, as well as transfer part of the risks to the private sector, to use managementskills, expertise and experience of the private sector to improve the quality of socialservices provided to the population increase efficiency infrastructure management.– 567 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Schleswig-Holstein– 568 –II WG homework 1 – Answer from Schleswig-HolsteinBernd Heinemann, MdL26. Februar 2014Vermerk zur Vorbereitung:BSPC Working Group on Innovation in Social and Health Care1. What, from your perspective, are the main challenges facing social and health care todayand in the future?For Schleswig-Holstein the main challenges of social and health care at present (and probably grow-ing in the future) are:- The demographic and social change. The growing average age causes a decreasing numberof payers to social insurances while the number of recipients of benefits grows. The willing-ness to unpaid social work declines. The demographic change also leads to an increasingnumber of handicapped and disabled persons, care recipients and age-related diseases. Es-pecially in rural areas, the growing age of the inhabitants leads to new challenges, such asmobility, adaption of public services and a growing need of social and health care, which arecontrary to the following two points.- A lack of qualified personnel, especially for nursing care. It is mainly caused by unattractiveconditions such as a low reputation of the career, relatively low payment and dissatisfyingworking circumstances.- General medical care. Especially in rural areas, there’s a lack of general practitioners. Withinthe next five years, one quarter of the GPs in rural areas will retire. Young academics shyaway from establishing themselves in rural areas because of high workload, high investmentcosts and living in rural areas in general, which commits them to their surgery for years. Manyyoung doctors prefer not to be self-employed.- Funding. Due to the debt limit and the pressure on social insurances it gets harder to financesocial and health care projects – in times, when modernization and change are exceptionallyneeded.- High insurance rates and a drop in the birthrate apply pressure on midwifery, especially in theperipheral areas2. Have you launched any public strategies and programs for ISHC? Are any new initiativesplanned? What are your experiences and results so far concerning public programs andmeasures to support ISHC?3. Have you launched any public awareness campaigns concerning ISHC? Are any new initia-tives planned?There are different strategies and programs in Schleswig-Holstein, initiated by different actors in thesocial and health care sector. Because of the autonomy of the German public health sector and thefederal structure only specific programs and initiatives from Schleswig-Holstein or (co)financed bySchleswig-Holstein are mentioned.- “Gesundheitsinitiative Schleswig-Holstein” (since 2000) – Network-building between pro-viders of health services, medical associations, health insurances and science. Intention is toprovide information and transparency about health proposals and to secure a regional and so-cially just medical care.- “Medibüro” – medical care for people without health insurance, especially immigrants; since2014, Schleswig-Holstein provides financial support to such initiatives- “Kompetenzzentrum Demenz” – coordination and support of helpdesks and facilities deal-ing with dementia- “Pflegestützpunkte” – support and guidance for people with care dependency- Funding of innovative low-threshold care and self-help projects, especially for people effectedby dementia- “Sozialräumliche Eingliederungshilfe” – model project of financing and planning of publicsocial benefits for disabled people in Nordfriesland- “Partyprojekt Odyssee” – prevention of addiction of young people, especially against alcoholand drug addiction by guidance in discotheques and during festivals– 569 –II WG homework 1 – Answer from Schleswig-HolsteinBernd Heinemann MdL, 03.03.14VermerkSeite 2Initiatives financed by other public institutions:- ”Land.Arzt.Leben” – Image campaign of the KVSH (association of the CHI physicians) withsupport for students and general practitioners in training to promote settlement in rural areasPlanned or in development:- A Chamber of Nursing- Modernization of nurse schooling and a nursery degree course- Regional health conferences – network-building in regional contexts- An agenda for disabled people- An dementia agenda- Modernization of the psychiatry structure, particularly ambulantory care and psychosomaticcare- A concept for midwifery- An initiative for diabetes prevention4. Have you launched any public economic support mechanisms for ISHC, such as dedicatedfunding, seed money or tax incentives? Are any new initiatives planned?Because of the federal structure of Germany, the possibilities of tax incentives funding for the federalstates are relatively limited. Funding of social projects and initiatives is mostly realized by structuralfunding or project funding. The project funding could often be described as kind of seed money.The health care projects and programs are often co-financed or initiated by the public social insuranc-es and/or the medical associations. The influence of the states is often limited to network-building orcooperation. Dedicated funding is reduced to a special group of projects like debt counseling, which ispartly financed by gamble fee.5. In general, what do you see as the main obstacles for promoting and implementing ISHC?What kind of political support and measures are conceivable to overcome the obstacles?Main obstacles for a federal state in Germany are:- the self-administration of the German health system, which includes many actors with differentpolitical and economical aims- the mostly communal-based and partly private social care structureBoth structures have well justified historical and political origins, but are very hard to change for a sin-gle federal state. Innovation is mostly implemented by the structures themselves, but public further-ance is limited by financial aspects and competence of levels.From the view of a German federal state there are mainly two ways to implement innovative projectsconcerning social and health care: First, to implement model projects in cooperation with different wel-fare and communal actors. Second is to affect to changes at federal or communal level.– 570 –Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Åland– 571 –II WG homework 1 – Answer from ÅlandQuestions to the BSPC Member States on Strategies andMeasures to Support Innovation in Social and Health Care(ISHC)Answers from Annette Holmberg-Jansson, member of the ÅlandParliament and BSPC ISHC workinggroup1. What, from your perspective, are the main challenges facing social and health care todayand in the future?- Ageing populations- The problem of choosing what health care measures/technologies to implement in publiclyfunded healthcare services as increasing medical possibilities with innovation andevelopment seems to inevitably increase healthcare costs (although it can lead to decreasedcosts elsewhere - decrease sick leave/pensions payments etc.)- Downsides of a more globalized healthcare/population: emergence of new types of as wellas an increase in known mulitresistant bacteria, cultural and linguistic challenges, follow-upof procedures/medication initialized elsewhere etc.- The need within elderly care for and availability of multi-professional staff to work theprevention, activating and rehabilitation.2. Have you launched any public strategies and programs for ISHC? Are any new initiativesplanned? What are your experiences and results so far concerning public programs andmeasures to support ISHC?- A public vaccination program against TBE (tick-borne encephalitis) was introduced inÅland in 2006 (Austria is the only other territory in Europe that provides this). Completeevaluation results are pending. The initiative has from a pure medical standpoint had apositive effect; annual cases of TBE in the Åland islands has decreased since launching theprogram.- Prevention and enhanced structures for discontinuation of tobacco usage in the Ålandislands. Åland has the lowest prevalence of tobacco smoking among adults in the EU (12%). Including other usage of tobacco (snus) the figure is substantially higher but still lowerthan the EU average. The same figures for youths are not as good comparatively forÅland. In order to further lower and maintain a top position in regards to tobaccousage among adults and to lower the figures among youths the government of Åland will– 572 –II WG homework 1 – Answer from Åland2014 launch a public health program, Tobakskampen, which gives the general public accessto a new smoking cessation program in a primary health care setting, as well as informationcampaigns and special training for school nurses for tobacco prevention.- There are plans for reorganization of social care in order to make sure that all get the samebenefits regardless in which municipality the individual has its home.3. Have you launched any public awareness campaigns concerning ISHC? Are any newinitiatives planned?- Increased awareness of and easier access to diagnostics of sexually transmitted infections(STIs). Åland has for the past three years had the highest incidence of genital chlamydia inFinland. Syphilis reemerged 2012. There are a number of HIV cases. Talks on STIs has beengiven to all high school pupils (grade 1) in Åland 2013 and will be held annually (andaugmented with talks for health care providers), the educational health care services andthe publicly funded health care provider (ÅHS) have facilitated access to testing for STIs,the government of Åland will in the beginning of 2014 launch a website, www.klamydia.ax,where the public will be able to order test kits for chlamydia and gonorrhea for home usefree of charge and also will be able to read up on STIs.- Researching occurrences of previously unknown tick-borne diseases in the Åland islands.Primarily (first half of 2014) the government of Åland funds planned testing of lab specimenfrom 100 islanders for the occurrence of antibodies against borrelia miyamotoi, a borreliaspecies originally found in Japan and in recent years found to exist in Russia among othermore nearby places to Åland. Infection with b miyamotoi cannot be diagnosedwith currently used testing for borrelia (Lyme disease) in the Nordic countries. Symptomscan be similiar.4. Have you launched any public economic support mechanisms for ISHC, such as dedicatedfunding, seed money or tax incentives? Are any new initiatives planned?- There have been resources allocated in the budget approved by the parliament lastdecember. The government is about to investigate how to change the existing taxregulations (tax reductions for health care) in order to pinpoint individuals that need themmost.5. In general, what do you see as the main obstacles for promoting and implementing ISHC?What kind of political support and measures are conceivable to overcome the obstacles?- It is though for our small community to upheld social and health care taking into account thecontinuous development in these fields and the economic realities that exists. That can onlybe done in close cooperation with others and if possible by sharing physicians andinvestments.–– 557733 ––Baltic Sea Parliamentary ConferenceIIWG homework 1Answer from Sweden– 574 –II WG homework 1 – Answer from SwedenHomework 1What, from your perspective, are the main challenges facing social and health care today and inthe future?An aging population in combination with urbanization and technological development in the healthand medical area bring challenges in relation to:• Stable financing of the welfare sector.• Meeting rising demands of health and social care.• Meeting demands of more technologically advanced (and more expensive) treatment methods.• Ensuring equal access to health and social care of high quality in all of Sweden• Ensuring the long-term provision of health and social care professionals in all of SwedenIn the health care area there is right now intensified national political focus on cancer care, care ofpeople with chronic diseases, reproductive health and psychiatric health and care.Have you launched any public strategies and programs for ISHC? Are any new initiativesplanned? What are your experiences and results so far concerning public programs andmeasures to support ISHC? Have you launched any public awareness campaigns concerningISHC? Are any new initiatives planned? Have you launched any public economic supportmechanisms for ISHC, such as dedicated funding, seed money or tax incentives? Are any newinitiatives planned?Examples of strategies, programs and projects in ISHC are listed below. The list is not exhaustive.Some programs and projects have been evaluated, but it is not possible to summarize those evaluationsin this document, so the question of experiences and results will not be answered.• The National Innovation StrategyIn 2012 the government decided on the National Innovation Strategy. The strategy is available throughthis link. The strategy concerns several policy areas including innovation for a more effective publicsector (thus including health and social care).• VINNOVA, The Swedish Innovation AgencyVINNOVA is a Swedish government agency working under the Ministry of Enterprise, Energy andCommunications. Health and Healthcare is one of VINNOVA's strategic areas. The key areasidentified by VINNOVA are: services within health and social care, the link between health, climateand environment and the healthcare sector as a production system. The VINNOVA programInnovations for Future Health aims to utilise high-quality Swedish research in order to prevent andtreat lifestyle diseases and drug-resistant infections.• Agreement between VINNOVA and SALAR (Swedish Association of Local Authorities andRegions)SALAR and VINNOVA has agreed to work together to support local authorities and regions todevelop leadership and organizational prerequisites for innovation. The cooperation is also meant tostimulate the development of smart welfare services supported by new technology.• Technology for elderlyDuring six years, the Swedish Government supported the development of products and services thatcan assist elderly people and their relatives in everyday life. The Technology for Elderly Programmewas coordinated by the Swedish Institute of Assistive Technology. 100 projects received support fromTechnology for Elderly 2007–2010. For the period 2010–2012, the Government has reserved an–– 557755 ––II WG homework 1 – Answer from Swedenaddition of 66 SEK million (approximately 6,97 EUR million). Companies, organizations and localgovernment authorities applied for project funding in this area through two applications which areopen twice during the period. The objective was to test and develop new technology for elderly in theirhomes.• Innovation Centers and Test beds within the Health ServiceThe idea of Innovation Centers and Test beds within the Health Service is that these will support thedevelopment of ideas into needs-driven innovations from the health service within county councils andmunicipalities. The total potential for further developing innovations within the field is, according toVINNOVA, considered to be great. However, systems/milieus which can advance concrete ideas fromthose working in the health service need to be developed. Calls for proposals under this programmehave been held 2009 and 2013.• Innovation procurementProcurement for development and implementation of new solutions, i.e. innovations. Innovationprocurement includes both procurement made in such a way that it does not rule out new solutions, socalled innovation-friendly procurement, and procurement of innovations, i.e. procurement of thedevelopment of new solutions not yet available on the market. VINNOVA launched it’s InnovationProcurement programme in 2011, aiming to increase and extend the development of innovationprocurement, chiefly in the public sector.• National e-health strategyThe National e-health strategy was adopted by the government I 2010. was adopted in 2010.1 The aimof the strategy is accessible and secure information in health and social care.• Swedish Agency for Economic and Regional Growth have worked with “Developmentchecks” for companies in health and social care.The companies have applied for funding for developing new knowledge, methods, processes or goods.The program ran from 2011 to 2013 and distributed 15,3 MSEK to 163 companies in health and socialcare.• The Committee for DigitizationThe Committee for Digitization was established by the Swedish Government in 2012 to analyse andmonitor progress in terms of meeting the ICT-policy goal; that Sweden should become the best inworld at exploiting the opportunities of digitization. The Committee is also tasked with highlightingthe benefits associated with digitization, sharing best practice and communicating the actions andgoals of the Swedish Digital Agenda. The Committee is responsible for managing the signatories ofthe Digital Agenda which are companies, not-for-profit entities and others who have agreed to work inline with the objectives of the Digital Agenda. Finally, the Committee should present policy proposalsneeded to achieve the ICT-policy goal.1 National eHealth – the strategy for accessible and secure information in health and social care–– 557766 ––Baltic Sea Parliamentary ConferenceII. WG homework 2Questions to the BSPC Member States on ethical aspects of ISHC1. What, in your opinion, are the major ethical issues and dilemmas caused by the progress in medical and socialtreatment methods and therapies?2. What policies and methods have you applied, or planned, in order to guide the prioritizing between differentpatient groups (different kinds of diseases and ailments), in a situation where treatment potentials are growing butpractical resources are scarce? Who has the responsibility for setting and making priorities?3. To what extent will a patient ́s lifestyle, behavior and self-responsibility influence the choice of treatment/therapyfor him/her, especially when it comes to new and more expensive treatments?4. What steps (legislation, regulations, technical, etc) are taken or planned in order to safeguard patient security andintegrity in the increasingly digitized patient information systems? How is the patient ́s access to her/his owninformation secured and regulated?5. To what extent and how are ethical issues acknowledged and incorporated in education, training and competenceenhancement of health and social welfare personnel?– 577 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Denmark– 578 –II WG homework 2 – Answer from DenmarkBSPC Working Group on Innovation in Social and Health CareHomework 2Contribution from Denmark1. What, in your opinion, are the major ethical issues and dilemmas caused by the progress inmedical and social treatment methods and therapies?Progress in medical treatment does not only create ethical dilemmas, but can also help overcome someof these e.g. by way of improving services, improving the easy and equal access to healthcare, reducingpatient-risk, improving knowledge based decision-making and patient involvement etc.Among ethical issues and dilemmas which can be expected in the future due to medical progress, anexample could be the issue of early diagnostics e.g. the possibility of predicting a person’s futurediseases either based on new ways of (very early) biomedical screening or by way of genetic predictionor probability.2. What policies and methods have you applied, or planned, in order to guide the prioritizingbetween different patient groups (different kinds of diseases and ailments), in a situation wheretreatment potentials are growing but practical resources are scarce? Who has the responsibilityfor setting and making priorities?Overall principlesThe Danish Healthcare Act (Sundhedsloven) states specifically that the purposes of the law is to ensurerespect for each individual and to establish the requirements to the healthcare system in order to ensure,firstly, the easy and equal access to the system.One of the overall principles governing the Danish healthcare system is the equal access to services.And the healthcare system is, with few exceptions, financed collectively trough taxes.The level of service in the Danish healthcare sector is – in general – not regulated directly by law.However, there are a few exceptions - for in-stance regarding treatment for assisted reproduction. In thiscase the service level at the regional hospitals has been regulated by law.This allows the regions and municipalities to organise the health service for their citizens according tolocal priorities and available facilities. Thus, the individual regions or municipalities can adjust servicesand prioritise within the financial possibilities and within the national legal limits.So there is no overall a priori prioritization between diseases and ailments. The access to healthcare isfirst and foremost guided by the individual need of the specific patient.–– 557799 ––II WG homework 2 – Answer from DenmarkHowever, both the national, regional and municipal governments (all three levels are responsible for thehealthcare sector) can make strategic political and/or financial prioritizing in order to improve quality andservices in specific areas. This has been seen e.g. in cancer care and, more recently, within psychiatriccare.Specific tools and structures to guide prioritization in treatmentA number of different tools and structures are used in order to support the underlying prioritization andclinical choices regarding the individual patientClinical Guidelines and evidence based approachesThe overall principle guiding prioritization is the evidence based approach.There is widespread use of clinical guidelines outlining evidence-based approaches and best practice.These guidelines are made on a national, regional and, to a limited degree, municipal level as well aswithin each medical society, the nursing society etc.In 2012 a major national program to establish national evidence based clinical guidelines was started.This program is run by the Danish Health and Medicines Authority.Also in recent years, there has been an increased development and use of clinical guidelines forvisitation.If evidence based treatment is not available in Denmark.In cases, where the needed highly specialized treatment is only available abroad, it is possible for thepatient to be referred to treatment abroad.In cases where all evidence based possibilities for treatment are exhausted, the patient can be referredto a national second opinion panel.The Coordination Council for the Application of Hospital Medicine (KRIS)The Danish Regions’ board established KRIS in 2012 with the purpose of coordinating the application ofnew hospital medicine, including indication extensions, across the regions.The council shall in particular coordinate the application of cancer medicine.The Council for the Application of Expensive Hospital Medicine (RADS)In 2009, the board of Danish Regions established RADS with the aim of agreeing on the application ofexpensive hospital medicine across the regions.The purpose of RADS is to ensure that all patients have equal access to treatments. This isaccomplished through common clinical treatment guidelines.RADS has been authorized to develop recommendations for the products that account for 80% of totalexpenditure for hospital medicine.While KRIS mainly deals with new cancer medicine, RADS’ work concerns potentially all areas, wheremedicine can be ranked in order to guide the healthcare professionals and for the purpose of makingtenders.–– 558800 ––II WG homework 2 – Answer from Denmark3. To what extent will a patient ́s lifestyle, behaviour and self-responsibility influence the choice oftreatment/therapy for him/her, especially when it comes to new and more expensive treatments?It is too narrow a question just to focus on for example lifestyle as the deciding factor in who gets accessto new and more expensive treatments. The Danish Health Sector is publicly funded and with free andequal access. Of course there can probably be instances when a doctor on medical grounds cannotrecommend a certain procedure for example when a patient has an excessive drinking habit. But the keyis patient involvement and empowerment.Patient empowerment is for many reasons a high political priority in Denmark and part of the futuredevelopment of the healthcare sector. The Danish government has announced its decision to launch astrategy of patient empowerment that will emphasise the many positive effects of involving patients andtheir relatives and establish goals for the changes that the different actors in the sector must strive toachieve.A key element in patient empowerment is for patients to be actively involved in the choice of treatmentand that patients are well informed and educated in order to enable them to manage their own health.Therefore one aim is to spread the effects of shared decision-making. Shared decision-making supportsthe patient’s active disease management and informed choices.By involving patients in the decisions about their own health and treatment, the health outcomes,compliance and the quality of the health care can be improved. Empowerment can bring greater controlof symptoms, better compliance and lifestyle changes, less anxiety over health issues, enhanced qualityof life and more independence and autonomy. Empowered patients are able to make informed choicesabout treatment and options for managing their own condition. And studies show, that patients choosethe more conservative treatment, when they are faced with the choice and are well informed about theconsequences.Patient empowerment is already widespread in the Danish healthcare system, with more than 300projects around the country. The aim of the strategy is to place patients at the centre of the healthcaresystem, and make sure that patients are part of the decisions concerning their own health, treatment andrehabilitation.4. What steps (legislation, regulations, technical, etc) are taken or planned in order to safeguardpatient security and integrity in the increasingly digitized patient information systems? How isthe patient ́s access to her/his own information secured and regulated?The Danish legislative system contains one track regarding data protection (based on the European dataprotection directive) which regulates the technical and organisational handling of sensitive data, andanother track regarding access to patient data (in our health legislation). The legislation includesrequirements to log access to patient data and to follow up on possible unauthorized accesses.Unauthorized access is subject to a fine and/or imprisonment, and may - in very severe cases - haveconsequences for upholding an authorisation to practice as a health professional.Patients have access to their own information based on a general principle of access to own informationunder the freedom of information legislation. Furthermore a direct electronic access is established to arange of patient data systems, which are made available via the Danish eHealth portal www.sundhed.dk.Access is regulated with a technical solution called nemID, which is a digital signature, making sureaccess is only granted to the citizens’ own information. For some systems the patient also has directelectronic access to log data showing who has accessed his/her data.–– 558811 ––II WG homework 2 – Answer from Denmark5. To what extent and how are ethical issues acknowledged and incorporated in education, trainingand competence enhancement of health and social welfare personnel?Ethical issues are part of the professional activities for health personnel and are a multifactorial process.Competences are achieved through education both theoretical and clinical. The main aim of theeducation for all health personnel is respect of the integrity and autonomy of patients in everydaypractice.In the postgraduate education for physicians competences are listed for the seven physician roles,medical experts, communicator, collaborator, manager, health advocate, scholar and professional in thecurriculum for specialization. All competences must be achieved through the formalized medical trainingeither by courses including patient cases or in the clinical setting. Ethical issues are part of competencesin all roles but may especially be a part of competences listed for the professional role. Some of theelements that are included in the competence-based education are: Identification of and solution to healthcare problems including medical priority-setting Exercise diligence and conscientiousness Management of professionalism in compliance with the Hippocratic Oath and legislation Use of the professional expertise while acknowledging the ethical dilemmas and the complexity,unpredictability and uncertainty that arise in everyday practice. Knowledge of conflict resolution and be able to act accordingly–– 558822 ––Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Estonia– 583 –II WG homework 2 – Answer from Estonia512–– 558844 ––II WG homework 2 – Answer from Estonia513–– 558855 ––Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Finland– 586 –II WG homework 2 – Answer from FinlandBaltic Sea Parliamentary Conference BSPCThe BSPC Working Group on Innovation in Social and Health Care26 May 2014/The WG SecretariatHomework 2 – Ethical Aspects of ISHC1. PurposeThis is the second homework of the BSPC Working Group on Innovation in Social andHealth Care (WG ISHC). It addresses a number of questions concerning the ethicalaspects of innovation in social and health care.Members of the WG are kindly requested to produce a concise response (a few pages) tothe questions below. The response should be submitted to the WG Secretariat preferablybefore the next WG meeting in Birstonas 19-20 June. If this is not possible, please informthe WG Secretariat asap.The answers will also be used to amend and develop the WG Scope of Work and toprovide input and inspiration to the political recommendations of the WG.2. BackgroundIn general, innovation in social and health care (ISHC) is conducive to an enhancedcapacity to provide qualified health and social services. Novel and improved medical andsocial solutions makes it potentially possible to diagnose, prevent, treat and cure a widerrange of illnesses and ailments. New forms of treatment and therapies, such as distancetreatment, self-care and client monitoring, are enabled. More efficient andcomprehensive systems for registering, coordinating and monitoring patient informationfacilitates treatment and follow-up of patients. Digital systems facilitate prescription ofpharmaceuticals.However, ISHC also entails a number of ethical questions and dilemmas, based e.g. onthe fact that resources will in all likelihood always be insufficient to cure all needs fairlyand equitably. These dilemmas concern for instance resource allocation betweenemerging health technologies, prioritizing between different patient groups, balancingbetween specialized (narrow) care and general (broader) care, weighing patient integritywith information access, et cetera.Against this background, the BSPC Working Group on ISHC would like to hear yourcomments on the questions below. We would like to stress that our wish is to obtain briefand concise answers, not extensive dissertations. The purpose is to acquire a cursory andhopefully comparable overview of how the ethical dilemmas posed by ISHC areapproached in the countries of the Baltic Sea Region.3. Questions1. What, in your opinion, are the major ethical issues and dilemmas caused by theprogress in medical and social treatment methods and therapies?In health care, the overarching ethical issue revolves around the prioritisation and cost-effectiveness of care. A key question is where to draw the line: for how long is itreasonable to offer care that has high costs but only modest effects on the patient?Furthermore, it should be discussed to what extent decisions regarding prioritisation of–– 558877 ––II WG homework 2 – Answer from Finlandcare should be made by health care professionals and experts, and to what extent bypolitical decision-makers.In the domain of social services, at least in Finland the question is not so much ofprioritisation, but of how to make these services reach those who are most in need.Often those who benefit the most from different services and measures are those whohave lesser need for them in the first place.2. What policies and methods have you applied, or planned, in order to guide theprioritizing between different patient groups (different kinds of diseases and ailments), ina situation where treatment potentials are growing but practical resources are scarce?Who has the responsibility for setting and making priorities?Finland introduced a National Health Care Guarantee in 2005. The guarantee definesmaximum waiting times for hospital and primary care services. In addition, uniformgrounds for access to non-emergency care were introduced. The guarantee ensures thatpatients’ need for treatment is assessed within three days of their contact with a healthcentre, and any treatment that is considered necessary must be provided within threemonths of the assessment.Some important changes have been brought about by the EU directive on the applicationof patients’ rights in cross-border healthcare. According to the Article 7 of the directive, amember state must reimburse the costs of a patient’s cross-border health care on thesame grounds that they would be reimbursed if the care was given in the member stateitself. In consequence, Finland must for the first time determine the health care servicerange in order to create an understanding of which treatments are eligible forcompensation. Determining the service range required the parliament to add a newsection to the Health Care Act in December 2013. The new section also states that healthcare that has low effectiveness, as well as costs that are unreasonable in relation to theperceived health benefits to the patient, may be excluded from the service range.Work on determining the service range has recently begun in the service range councilunder the direction of the Ministry for Social Affairs and Health. Current scientific andevidence-based knowledge on health care and the effectiveness of treatments will beused as a basis for this work. The service range will also be constantly updated accordingto new knowledge in the field of medicine and advances in technology.The final responsibility for assessing individual patients’ treatment needs will remain withthe health care professionals, however. Their work is supported by the Current CareGuidelines. They are independent, evidence-based clinical practice guidelines that areproduced with public funding and developed by the Finnish Medical Society Duodecim, inassociation with various medical specialist societies. The guidelines cover importantissues related to Finnish health, medical treatment as well as prevention of diseases. Theguidelines are intended as a basis for treatment decisions, and can be used byphysicians, healthcare professionals and citizens.In addition, the National Advisory Board on Social Welfare and Health Care Ethics ETENE,operating under the Ministry of Social Affairs and Health, provides assistance on ethicalissues. The Advisory Board submits initiatives, publishes recommendations andstatements, provides expert assistance, prompts public debate, and disseminatesinformation on national and international ethical issues in the field of social welfare andhealth care.Faced with an increasing scarcity of resources, there is a growing need for bettermethods to evaluate and assess the effectiveness and cost-effectiveness of differentmethods of treatment, as well as their effects on quality-adjusted life years of patients.– 588 –II WG homework 2 – Answer from FinlandHowever, the main purpose of this work should not be cost-effectiveness in itself, butincreasing patients’ ability to sustain oneself and live independently, with the support ofsocial and health care professionals when necessary.3. To what extent will a patient’s lifestyle, behavior and self-responsibility influence thechoice of treatment/therapy for him/her, especially when it comes to new and moreexpensive treatments?All diseases should always be treated, in spite of the extent to which they have beencaused by the patient’s lifestyle or behavior. However, it is increasingly important toprovide information on the consequences and health effects that different lifestyles mayhave on an individual. In addition, certain medical procedures, such as certain surgeries,may necessitate changes in a patient’s lifestyle, e.g. weight loss, if only for medicalreasons.4. What steps (legislation, regulations, technical, etc) are taken or planned in order tosafeguard patient security and integrity in the increasingly digitized patient informationsystems? How is the patient ́s access to her/his own information secured and regulated?Finland is in the process of introducing the new electronic Patient Data Repository, orKanTa. It offers citizens the possibility to examine their own medical records online. Anational patient data management service is also maintained as a part of the archive.Through this service, a healthcare professional will get an overview of the patient's stateof health, in the same way that citizens do on their own My KanTa pages.Patient information held in the Patient Data Repository is available to the service providerthat entered the information. Disclosure of the information to other healthcare serviceproviders requires consent from the patient. The patient’s consent covers all medicalrecords already held in the system, as well as any records entered into it later. Consentsand refusals can be managed through a healthcare service provider that has joined theservice, and in the future through the My KanTa pages.Healthcare professionals can access patient data systems with their healthcareprofessional cards. All data transfers between the healthcare system and Patient DataRepository are encrypted. Every access to patient records is entered in a log whichpermits ex-post control.The development of the information systems in social and health care is based on the Acton the Electronic Processing of Client Data in Social and Health Care, and the Act onElectronic Prescriptions, which were both passed in the Finnish parliament in 2007. Theseacts include sections and guidelines on patient security as well as on the supervision ofinformation security.5. To what extent and how are ethical issues acknowledged and incorporated ineducation, training and competence enhancement of health and social welfare personnel?The role of ethical issues is becoming increasingly important both in the education andpractical training of social and health care professionals. Also questions arising from thetreatment of patients from different cultures have been taken into account to a muchgreater extent in recent years.The National Advisory Board on Social Welfare and Health Care Ethics ETENE (seequestion 2) also provides ethical guidelines. In addition, each different professional grouphave their own sets of ethical guidelines which are maintained by their respective– 589 –II WG homework 2 – Answer from Finlandprofessional organisations. Furthermore, many work communities in the field of socialand health care also have their own guidelines and principles concerning ethical issues.All of these guidelines are being constantly updated to keep up to date with the rapidchanges in work environment.– 590 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Germany– 591 –II WG homework 2 – Answer from GermanyFranz Thönnes, MdBFormer Parliamentary State SecretaryDeputy Chairman of the Foreign Affairs CommitteeChair of the German-Nordic Parliamentary Friendship GroupMember of the BSPC Standing CommitteeFranz Thönnes MdB • Platz der Republik 1 • 11011 BerlinMr Hermann Gröhe, MdBFederal Minister of HealthFriedrichstr. 10810117 Berlin12 June 2014BSPC Working Group on Innovation in Social and Health CareDear Minister,At the 22nd Baltic Sea Parliamentary Conference (BSPC) in August 2013 in Pärnu, theparticipants decided to form the Working Group mentioned above. In my capacity as amember of the German Bundestag’s delegation to the BSPC, I am part of the workinggroup.This working group deals with the issue of qualitative and equitably distributed socialand medical services for the citizens of the Baltic Sea Region. The Working Group’sobjective is to elaborate political positions and recommendations pertaining toinnovation in social and health care. These will be addressed to the national and regionalgovernments concerned. They will be an expression of the political views and positionsof parliamentarians from the Baltic Sea Region.At the start of this year, I wrote to you with an initial list of questions relating to thisworking group. Now, as a second step, the working group is drawing up a comparativeoverview of how the Baltic Sea states are approaching the ethical challenges posed byinnovations in social and health care:1. What are the most important ethical questions and challenges in the context ofprogress in medical treatment methods and therapies?2. What political steps or methods should guide the prioritisation of different groupsof patients (with different clinical pictures and conditions) at a time when thepotential to treat conditions is growing but resources are limited in practice? Andwho takes responsibility for these priorities?3. To what extent will the patient’s lifestyle, behaviour and personal responsibilityinfluence the choice of treatment/therapy, at a time of new and ever moreexpensive treatment methods?4. What steps (legal, regulatory, technical, etc.) are being taken or planned toensure the patient’s safety and integrity as patient records are increasinglydigitised? And how is the patient’s access to his or her own data safeguarded andregulated?5. To what extent are ethical issues taught and incorporated in the education,training and continuing education of health workers?Bundestag Email addresses Constituency officePlatz der Republik 1 franz.thoennes@bundestag.de Oldesloer Straße 2011011 Berlin 23795 Bad SegebergTel.: +49 (0)30 / 227-7 11 28 buergerbuero@thoennes.de Tel.: +49 (0)4551 / 96 83 83+49 (0)30 / 227-7 13 28 Fax: +49 (0)4551 / 96 73 38Fax: +49 (0)30 / 227-7 68 28 http://www.thoennes.de– 592 –II WG homework 2 – Answer from GermanyDespite the short notice, I would be very grateful if you could answer these questions onbehalf of your ministry by 30 June 2014.Thank you very much in advance for your assistance.Yours sincerely,2– 593 –II WG homework 2 – Answer from GermanyFederal Ministryof HealthHermann GröhePOSTAL ADDRESS Federal Ministry of Health, 53107 BonnMr Franz Thönnes Federal MinisterMember of the German Bundestag Member of the German BundestagDeputy Chairman of the Committee on Foreign Affairs OFFICE ADDRESS Rochusstraße 1, 53123 BonnFormer Parliamentary State Secretary POSTAL ADDRESS 53107 Bonn11011 BerlinTEL +49 (0)228 99 441-1003FAX +49 (0)228 99 441-1193EMAIL poststelle@bmg.bund.de8 July 2014Dear Mr Thönnes,Many thanks for your letter of 12 June 2014, in which you raise importantquestions relating to the ethical challenges posed by innovations in social andhealth care, in connection with your work as a member of the Baltic SeaParliamentary Conference.Although the situation in terms of social and health policy is very varied in theBaltic Sea countries, and the focus is currently on challenges such as communicablediseases (HIV/AIDS, TB, hepatitis) and antibiotic resistance, it is useful to lookbeyond the present day, to reflect on the future of our social and health systemsand to discuss criteria and strategies to ensure their further development isethically responsible. Of course, national regulations and experiences cannot beduplicated exactly in other countries, but they can provide important suggestionsand possibly guidance for the discussions taking place there. With this in mind, Iam pleased to provide the enclosed answers to your questions.I hope that this statement will be of some assistance to you in your work as amember of the Baltic Sea Parliamentary Conference, and I would like to take thisopportunity to offer you my best wishes.Sincerely,Yours (m.p.)Sgd. Hermann Gröhe3– 594 –II WG homework 2 – Answer from Germany4 July 2014Statement from the Federal Ministry of Health in response to questionssubmitted by Franz Thönnes, Member of the Bundestag and formerParliamentary State Secretary, in connection with the Working Group onInnovation in Social and Health Care of the Baltic Sea Parliamentary ConferenceQuestion 1 (What are the most important ethical questions and challenges inthe context of progress in medical treatment methods and therapies?):In view of demographic change and the scientific and technical progress being made inmedical provision and long-term care, we need a broad debate about the kind of societyin which we want to live in future, how that society should deal with people who are ill,elderly, in need of care or dying, and how we can strike and shape the balance betweenpersonal responsibility, subsidiarity and solidarity. As we seek to answer these questions,we have, alongside our individual values, a common, binding framework in the principlesenshrined in the Basic Law (the German constitution), above all that of human dignity.The constitutions of other European countries enshrine similar values.We should seek as broad a consensus as possible in the fundamental debate about thefuture of our solidarity-based health system. Once society has reaffirmed how it seesitself – a process which must be repeated periodically – decisions can then be taken atpolitical and legislative level, based on this, about the appropriate legal framework andthe administrative implementation.In our view, one of the fundamental principles of our welfare state is that no one shouldbe left to face the risk of illness and the associated costs and burdens alone. Everythingthat is medically and reasonably necessary should continue to be covered by statutoryhealth insurance in future.Question 2 (What political steps or methods should guide the prioritisation ofdifferent groups of patients (with different clinical pictures and conditions) at atime when the potential to treat conditions is growing but resources are limitedin practice? And who takes responsibility for these priorities?):Any “prioritisation of different groups of patients (with different clinical pictures andconditions)” would be ethically problematic and is unnecessary in practice. However, theelimination of oversupply and undersupply of services in the health system andinappropriate treatment remains a permanent challenge. The common aim should be toensure equal access to health services and goods, provided that they are medically andreasonably necessary. At the same time, society as a whole needs to recognise thathigh-quality health care for all, in a system based on solidarity, has a cost – particularlyin an ageing society in which – happily – research and development is constantlyproducing new, more targeted means of helping and treating people. The fundamental4– 595 –II WG homework 2 – Answer from Germanydebate referred to in the response to question 1) should help to bring about thisrecognition.It would be neither ethically justifiable nor economically advisable, however, to spendthe funds pooled by the community of insured persons on unnecessary services, as thatwould mean this money was no longer available for health-care objectives whoseimportance is accepted. For this reason, an evidence-based approach and efficiency andquality assurance are key instruments for a health system based on the principles ofsubsidiarity, solidarity and good health care for all who need it.The Fifth Book of the Social Code already stipulates that services which are unnecessaryor uneconomic may not be paid for by statutory health insurance. At the same time, allinsured persons are entitled to services whose quality and effectiveness is in line with thegenerally accepted state of medical knowledge and which reflect medical progress.A proven system is in place in Germany to determine what is appropriate, medicallynecessary and economic. The decision is taken by a body which forms part of the healthsystem’s joint self-government structure: the Federal Joint Committee. On the basis ofclear statutory regulations, it issues guidelines specifying what entitlement peopleinsured under the statutory health insurance scheme have to certain treatments orinvestigations. The Federal Joint Committee is composed of representatives of paneldoctors and dentists, psychotherapists, hospitals and health insurance funds;representatives of patients’ organisations are also entitled to participate in its discussionsand put topics on its agenda. The Federal Joint Committee establishes the generallyaccepted state of medical knowledge on the basis of evidence-based medicine; itsdecision-making process is transparent. It is supported by the Institute for Quality andEfficiency in Health Care (IQWiG), which carries out assessments of this kind (knowninternationally as “health technology assessments”) on its behalf. In addition, the FederalJoint Committee takes decisions on quality assurance measures for the out-patient andin-patient sectors of the health system. However, Parliament has not empowered theFederal Joint Committee to exclude medically necessary services to which no alternativeis available (rationing), or to establish priorities among these services (prioritisation).Another important instrument in safeguarding a high level of quality and equal access tohealth services for the future, despite limited financial resources, is strengthening thecompetitive focus of the health system. Patient-centred competition on prices and qualityraises the quality of care and allows efficiency reserves to be unlocked (“rationalisationinstead of rationing”). A solidarity-based framework ensures that the competition focuseson the needs of the insured and patients.5– 596 –II WG homework 2 – Answer from GermanyQuestion 3 (To what extent will the patient’s lifestyle, behaviour and personalresponsibility influence the choice of treatment/therapy, at a time of new andever more expensive treatment methods?):Our health-care system must be supplemented by disease prevention and healthpromotion. Our aim should be to use health education to foster the individual’s will andability to lead a health-conscious lifestyle. When people fall ill, however, they shouldreceive the medically necessary treatment, and the costs should be covered by statutoryhealth insurance. This also holds true in particular for the new and expensive treatmentmethods you mention, provided that they meet the requirements set out in the responseto question 2) and have undergone, where necessary, the Federal Joint Committee’sbenefit assessment and decision-making process. In this context, it must be ensuredthat the choice of therapy is always guided only by the best interests of the patient, andthat his or her stated wishes are respected. The economic interests of the serviceprovider must not play any role.The choice of therapy should only take place after a full and comprehensible discussionof the treatment options with the patient, and with the patient’s free, informed andspecific consent. As part of such discussions, information is often provided about howpatients can support their recovery and avoid relapses by making changes to theirlifestyle.At the same time, we must strengthen the incentives for health-conscious behaviour.This is already the case for dental care, for example, where a higher share of patients’costs are reimbursed if there are records that they have attended annual preventive careappointments. It is also already the case that preventive services are funded by thehealth insurance funds. The prevention law which is to be passed in the current electoralterm will strengthen this focus on disease prevention and prophylaxis.Question 4 (What steps (legal, regulatory, technical, etc.) are being taken orplanned to ensure the patient’s safety and integrity as patient records areincreasingly digitised? And how is the patient’s access to his or her own datasafeguarded and regulated?):With the electronic health card and telematics infrastructure, the conditions are beingcreated in Germany for greater patient autonomy, economy and efficiency in the healthsystem, with the aim of ensuring sustainable, integrated services. The use of medicaltelematics applications is voluntary for patients.Legal and technical steps have been taken to protect sensitive patient data fromunauthorised access. Firstly, the electronic health card individually encrypts the datausing state-of-the-art technological processes. Secondly, in addition to the electronichealth card and the insured person’s PIN, a second key – the doctor’s health professionalcard – is required to access medical data. The ways in which the data may be used are6– 597 –II WG homework 2 – Answer from Germanyclearly defined in law. Misuse is subject to criminal prosecution.Legal requirements with which bodies that collect, process or use personal data mustcomply are contained in general data-protection legislation (Section 9 of the Federal DataProtection Act) and, as regards the protection of social-security data, in Section 78a ofthe Tenth Book of the Social Code. To assist non-hospital doctors, the German MedicalAssociation and the National Association of Statutory Health Insurance Physicians haveissued recommendations on medical confidentiality, data protection and data processingin doctors’ surgeries (published in the Deutsches Ärzteblatt, 23 May 2014), whileguidance on hospital information systems (published in March 2014) is available forhospitals from the working group on health and social affairs established by theConference of Data Protection Commissioners of the Federation and the Länder.The right of patients to view their complete medical records is enshrined in Section 630gof the Civil Code.Question 5 (To what extent are ethical issues taught and incorporated in theeducation, training and continuing education of health workers?):The federal laws and statutory instruments governing the health professions, whichregulate the training required to become a doctor, dentist, psychotherapist, nurse,midwife, physiotherapist, paramedic and a number of other kinds of medicalprofessional, are implemented by the competent authorities of the Länder (federalstates). The requirements enshrined in federal law form the framework for the training,which the Länder or the universities flesh out in detail in the specific curricula. Thisincludes determining to what extent ethical issues are to be examined during thetraining. The training regulations for medicine, nursing and physiotherapy, for example,expressly require ethical issues to be covered during training.Continuing education is a matter for the Länder. The same is true of health professionswhich are regulated by the Länder without federal involvement, such as the trainingrequired to become a health-care or care assistant.In general, it should be noted that ethical issues are of greatest relevance for healthprofessionals in relation to specific individual cases. Given this, their training andcontinuing education should, above all, equip them to reflect on the ethical issuesinvolved in specific cases and to act responsibly in their dealings with the peopleaffected. By contrast, the preceding questions focus primarily on ethical and responsiblepolicy-making in the further development of health-care provision.7– 598 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Latvia– 599 –II WG homework 2 – Answer from LatviaLATVIJAS REPUBLIKAS LABKLĀJĪBAS MINISTRIJASkolas iela 28, Rīga, LV-1331 Tālr. 67021600 Fakss 67276445 E-pasts: lm@lm.gov.lvUz 30.05.2014. Nr. 2/0514-103Baltic Assembly and the Baltic Sea Parliamentary ConferenceWorking Group on Innovation in Social and Health Careanete.kalnaja@baltasam.orgThe Ministry of Welfare of Republic of Latvia has received the questions of theBaltic Parliamentary Conference on Strategies and Measures to Support Innovation inSocial and Health Care.We would like to inform you that Ministry of Welfare is the leading institution ofthe state administration in the areas of labour, social security, children's and family rightsas well as equal rights for people with disability and gender equality.At present the services of social care are available to all those individuals whohave difficulties in self-care because of their age or functional disabilities and are in needof such services. The Ministry of Welfare hasn’t established any constraints due toclient’s lifestyle, behavior or self-responsibility.Also the Ministry of Welfare doesn’t store any medical data apart from the datastored by the Ministry of Health.I.Martinsone 67021668,Inga.Martinsone@lm.gov.lv,– 600 –II WG homework 2 – Answer from LatviaEthical Aspects of ISHC1. What, in your opinion, are the major ethical issues and dilemmascaused by the progress in medical and social treatment methods andtherapies?The main ethical issues and dilemmas are in the following areas: Genetic research and implementation of personalized medicine; Transplantation of organs and tissues; New medicines and new technologies of treatment; Artificial insemination; Patients’ data safety and protection.2. What policies and methods have you applied, or planned, in order toguide the prioritizing between different patient groups (different kinds ofdiseases and ailments), in a situation where treatment potentials aregrowing but practical resources are scarce? Who has the responsibility forsetting and making priorities?The Regulation of the Cabinet of Ministers of the Republic of LatviaNo.1529 “Procedures for Organization and Financing of Health Care”(adopted on 17 December, 2013) determines the priority patient groups: emergency care, children and maternity care, and health care services in case when a patient has prognosis of disability.The Regulation of the Cabinet of Ministers of the Republic of Latvia No.899“Procedures for the Reimbursement of Expenditures for the Acquisition ofMedicinal Products and Medicinal Devices Intended for Out-patient MedicalTreatment” determines the conditions for reimbursement of medicines. Allmedicines are classified into one of three reimbursement categories (100%,75% or 50%) depending on the illnesses for which they have been approved.Taking into account the mortality and morbidity data, for planning period2014 – 2020 the priorities will be planned in the field of oncology,cardiology, perinatal and neonatal period care, and in mental care.1– 601 –II WG homework 2 – Answer from Latvia3. To what extent will a patient ́s lifestyle, behavior and self-responsibilityinfluence the choice of treatment/therapy for him/her, especially when itcomes to new and more expensive treatments?Each person has the right to receive medical treatment corresponding to hisstate of health. Any discrimination is prohibited.Biological, psycho-emotional, social, economic, environmental, as well aslifestyle factors influence the health of each individual and, therefore, publichealth.A healthy lifestyle has an essential role in preserving and improving health.The most significant public health problems in Latvia are cardiac andcirculatory diseases, oncology diseases and external causes of death. Themain behavior factors, which facilitate the development of circulatorydiseases and oncology diseases, are unhealthy nutrition, insufficient physicalactivity and smoking. On the other hand, harmful alcohol use and riskybehavior are the main reason of external causes of death. The features of ahealthy lifestyle are sufficient physical activity, a rational or physiologicaldiet, and an absence of harmful habits (smoking and alcohol consumption).A patient has possibility to choose the most expensive treatment, but it is notalways covered by the state budget.4. What steps (legislation, regulations, technical, etc) are taken or plannedin order to safeguard patient security and integrity in the increasinglydigitized patient information systems? How is the patient ́s access toher/his own information secured and regulated?Patients’ data security is determined in several laws: Medical TreatmentLaw, Law on the Rights of Patients, and Personal Data Protection Law.According to The Regulation of the Cabinet of Ministers of the Republic ofLatvia No.243 “By-law of the Ministry of Justice” (adopted on 29 April,2003) the functions of the Ministry of Justice shall be to formulate policy inthe field of the protection of personal data.Additional on 11 March 2014 was approved The Regulation of the Cabinetof Ministers of the Republic of Latvia No.134 “The provisions on the singleelectronic health information systems”. This regulation determines the singleelectronic health information system manager, health information system2– 602 –II WG homework 2 – Answer from Latviadata stored and the processing procedures, as well as procedures for issuingdata. Health information system manager is the National Health Service.One of the issues on the NHS agenda is ensuring security of patient data.5. To what extent and how are ethical issues acknowledged andincorporated in education, training and competence enhancement ofhealth and social welfare personnel?Medical treatment institutions and professional organizations of medicalpractitioners shall establish medical ethics committees. Such committeesshall examine ethical matters related to activities of medical practitionersand new medical technologies.The Central Medical Ethics Committee shall operate in accordance withCabinet regulations and it shall examine ethical issues of biomedicalprogress relating to social problems.As regards health care personnel, it should be noted that everyone has anequal right to receive appropriate health care services, qualitative andqualified medical treatment regardless of gender, age, race, language,religion, sexual orientation, political or other opinion, national or socialorigin, ethnic origin, education, social and financial status, occupation,nature and severity of his or her disease, and other circumstances.According to the Medical Treatment Law the competence of medicalpractitioners in medical treatment, as well as the amount of theoretical andpractical knowledge shall be determined by the Cabinet, taking into accountthe point of view expressed in conformity with their competence by theLatvian Medical Association, Union of Professional Organizations ofMedical Practitioners of Latvia or Latvian Nurses Association.Students who have acquired the first or second level of a professional highermedical education programme and the amount of knowledge and skills thatcomply with specified qualification and competence requirements may takepart in medical treatment. The qualification requirements and amount ofcompetence is determined by the Cabinet Regulation No 286 of the Cabinetof Ministers from 24 of March, 2009 “Regulation on medical practitionerand student, who study in first or second level higher professional medicaleducation programs, competence in health care and theoretical and practicallevel”.The clinical and practical sections of medical education (including thatwhich may be acquired in residency) in the medical professions andspecialties shall be implemented by medical treatment institutions andmedical practitioners, which have obtained the right to educate medical3– 603 –II WG homework 2 – Answer from Latviapractitioners in accordance with the procedures specified in regulatoryenactments.In addition, recommendations for the health care practitioner for specifictherapeutic activities are included in clinical guidelines – taking into accountmedical principles based upon evidence, an established systematicdescription of the medical treatment process for a particular patient group inwhich the following are specified - the necessary activities, the order ofperformance thereof and the essential criteria for the choice of tactics for themedical treatment of a patient to achieve the best medical treatment result.4– 604 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Lithuania– 605 –II WG homework 2 – Answer from Lithuania534– 606 –II WG homework 2 – Answer from Lithuania535– 607 –II WG homework 2 – Answer from Lithuania536– 608 –II WG homework 2 – Answer from Lithuania537– 609 –II WG homework 2 – Answer from Lithuania538– 610 –II WG homework 2 – Answer from Lithuania539– 611 –II WG homework 2 – Answer from LithuaniaLIETUVOS RESPUBLIKOS SOCIALINES APSAUGOS IR DARBO MINISTERIJAMINISTRY OF SOCIAL SECURITY AND LABOURREPUBLIC OF LITHUANIAseeretariat of the Baltic Assembly 2014 ·06·3 o No. (28.5-62) SD - f/695Anete.Kalnaja@baltasam.org Ref. 30 05 No. 2/0514- 1032014.REGARDING QUESTIO.NS ON ETHICAL ASPECTS OF INNOVATION IN SOCIALAND HEALTH CAREDear Colleagues,On behalf of the minister of Social Security and Labour of the Republic ofLithuania Mrs Algimanta Pabedinskiene I would like to thank you for your letter of inquiryabout ethical aspects of innovation in social and health care.En.closed you will tind information that falls under the competence of theMinistry of Social Security and Labour. We hope this information will be useful for membersof the Baltic Sea Parliamentary Conference Working Group on Innovation in Social andHealth Care.The provision of social services in the Republic of Lithuania is govemed by theLaw on Socia1 Services. According to the principles of management, allocation and provisionof social services established in the Law, the social services must be provided ethically andrespecting the rights of service recipients. One of the main principles estabHshed in this legalact is the securing the participation of both the individua1 receiving the services (or his/herrepresentative) and the organisations defending the rights and interests of relevant socialgroupsin the social services' allocation and provision process. Social services are provided bysocial workers and other persons engaged in social work (individual care staff, employmentspecialists etc.). Social workers take guidance from the professional code of conduct in theirwork. Therefore, the issue of violation of ethical standards in the social services' area inLithuania arises only in iso,lated cases, due to the lack of professional competences orresponsibility on the part of individual social workers, e. g. when the client is not included inthe social care plan; the client bccomes a passive service recipient without assuming anyresponsibility. This reduccs the overall service efticiency, the client is not enabled to makechanges; his/her motivation and ability to function independent!y are not promoted.Provision of social services is started when the need for such services is set.Social services are provided without prioritisation of client groups. According to the Law onSocial Services, municipalities are responsible for the ensuring the social services' provisionto residents in their respective territories. They carry out evaluations of residents' needs, planand organise social services, and forecast and determine the scope and types of the soCialA.Vivulskio str. 11 Te).: +370 5 266 8176, +370 5 266 8169LT-03610 Vilnius Fax.: +370 5 266 4209Lithuania E-mail: post@socmin.lt540– 612 –II WG homework 2 – Answer from Lithuania2services required. Financial Hability for the provision of social services to individuals withsevere disabilities lies with the State: social care for such persons is financed from the special-purpose allocations made from the national budget to municipal budgets.As already mentioned, provision of social services is started only uponassessment of the individual's needs for the services. Social services are provided irrespectiveof the individual's social status or assessed social risk. The social services' provision isfocused on the enhancement of the recipient's responsibility and motivation to change, so thatthe individual would realisethe importance of self-help and become a full-fledged n1ember ofsociety.Personal data protection in Lithuania is govemed by the Republic ofLithuania Law on Legal Proteetian of Personal Data. The purpose of the law is to proteet theindividual's right to the immunity of his/her private life by processjng personal data andinformation. Social services are provided following the principle of confidentiality. This isone of the key principles to be adhered to by specialists providing social services. The duty tomaintain confidentiality is established in all legal acts goveming the quality assurance insocial services; all social service institutions' staff engaged in the service provision must signcon:fident.iality undertakings.Curricula of educational establishments trruning social workers includesubjects on ethical principles and issues arising from non-compliance; students are madeconversant with the Code of Conduct of Social Workers. TheProcedurefor the ProfessionalSkills Improvement for Social Workers and Assistant Social Workers approved by Order ofthe Minister of Social Security and Labour establishes that all social workers and assistantsocial workers must take part in skills improvement course for at least 16 hours per year.Managetnent of institutions providing social services have the right to propose subjectsrelated to professional ethics for inclusion in the skills improven1ent programmes.Yours faithfully,V.ice-mi.nister Gintaras Klimavicius541– 613 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Mecklenburg-Vorpommern– 614 –II WG homework 2 – Answer from Mecklenburg-Vorpommern– 615 –II WG homework 2 – Answer from Mecklenburg-VorpommernAppendixResponse by the Ministry of Social Affairs to the BSPC questionnaire oninnovation in social and healthcare1. What, in your opinion, are the major ethical issues and dilemmas caused by theprogress in medical and social treatment methods and therapies?Medical progress is not possible without new medication and therapies being testedon humans. In the field of tension between the desire for medical progress on theone hand and the protection of the integrity of the human body on the other hand,ethical questions are continuously posed, especially if medical research involvinghuman subjects is carried out in developing and emerging countries. The same istrue with regard to animal testing, especially when the medical use of the substancesto be tested is rather doubtful.2. What policies and methods have you applied, or planned, in order to guide theprioritizing between different patient groups (different kinds of diseases andailments), in a situation where treatment potentials are growing but practicalresources are scarce? Who has the responsibility for setting and makingpriorities?One form of prioritizing in the healthcare field already takes place with regard to thedefinition of the Statutory Health Insurance’s services through the institutions of self-government of the social insurance funds.Here it becomes apparent how difficult the dealing with services cuts in thehealthcare sector is and how difficult it is to communicate these cuts to the patients –especially with regard to severely ill people.Also considering the judgments of the German Federal Constitutional Court,according to which a prioritizing of health services might not be in line with theGerman Basic (constitutional) Law, a civil society should abstain from discussingindividual benchmarks, along which a prioritizing of patient groups should take place.A civil society will not be strengthened through separation or division but throughactive solidarity, as is mostly the case in the case of the social security system in theFederal Republic.3. To what extent will a patient ́s lifestyle, behavior and self-responsibility influencethe choice of treatment/therapy for him/her, especially when it comes to new andmore expensive treatments?Regarding healthcare:Every person is called upon to self-responsible mind their health and to contribute totheir health with the adaption of their lifestyle and food patterns in case of illness.Nevertheless, new and cost-intensive treatment methods have to be made availableas equally as possible to all people, irrespective of their personal lifestyles and theirfinancial backgrounds.– 616 –II WG homework 2 – Answer from Mecklenburg-Vorpommern4. What steps (legislation, regulations, technical, etc) are taken or planned in orderto safeguard patient security and integrity in the increasingly digitized patientinformation systems? How is the patient ́s access to her/his own informationsecured and regulated?The protection of private data is an important, constitutionally protected good.Therefore, the necessary regulations in this regards will have to be determined at thefederal level as well as in the data protection laws of the federal and state level.Everyone participating in the provision of healthcare has to ensure that in practicesas well as in hospitals and in every other healthcare or care treatment the integrity ofpatients’ data is guaranteed.5. To what extent and how are ethical issues acknowledged and incorporated ineducation, training and competence enhancement of health and social welfarepersonnel?Ethical issues are part of the education, training, and continuous professionaldevelopment of medical staff.– 617 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Norway– 618 –II WG homework 2 – Answer from NorwayHomework 2 – Ethical Aspects of ISHCNorway1. What, in your opinion, are the major ethical issues and dilemmas causedby the progress in medical and social treatment methods and therapies? Ethics must prevail over technology; ethical awareness of the causes of an innovation and its effects; ensuring patient security, information and integrity; medical possibilities can create demand for expensive medicines and treatments,entailing a risk for inequalities between patient groups; medical innovation can create dilemmas about ethically controversial treatments,like stem cell treatment and prenatal diagnostics; overdiagnostics; care personnel is replaced with machines; medical surveillance methods might conflict with integrity.2. What policies and methods have you applied, or planned, in order toguide the prioritizing between different patient groups (different kinds ofdiseases and ailments), in a situation where treatment potentials aregrowing but practical resources are scarce? Who has the responsibilityfor setting and making priorities? Parliament and Government have the responsibility for overarching priorities; at local level and in constrained resource situations, the municipal health services,under the Municipal Board, conducts prioritizations. Some municipalities haveethical committees; no formal prioritization guidelines at municipal level; concrete prioritization is carried out by the medical services at operational level,guided by the Prioritization Ordinance; public inquiry 1987 on prioritization; in 2013, launch of a new prioritization committee, to report in 2014; National Board for Quality and Prioritization in Health Services.3. To what extent will a patient ́s lifestyle, behavior and self-responsibilityinfluence the choice of treatment/therapy for him/her, especially when itcomes to new and more expensive treatments? prevention and information have central roles in curbing the growth of lifestyle-related diseases; lifestyle, behaviour and “self-inflicted” diseases should not be taken into accountwhen determining the care need for a patient; on purely medical grounds, however, changes in behavior/lifestyle might berequested/prescribed in order to achieve full effect of a cure; assessments can be made on pure medical grounds whether a behaviour mightcounteract the effects of a therapy/cure.4. What steps (legislation, regulations, technical, etc) are taken or plannedin order to safeguard patient security and integrity in the increasinglydigitized patient information systems? How is the patient ́s access toher/his own information secured and regulated? Health care personnel is by law forbidden to share any patient info with any otherthan those directly involved in the patient ́s care; the patient has the right to access his/her own journal;– 619 –II WG homework 2 – Answer from Norway several electronic information systems, but no comprehensive national journal; Legislation on patient journals and on health information registers is currentlyunder treatment; reconcile the objective of swift access to accurate patient data with the goal tosecure patient security and integrity; new and clearer routines for authorization, authentication, electronic signature,data logging etc are under development, to be presented to the Parliament in2014.5. To what extent and how are ethical issues acknowledged andincorporated in education, training and competence enhancement ofhealth and social welfare personnel? Ethical issues are an integral part of all strands of health education; the different groups of medical practitioners have their own ethical committees; Center for Medical Ethics in Oslo carries our research, e.g. on ethics andpsychiatric care; in 2007, start of a national effort to bolster ethical competence in municipal healthservices.– 620 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Åland– 621 –II WG homework 2 – Answer from ÅlandBSPC Working Group on Innovation in Social and Health CareHomework IIAnswers from Annette Holmberg-Jansson, member of the ÅlandParliament and BSPC ISHC workinggroup1. What, in your opinion, are the major ethical issues and dilemmas caused by the progressin medical and social treatment methods and therapies?The continuous development and innovation in medical treatment both create and ease ethicaldilemmas. It will probably continuously be more difficult to grant equal access to all citizenswhen treatments become more costly. There are also ethical aspects regarding what diseasessociety should try to ease and what kind of patients (e.g. even very old and weak) that shouldhave help from the society. Innovation also creates possibilities of predicting a person’s futurediseases.2. What policies and methods have you applied, or planned, in order to guide the prioritizingbetween different patient groups (different kinds of diseases and ailments), in a situationwhere treatment potentials are growing but practical resources are scarce? Who has theresponsibility for setting and making priorities?The first paragraph in the Åland healthcare Act (Landskapslag om hälso- och sjukvård) statesthat the law intends to ensure that the entire population of Åland is entitled to such health careas everyone's health condition requires, within the limits available to health care available at therespective time.The healthcare system is, with few exceptions, financed collectively trough taxes and quitesmall fees. One of the overall principles governing the healthcare system is the equal access toservices. The Åland Parliament decides annually the budget for the Åland healthcare authority(Ålands hälso- och sjukvård). The authority are runned by a board that decides where to allocatethe resources. The final responsibility for assessing individual patients’ treatment needs willremain with the health care professionals, however.3. To what extent will a patient ́s lifestyle, behaviour and self-responsibility influence the choiceof treatment/therapy for him/her, especially when it comes to new and more expensivetreatments?Health care should, except in statutory exceptions, be given in cooperation with the patient.Patients are more enlightened today because the information is easily available on the internet.Legislation on cross-border health care also gives opportunities to receive healthcare from other– 622 –II WG homework 2 – Answer from Ålandcountries. New and more expensive treatments create a challenge for health care, given its costs,that calls for demands on prioritising. Work on prioritising has begun.4. What steps (legislation, regulations, technical, etc) are taken or planned in order to safeguardpatient security and integrity in the increasingly digitized patient information systems? Howis the patient ́s access to her/his own information secured and regulated?According to the Åland of the Act on the patient's status and rights as the Finnish law of thepatient's status and rights (FFS 785/1992) with specified derogations apply on the ÅlandIslands. Only personnel involved in the care of a patient read or manage patient records only tothe extent that their duties and responsibilities require. The systems have a log that can controlwho has been inside the patient records.Unfortunately a patient is not able to access their medical record in digitally. In order to be ableto offer the possibility the Åland healthcare authority must change medical record system.5. To what extent and how are ethical issues acknowledged and incorporated in education,training and competence enhancement of health and social welfare personnel?In training ethics is a special subject where you get acquainted with various ethical theories.These theories are deepened through various discussions on ethical issues. Discussions of thevarious ethical issues are ongoing on different units within the Åland healthcare authority. Thisfall all supervising nurses and chief nurses will to participate in an ethics training to increase thesupervising nurses’ opportunities to lead this type of discussions. There is also an ongoing workon various units in the development of values. In this work includes much ethical discussions.– 623 –Baltic Sea Parliamentary ConferenceIIWG homework 2Answer from Sweden– 624 –II WG homework 2 – Answer from SwedenWhat, in your opinion, are the major ethical issues and dilemmas caused by the progress inmedical and social treatment methods and therapies?Swedish National Council on Medical Ethics (SMER)There has been a National Council on Medical Ethics in Sweden since 1985, when it was establishedby the Government. The Council is entrusted with task of providing guidance to the Government andthe Riksdag. In light of rapid developments in the field, the Council is to assess the consequences ofmedical research, diagnostics and treatment for human dignity and the privacy of the individual.1According to its directives, the Swedish National Council on Medical Ethics has the following tasks:• to serve in an advisory capacity to the Government and the Riksdag, for example as a referralbody• to "keep a look-out" for developments in the area of research and• to be a "bridge-builder" between researchers and decision-makersThe work and areas of interest of the Swedish National Council on Medical Ethics extend over mostdisciplines in the medical field.23What policies and methods have you applied, or planned, in order to guide the prioritizingbetween different patient groups (different kinds of diseases and ailments), in a situation wheretreatment potentials are growing but practical resources are scarce? Who has the responsibilityfor setting and making priorities? To what extent will a patient ́s lifestyle, behavior and self-responsibility influence the choice of treatment/therapy for him/her, especially when it comes tonew and more expensive treatments?Priorities in health and medical careIn 1997, the Riksdag decided on priorities for health and medical care. According to the Riksdagdecision, all priorities are to be made consciously, be part of a transparent process and be based onthree ethical principles. The care providers have to account for the reasons for their priorities and basetheir decisions on the best possible knowledge. The National Board of Health and Welfare's Nationalguidelines are intended to support them in their work.4The ethical platform as decided on by the Riksdag is to govern all the priorities made in health andmedical care. These priorities shall be based on three fundamental principles:• Human dignity - All human beings are of equal value and have the same rights regardless ofpersonal characteristics and functions in society.1 SMER's website, http://www.smer.se/om-smer/, visited on 24 Fabruary 20152 For further information about the Swedish National Council on Medical Ethics, see http://www.smer.se/3 Link to National guidelines4 The website of the National Board of Health and Welfare,www.socialstyrelsen.se/effektivitet/resursfordelningochprioriteringar/prioriteringarihalso-ochsjukvarden, visited on 23February 2015.– 625 –II WG homework 2 – Answer from Sweden• Needs and solidarity – Resources should be distributed primarily to the areas in which theneeds are greatest.• Cost-effectiveness – A reasonable relationship between costs and effects should be soughtwhen choosing between areas of activity or measures measured in terms of health and qualityof life.The three principles are ranked in such a way that the principle of human dignity goes before that ofneeds and solidarity, which in turn goes before the principle of cost-effectiveness. This means forexample that serious illnesses take precedence over more minor ones, even in cases where the care ofthe more serious illnesses costs substantially more.5It is not compatible with ethical principles to generally allow need to be given lower priority becauseof a patient's age, birth weight, lifestyle or economic circumstances. However, it is compatible withthe ethical principles in individual cases to take into consideration circumstances that limit theusefulness of particular medical treatment for the patient.6There is a national model to determine how priorities should be set by health and medical care in acertain area,that is how priorities should be set vertically. According to the National Board of Healthand Welfare, the purpose of the model is to improve communication between both professions andcare providers, and county councils and municipalities concerning the priorities that must be made.The question of priorities is applicable on several levels, for example between organisations andauthorities and between different regions.78What steps (legislation, regulations, technical, etc) are taken or plannedin order to safeguard patient security and integrity in the increasinglydigitized patient information systems? How is the patient ́s access to her/his own informationsecured and regulated?The Patient Data Act (2008:355)The processing of personal data in health and medical care is regulated in the Patient Data Act(2008:355), which came into force in 2008. The Act regulates for example:- coordination of patient records, which means that several care providers can allow and obtaindirect access to each other's medical documentation provided they meet the requirements ofthe Patient Data Act.- internal secrecy, a regulation stating that only the person who needs the information in his/herwork in health and medical care may be given access to patient data. This is clarified by thefact that the Act places demands on assigning authorisation and access controls.- the extent to which patients can block data, both in the care providers' system of medicalrecords and for other care providers in the case of coordinated patient records.5 Ibid.6 Ibid.7 Ibid.8For further information, see for example the website of the National Board of Health and Welfare,http://www.socialstyrelsen.se/effektivitet/resursfordelningochprioriteringar/prioriteringarihalso-ochsjukvarden and thePriority Centre or National Centre for Priority Setting in Health Care, http://www.imh.liu.se/halso-och-sjukvardsanalys/prioriteringscentrum?l=sv– 626 –II WG homework 2 – Answer from Sweden- how a patient can obtain direct access to his/her data. A care provider may give a patient directaccess, for example via the Internet, to documentation and logs. 9In accordance with the Patient Data Act, a care provider has the possibility, but no obligation, to give apatient access to his/her own patient data by electronic means. A requirement, however, is that the careprovider first makes an assessment of which data it is suitable to release. The care provider must alsotake appropriate security measures. 10Furthermore, the Patient Data Act says that a care provider at the request of a patient shall provideinformation about the access to a patient's data that has occurred. The care provider is obliged toprovide the information on paper and may, but has no obligation to, give the patient direct access tothe information. This presupposes that the security requirements have been met in the same way asapplies to patients' direct access to their own medical records. However, the patient has only the rightin this way to find out which care centre (but not which user) has had access to the data and at whattime. The information should be formulated in such a way that the patient can judge whether accesswas justified or not.11129 The Data Protection Authority's website, http://www.datainspektionen.se/lagar-och-regler/patientdatalagen/#1, visited on 23February 201510 The Data Protection Authority, The Patient Data Act and personal privacy, November 2008www.datainspektionen.se/Documents/faktablad-patientdatalagen.pdf11 The Data Protection Authority, The Patient Data Act and personal privacy, November 2008www.datainspektionen.se/Documents/faktablad-patientdatalagen.pdf12 For further information, see the Data Protection Authority's website, http://www.datainspektionen.se/lagar-och-regler/patientdatalagen/#1– 627 –Baltic Sea Parliamentary ConferenceII. WG homework 3Questions to the BSPC Member States on the demographic perspectives and the mobility of elderly1. What is the situation: What are the demographic perspectives for your country?2. What is done: If your country faces an elderly boom, how does it prepare for this?3. How is the mobility of elderly people, both at home and outside of their homes, organized in order to allow for aself-determined life? (f.ex. what services and tools are offered within elderly people’s homes)– 628 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Denmark– 629 –II WG homework 3 – Answer from Denmark31.10.14.BSPC Working Group on Innovation in Social and Health CareHomework 3, Contribution from DenmarkWhat is the situation: What are the demographic perspectives for your country?An ageing population combined with an increasing demand for health and care services will cause anincreasing pressure on public expenditure and thereby challenge the possibility of upholding a sustainableeconomy.Approximately 5.6 million people live in Denmark and about 18 % of the population is 65 years old or older.In 2040 Denmark is expected to have a population of 6 million people, and about 25% of the population isexpected to be 65+. The number of Danes over 80 years of age is, however, expected to rise from about235,000 in 2014 to about 609.000 in 2050. This is worth noticing since the majority of users of homecareservices are above the age of 80: About 50 % of the 85 to 89-year-olds and about 85% of the citizens abovethe age of 90, who still live at home, receive home care services.What is done: If your country faces an elderly boom, how does it prepare for this?By 2040 the number of Danes above the age of 67 is expected to have grown with 60 %, and thedemographic development has forced Denmark to rethink its social protection system.While some of tomorrow’s seniors will be in need of extensive care, others will be in good health and leadactive lives. Consequently, Denmark has aimed at developing solutions that fit both the need of thoseseniors who can get by with little help and those who are in need of extensive care.The Danish healthcare system is undergoing structural reforms which in combination with other reforms aredesigned to help and preserve the Danish welfare system including the healthcare system. The structuralreforms in the healthcare sector focus on providing more high quality healthcare for the total resources.Recent reforms and policy initiatives:Policy initiative:In august 2014 a new strategy for the Danish health care system was presented. With the strategycomes 700 billion euros in 2015-2018 to invest in chronic diseases, cancer, better quality and a morecoherent health care system.General reforms:- Structure reform of local government (2007)- New budget law – cap and sancations (2012)Healthcare specific reforms:- A better and more centralized planning of specialized functions- New hospital structure (ca. 5,5 billion euros)- Incentive committee - improving financial incentives– 630 –II WG homework 3 – Answer from DenmarkIn addition, there is a major focus on preventive measures to improve the healthcare status of the population,on building a healthcare system which is more coherent (hospitals, GP’s and municipal health care) and oninvolving patients in their own treatment by new technology ect. These measures aim at avoiding extendedhospitalizations and readmissions in general, improving quality of care and controlling public healthexpenditure in the future. The aim is to deliver healthcare services at the lowest possible cost level whilemaintaining the same or better outcome and quality.How is the mobility of elderly people, both at home and outside of their homes, organized in order toallow for a self-determined life? (f.ex. what services and tools are offered within elderly people’shomes)In Denmark, there is a general focus on providing citizens in need of assistance with personal care, trainingand practical support in order to enable them to take care of themselves in everyday life, for as long aspossible.Traditionally, Denmark has offered two types of eldercare: Homecare and Nursing homes.Homecare is targeted at elderly Danes, who live at home but are unable to manage everyday life withouthelp. Citizens are both entitled to practical assistance (e.g. cleaning and laundering) and personal assistance(e.g. bathing or shaving). Both types of assistance are free of charge and are available 24 hours a day.Citizens, who stay at nursing homes, are usually in need of more care than receivers of home care. By lawthe citizen’s apartment at the nursing home is his or her home. It is furnished with the citizen’s own furniture,and he or she has the same rights as tenants, who rent an apartment anywhere else in Denmark. The care,which the citizen receives, is provided free of charge.In order to accommodate the needs of those seniors, who are in relatively good health activating care isemphasized as a supplement to homecare and nursing homes. Activating care means that the old personlearns how to minimize or how to cope with his or her disabilities, e.g. by using welfare technology. Activatingcare takes both the citizen’s physical and mental well-being into account, e.g. by offering to help a lonelysenior getting into contact with other seniors.– 631 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Finland– 632 –II WG homework 3 – Answer from FinlandBSPC ISHC Homework, November 20141. What is the situation: What are the demographic perspectives for your country?As elsewhere, also in Finland the population is aging and the age structure of the society is starting to changerapidly. By the year 2030, the working age population (15–64 years old) is expected to decrease by 117 000,even if immigration is accounted for. The share of working age population would decline from 65 % in 2012to 58 % in 2030. The shift is almost entirely due to an increase in the population over 65 years of age.2. What is done: If your country faces an elderly boom, how does it prepare for this?- Decision on pension reform: Finnish labour market organisations recently reached an agreement on apension reform that will gradually increase the minimum retirement age from 63 to 65 by the year 2025. Afterthis, the minimum retirement age will be tied to the increase in life expectancy. For example, the projectedminimum retirement age for someone born in 1990 would be 67 years and 9 months. There will also beincentives to keep working even after reaching the minimum retirement age. The government is expected topropose the law amendments in the summer of 2015.- Social welfare and health care reform: Social welfare and health care services are currently organised bymunicipalities. In the new model, the arrangement and the provision of services will be separated. Theresponsibility for organising the services will rest with five social welfare and health care regions. The reformwill integrate social welfare and health care services as widely as possible, so that primary and specialisedservices form a seamless service package. The reform should guarantee more equal services across thecountry, while limiting the increase of expenses due to aging and higher need for care. The new regionsshould be running in 2017.- Structural Policy Programme: The reduction of the number of people in working age is causing issues forFinland's financial sustainability. In 2013, the Finnish government started a Structural Policy Programmeaimed at strengthening economic growth conditions and bridging the sustainability gap. The programme isbuilt on a large number of concrete structural policy measures to improve the productivity of the publicservice system and to increase the employment rate. The implementation of the programme is currentlyunderway. As a part of the programme, institutional care in care for the elderly will be reduced in favour ofcare provided at home.3. How is the mobility of elderly people, both at home and outside of their homes, organized inorder to allow for a self-determined life? (f.ex. what services and tools are offered within elderly people’shomes)- Informal care carried out by family members, relatives etc.: Improvements in support for informal care havebeen implemented over the years. A new Act on Support for Informal Care came into effect in 2006. Supportfor informal care is a service entity that consists of any necessary services for the care receiver, care allowanceand leave for the carer, and supporting services to informal care. The number of persons receiving supporthas increased steadily. The number of persons collecting support has increased from 13000 in 1994 toapproximately 36000 in 2010. From a municipal viewpoint, informal care is a very inexpensive form ofarranging care, and thus it will be more strongly encouraged in the future. New legislation is currently beingplanned to improve the support system.- New legislation in care services: The Act on Care Services for the Elderly entered into force in July 2013. Itincludes a number of measures to ensure that elderly people will receive care and treatment according to theirindividual needs and on an equal basis nationwide through high-quality social welfare and health care services.Elderly persons now have the right to a comprehensive evaluation of service needs, which will then be usedto draw up an individual service plan. Precedence is given to services provided at home, and institutionallong-term care will only be considered if medically justified. Elderly couples, whether married or not, willhave to be offered the option of cohabitation in long-term care. Home service and home nursing care assistwhen an older person requires help at home due to diminished functional capacity or illness.– 633 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Latvia– 634 –II WG homework 3 – Answer from LatviaBaltic Sea Parliamentary Conference on Strategies and Measures toSupport Innovation in Social and Health Care:Answers to questions concerning demographic problems1. Whatisthesituation:Whatarethedemographicperspectivesforyourcountry?Atthebeginningof2014thenumberofpopulationinLatviawas2001468,comparedto 2013 the population has decreased by 1.10 % (Source: Central Statistical Bureau).Even though the population decrease is slower in recent years, there is a populationdecline of over a fifth since 1990. Such situation has occurred mainlydue to negativenaturalincreaseofpopulation,lowbirthrateandemigration.In2013thecrudebirthrateinLatviawas10.2per1000inhabitantshavingatendencyto increase as birth increase is observed for the last three years. However, at the sametime Latvia had one of the highest crude death rates observed in the EU - 14.3 per 1000 inhabitants. Consequently, Latvia was one of thirteen EU Member States, whichhadnegativenaturalpopulationchangehavingoneofthelargestdecreases-4.0personsper1000inhabitants(Source:Eurostat).Beyond the natural rate of population decline, high rates of emigration is notable inLatvia,whichincreasedaftertheaccessionoftheEUandeconomiccrises.Afterapeakin2001,workforceemigrationsloweddownin2002-2007andregainedmomentuminmid-2008 and especially in 2009. In 2010 the emigration was at the highest point forthe last 10 years. In past 13 years 259 thousand people (more than 10% of allinhabitants) have emigrated to other countries and have not returned (Source: CentralStatisticalBureau).However,working-agepopulationisdecreasingevenfasterthantheoverallpopulation,which is primarily due to low birth rates in 1990s and high emigration rates of thepopulation under the age of 35 years in recent years. As a result currently 40% of thepopulation (793274persons)areaged50orolder, constitutingnearly30percentoftheworking-agepopulation.According to the World Bank calculations based on data from the UN PopulationDivisionandLatvia’sCentralStatisticalBureauthepopulationisprojectedtocontinueto decline, shrinking by just under 10 percent over 2012-2030. However, theseprojections might be over-optimistic taking into consideration past trends. Themedium-fertilityvariant assumes that the total fertilityrate increases to a range of 1.6to1.8inLatviaover2010-2030.In2012TotalfertilityrateinLatviawas1.44.Iftotalfertilityrateremainsatthecurrentrate,thenthepopulationwilldecreasefurther.2. Whatisdone:Ifyourcountryfacesanelderlyboom,howdoesitprepareforthis?Issues linked to the ageing population recently feature relatively highly in the publicand political debate in Latvia. There have been some promising initiatives organized– 635 –II WG homework 3 – Answer from LatviabydifferentMinistries,socialpartnersandNGOsbutaneedwasidentifiedtoensureamorecomprehensiveandstructuredapproachinthisfield.Thereforeinordertoaddressactive ageing challenges the Ministry of Welfare is implementing a project „Latvia:Developinga Comprehensive Active AgeingStrategyfor Longer and Better WorkingLives" with the support from the EU. The objective of the project is to develop anevidence-basedandcomprehensiveactiveageingstrategyinLatviathatwouldfacilitatelonger and better working lives. Within this project the World Bank is carrying out astudy and will give recommendations for improving active ageing policy and fordevelopinganactiveageingstrategy.TheMinistryofWelfarehasalsoformedstrategicpartnership with the Austrian Federal Ministry for Labour and Social Affairs andConsumerProtection,Ministryof LabourandSocialPolicyofPolandandMinistryofSocialAffairsoftheRepublicofEstoniainordertoexchange goodpracticeexamplesand experience. General active ageing issues as well as specific topics, such asemployment,health,socialsecurityandcareforfamilymemberswillbecovered.Theimplementation of the project is in the initial stage, mainly best practices have beenidentifiedandpossibilitiestoadjustthemfortheLatvia’ssituationhavebeendiscussed.ConcerninglabourmarketalsotheMinistryofEconomicsofLatvia,whichisworkingwith labour market forecasts, draws attention to the ageing population and changinglabour force supply due to it. Analysis shows that aging of the labour force are aparticularconcernamongmanagersinareasofmanufacturingandspecializedservicesaswellasseniorspecialistsinscienceandengineering,healthcareandeducation.Another area of particular interest regarding active ageing is life-long learning,especiallytakingintoconsiderationthatin2013inLatviaonly2.6%ofpersonsinagegroup 55-74 were involved in lifelong learning, while the indicator for persons in theagegroup18-74was10.1%(Source:Eurostat).The Ministry of Health of Latvia develops and implements public health policy withthe aim to prolong the healthy life years of the Latvian population and to preventuntimelydeaths,whilemaintaining,improvingandrestoringhealth.Currentlyasmainpriority areas for investment are set cardiovascular diseases, oncology, perinatal andneonatal period care and mental health care. Meanwhile there is an emphasis on theaccess to health services and especially for people at risk of social exclusion andpoverty,includingelderly. Healthyageingisalsopromotedbyemphasizingtheroleoflocalgovernmentsinbuildingahealthyenvironment.TheMinistryofHealthofLatviahas developed Guidelines for Health Promotion in Municipalities, which providemunicipalities with science-based information about health promotion (physicalactivities; nutrition; prevention of addiction-inducing substances; family health,including safety promotion; injury prevention etc.) and development of healthybehavioursandlifestyleofthelocalpopulation.Apart from the promotion of healthy ageing, there is a wide range of active ageingactivities implemented in local governments. Mostly these activities are implementedwiththeaimtopromotesocialactivityofelderly,howevertherearealsogoodpracticeexamples of providing social support, ensuring the environmental accessibility andpromotinglife-longlearning.– 636 –II WG homework 3 – Answer from LatviaAdditionally, there have been recent changes of transfers for retirees are aimed toensure long-term sustainability of the pension system and to deal with demographicchallenges (such as ageing, shrinking of working age population, low birth rate andemigration).AccordingtotheLawonStatePensions,asof2014:– theretirementagehasbeenincreasedgraduallybythreemonthseveryyearuntilreaching 65 years by 2025. At the same time, the possibility to request an old-agepensiontwoyearspriortoreachingthedefinedretirementageispreserved;– the minimum length of social insurance period has been increased from 10 to15 years, granting the rights to receive an old-age pension and from 15 to 20yearsstartingwith2025;– expenditures for payment of an old-age and disabilitypension will be ensuredfromthestategeneralgovernmentbudget,thusunburdeningthesocialinsurancespecialbudget;– thesocialcontributioncaphasbeenrestored–EUR46.4thousandperyear.3. Howisthemobilityofelderlypeople,bothathomeandoutsideoftheirhomes,organizedinordertoallowforaself-determinedlife?(f.ex.whatservicesandtoolsareofferedwithinelderlypeople’shomes)At the end of 2012, there were 82 municipal nursing homes for elderly people, with5647recipients.Theaveragenumberofbedsis5798,whichconstitutes15,28bedsper1.000personsaged65+.There are no specific cash benefits for older people, but there is a personal care cashbenefit of discretionary use for disabled people. In 2012 there were 11,480 personsreceivingthisstatebenefiteachmonth. Mostbeneficiaries,58.3%ofall, werepeopleabovetheageof65years.There is also a cash benefit for disabled people with walking difficulties. It aims tocompensate for expenses on specially adapted cars or other means of transportation.Thenumberofrecipientswas17,500in2013,45,6%ofthemolderthan65years.Nursing homes for elderlyas a rule are organized and run bythe local municipalities.TherearealsoseveralprivateandNGO-runelderlyhomes;municipalitiesusuallypayfor the services of these institutions subject to means-testing of recipients andnegotiatedpriceswiththeinstitution.Formal home care is provided bylocal social services, NGOs, charities, some privateentities (agencies) and individuals. Some municipalities offer other types of homesupportforolderpeoplelikesecuritybuttons,deliveryofwarmmeals,laundryservicesandassistance.Therearenobenefitsforelderlyhomecareforeseenatthestatelevel.However,anewbenefit for disabled persons who need personal care was introduced in 2008,irrespective of the age and income of beneficiary. The benefit is granted on the basisof a formal disability status and the need for personal care according to medicalassessment. The amount of this benefit is set at the level of EUR 142 per month. Theintroduction of this benefit was a response to a persistent shortage of accessible and– 637 –II WG homework 3 – Answer from Latviaaffordable specialised nursing home services and personal care services. Therefore,disabled persons are presumably using this benefit to pay for the provision of careservices.Depending on the municipalityadditional services are offered to support independentlivingamongelderlyanddisabledpersons.In2012,therewere10daycarecentresforolder people with 4944 recipients. Day care centres for people with dementia arerecentlybecoming more widespread in Latvia. Several municipalities have developednew ICT services like security buttons. Also mobile care teams are used to providemore differentiated services. However, coverage of these services is low andterritoriallyuneven.Noassessmentoneffectivenessofanypreventionorrehabilitationmeasuresisavailable.Although it has always been recognized that alternative care should be more widelydevelopedtherehasbeenverylittleprogressinthisdirectionespeciallyduringthecrisisyears. Home care services are underdeveloped and high demand for institutional careispersistent.TheMinistryofWelfarehasrecentlypublishedtheConceptpaperonthedevelopmentof social services for 2014 - 2020 (the government has approved it on 04.12.2013)where the move from institutional to home care is one of the top priorities for peoplewithlimitedabilitiestoperformtheiractivitiesofdailyliving.Specialattentionisgiventothetwotargetgroups:childrenandpeoplewithmentaldisorders.Forelderlypeople,thedocumentsetatarget of100%coverageinmunicipalitieswithhomecareservicesuntil 2017, to increase the number of recipients (elderly and disabled) of home careservices from the current 41 per 10,000 inhabitants to 55 in 2017 and to increase thenumberofrecipientsindaycarecentresfrom58to65per10,000inhabitants.– 638 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Lithuania– 639 –II WG homework 3 – Answer from Lithuania– 640 –II WG homework 3 – Answer from Lithuania– 641 –II WG homework 3 – Answer from Lithuania– 642 –II WG homework 3 – Answer from Lithuania– 643 –II WG homework 3 – Answer from Lithuania– 644 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Mecklenburg-Vorpommern– 645 –II WG homework 3 – Answer from Mecklenburg-VorpommernLandtag Mecklenburg-VorpommernJulian Barlen, MPMember of the BSPC Working GroupInnovation in Social and Healthcare_____________________________Contact:Olaug Bollestad Landtag Mecklenburg-VorpommernChairman of the BSPC Working Group Committee on European and Legal AffairsInternational Secretariat„Innovation in Social and Healthcare“D-19053 SchwerinWorking Group Secretariat Lennéstraße 1 (Schloss)The Norwegian Parliament Phone: +49 385 525-1530Telefax: +49 385 525-15350026 Oslo, NorwayE-Mail: pa3mail@landtag-mv.deInternet: www.landtag-mv.deSchwerin, 13 November 2014Working Group „homework“ – questionnaire on the state of innovation insocial and healthcare in Mecklenburg-VorpommernDear Ms. Chairman,With reference to the Secretariat’s email from 24 September 2014 regarding the3rd Working Group’s decision to carry out a “homework” on the state of innovation insocial and healthcare in our respective countries and regions, I hereby convey to youthe completed questionnaire of the state of Mecklenburg-Vorpommern.My colleague Wolfgang Waldmüller and I have forwarded the Working Group’ssurvey to the Ministry of Social Affairs in our state.In the appendix you will find a translation of the ministry’s responses.I’m looking forward to a constructive Working Group meeting in Copenhagen.Best regards,Julian BarlenAppendix– 646 –II WG homework 3 – Answer from Mecklenburg-VorpommernAppendixResponse by the Ministry of Social Affairs to the BSPC questionnaire oninnovation in social and healthcare1. What are the demographic perspectives for your country?In the period of 2010-2030 Mecklenburg-Vorpommern will lose about 10% of itspopulation. In some rural areas, the loss will amount to as many as 25%. At the sametime the population is aging rapidly. During this period, the percentage of those agedabove 65 will increase from 22% to 30%; in some rural areas even up to 40%.Mecklenburg-Vorpommern is facing major demographic challenges.2. Your country faces and elderly boom, how does it prepare for this?The strategy report of the State Chancellery from January 2011 about thedemographic change formulates strategic action guidelines for dealing with theconsequences of the demographic change in our state. Further details can be foundat: www.demografie-mv.de/cms2/Demografie_prod/Demografie/de/start/Demografiestrategie/index.jsp.Mecklenburg-Vorpommern features a clearly structured and robust central allocationsystem, which offers a good compromise between accessibility and the need forsufficient coverage. It is an important tool of spatial planning to establish equal livingstandards. Adapted to the specific regional structures of the state, its centrallocations make up the nodal points of the supply network, where institutions for theprovision of public services are bundled. Central locations feature direct bindingeffects for public providers of existential requirements, but they are also attractive forprivate providers. Within the system, priorities regarding, among others, the locationsof institutions for inpatient and outpatient medical care and drug and emergencyprovision as well as care services for the elderly and handicapped are determined.Additionally, the designation of rural areas with special demographic challenges andthe definition of measures for these areas – which can also include aspects of healthprovision – are currently discussed.Committees moderated by the federal state (as for example the Concerted Action inHealthcare, the state committee for cross-sectoral provision issues, the “RoundTable” for palliative and hospice care, the psychiatric advisory board and the statecare committee) provide opportunities for discussion and the cross-sectoraldevelopment of new and innovative measures concerning care.With the provision of care support points and social stations, central locations ensurebasic services in the field of care for disabled and elderly people.In the field of medical care provision, especially in rural regions, new forms of careare established or are being tested. Particularly relevant is for instance theapplication of telemedicine. The new profession as telemedicine-nurse – AGNES –was integrated successfully into basic health care.Apart from these facts, the Health Centers Woldegk and Mirow are examples for newapproaches to improve medical care, providing primary care and periodicallyspecialist treatment.– 647 –II WG homework 3 – Answer from Mecklenburg-Vorpommern3. How is the mobility of elderly people, both at home and outside of their homes,organized in order to allow for a self-determined life? (f.ex. what services andtools are offered within elderly people’s homes)Aspects of mobility and considerations regarding mobile offerings of health careinclude the bodies and round tables referred to under item 2. Furthermore, theLandtag commission of inquiry „Ageing in Mecklenburg-Vorpommern“ hascommissioned a study on mobility of elderly people.The planning of public transport is the responsibility of municipal level. Currently, acomprehensive research package for municipalities and regions that undergodemographic change (InnovaKomm) is initiated by the German Government that willlead to tangible improvements for the local population through innovations in theinteraction between humans and technology. The School of Applied Sciences inWismar is applying with a project.– 648 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Norway– 649 –II WG homework 3 – Answer from NorwayHomework 3 – NORWAY1) What are the demographic perspectives for your country?This figure shows that Norway will have a much older population in the coming years.Today around 11 % of the population is 70 years or older. In 2060 this group will constitute19 % of the population (in 2100, 23 %). Further, the amount of people over 80 will increasesignificantly.The critical growth of elderly in Norway is expected to happen from 2025. Until then itwill be relatively poor. Nevertheless, the elderly boom will be much weaker in Norway thanin many other countries due to a less negative birth rate (ab.1,8 in 2014) and immigration ofyounger cohorts.2) If your country faces an elderly boom, how does it prepare for this?The government’s white paper (nr. 29 2012-2013) “Care of tomorrow” present guiding lineson how Norway should deal with the elderly boom. This will mainly be done through:developing preventative services, early intervention and rehabilitation. Further, oneconcentrates on mobilizing different actors outside public sector (e.g. volunteers andrelatives), and on developing welfare technology so that the elderly could better managetheir everyday life. Several programs are developed to deal with this. Finally, in Norway, itis also a stated objective to induce a higher proportion of the healthy elderly population toretire later than the statutory minimum retirement age. One of the aims of the recent pensionreform is to contribute to this. Examples of ways of doing this are: to increase annual retirement pensions incrementally if the individual decides toremain in work longer to adjust retirement pensions to average life expectancy within the population at large.3) How is the mobility of elderly people, both at home and outside of their homes,organized in order to allow for a self-determined life?Norwegian municipalities use more resources on home-based services than on institutionalcare. Examples of such home-based services are nursing, ergonomics and physiotherapy.The elderly can get personal assistance in their homes, e.g. help to self-care, personalcare/treatment, and personal practical help for household shopping, food making, laundryand house cleaning. The municipalities also assist the elderly in participating in leisureactivities, e.g. providing a support person/befriender. Further, the municipalities receive– 650 –II WG homework 3 – Answer from Norwaygrants from the state for developing day activities for dement people still living at home.Elderly or functionally handicapped persons who are not able to use ordinary publictransport are offered a taxi-based arrangement.The government’s white paper (nr. 25 2005-2006) pointed at five main challenges for careservices today: daily life, meals, activities, and social and cultural relationships. Thisrequires increased professional and technical competence, involvement of more occupationalgroups and focus on both activities and socio-psychological well-being.The government sends signals of making «active elderly» as one of its main areas ofcommitment.– 651 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Åland– 652 –II WG homework 3 – Answer from ÅlandAnswwers from AnnnetteHolmmberg-Jansson,, membber ofthe Åland Parliaament andBSPCC ISHCC workinng grouupHommework 33 – ÅLANND1) Whaat are the ddemographhic perspecttives for yoour countryy?The total depenndency ratioo is expecteed to rise froom just undder 70 to 822 within tenn years andto 91 within 200 years. Thee change is more rapidd in Åland than in the Nordic aveerage. Thismeaans that eachh person inn working aagge within twwo decadess except itseelf will suppply almostanotther person.Deependency rattio % (20-64)2) If yoour countryy faces an eelderly booom, how dooes it prepaare for this??The Åland Govvernment haave had thee intention tto prepare aa new Act rreegarding ellderly care.The work has pproved to bbe difficult tto do beforre it is decidded how thee new Sociial WelfareAct will be formmulated in ÅÅland. Bothh legislationns are under work at thhe Åland goovernment.Ålannd is divideed into 16 mmunicipalities with respponsibilitiess regardingg social caree. It is nowdiscuussed to cenntralize somme of these responsibiliities to a neew municipaal body. Neext year thegoveernment willl appoint a working grroup regardiing the neww Act for eldderlycare.3) Howw is the mobbility of eldderly peoplle, both at hhome and ooutside of ttheir homess,orgaanized in orrder to alloow for a sellf-determinned life?The general priinciple is thhat old peopple should hhave the oppportunity too stay home as long asposssible. In ordder to do this they receiive servicesfrom the mmunicipalitiees. The eldeerly can getnurssing, personnal assistancce in their homes, perrsonal care//treatment aand personaal practicalhelpp for househhold shoppiing, food mmaking or deelivery, laundry and ceertain housee cleaning.The municipaliities also prrovide transsports to abble elderly tto participatte in normaal life. The– 653 –II WG homework 3 – Answer from Ålandgovernment provide the municipalities with virtual elderly care services. These services is infact a kind of interactive wellbeing TV in order to rise the elderly peoples physical and socialwellbeing, to increase safety and decrease loneliness through social interaction. Thegovernment continue its work to create a system for service vouchers that give the elderlypeople their own right to choose what kind of service the need and want.– 654 –Baltic Sea Parliamentary ConferenceIIWG homework 3Answer from Sweden– 655 –II WG homework 3 – Answer from SwedenWhat are the demographic perspectives for your country?Like many other states, Sweden faces an aging population. In 2013, 19.4% of theSwedish population was aged over 65 years, compared to an OECD average of16%, while 5.2% of the population was aged over 80, compared to an OECDaverage of 4.2%. Demographic projections signal that the share of the populationover 65 and over 80 years will increase, but will be below the OECD average by2050. Today, average life expectancy in Sweden is 84.4 years and is expected torise by 2.6 years by 2050.1The main challenge is maintaining stable finances for the welfare system in asituation where the working age population decreases in relation to the notworking population – a rising dependency quota. Calculations from StatisticsSweden show that one working person in 2013 provided for 0,71 not workingpersons. By 2060 it is estimated that one working person will have to provide for0,92 persons that doesn’t work.2 The demographic challenge will be different indifferent parts of Sweden since the effects of the aging population is reinforcedby an ongoing urbanization. Especially rural areas will develop an increasinglyproblematic demographic structure with a rising dependency quota. The numberof Swedish municipalities with a dependency quota above 1,0 has been estimatedto increase from 1 percent in 2013 to 41 percent in 2050. Mostly small and ruralmunicipalities are found in this group.3What is done: If your country faces an elderly boom, how does it prepare forthis?There are many policy decisions that is directly or indirectly influenced by theaging population. This section will not include all of these. Focus will be onnational government policy, but it may be noticed that both EU policy (forexample the EU 2020 strategy) and local policy is of importance to the issue.The main policy areas in relation to the demographic challenge is employmentpolicy, pension policy and health care policy. Several policy measures aim toincrease the number of years that people work. One example is extra tax relief forpeople that continue working after the age of 65. Also, there is ongoing policydiscussion about raising age limits both in the pension system and theemployment legislation. A government committee suggested several changes inage limits in 2013, among these was a raised retirement age and a right to work1 OECD (2013), “Long-term care in Sweden”, in OECD Reviews of Health Care Quality: Sweden2013, OECD Publishing http://dx.doi.org/10.1787/9789264204799-7-en2 Ds 2013:8 Framtidens välfärd och den åldrande befolkningen3 Ds 2013:8 Framtidens välfärd och den åldrande befolkningen– 656 –II WG homework 3 – Answer from Swedento 69 instead of 67. These suggestions are now processed in the “Pension Group”consisting of representatives from five parties in the Swedish Riksdag. Changesin age limits will be discussed in government talks with the social partners.4 Inthe end of the 1990’s the implementation of a new pension system started. Thenew system was adopted to achieve a sustainable pension system in relation tothe demographic challenges ahead.There are also policy discussions and measures aiming to achieve a more flexibleemployment market to allow people to “change paths” midlife, which also hasbearing on education policy.One of the challenges of an aging population is the demand for health care andsocial services. Besides the financing of these services, there is also a challengein ensuring the provision of health and social care professionals. Decisions havebeen taken to educate more people in the health care area. Also, validation ofcompetence for immigrants with healthcare education from other countries hasbeen prioritized. There are also measures to get young people to choose a careerin health care and social services to a higher extent than today.Besides the above mentioned, all measures to increase effectivity and quality inhealth care and elderly care may be included in what is done to meet the “elderlyboom”. All of those activities cannot be listed here. Projects in ISHC is describedin homework 1.How is the mobility of elderly people, both at home and outside of theirhomes, organized in order to allow for a self-determined life? (f.ex. whatservices and tools are offered within elderly people’s homes)Long term Care for the elderly in Sweden includes both varying forms ofassistance in a home environment and institutional (or special-housing) care (oldpeople’s homes, residential care, homes for the demented/dementia units, nursinghomes and similar). It includes personal care – such as help with bathing, gettingdressed and getting in and out of bed – as well as help with shopping, cooking,cleaning and laundry. It also provides elderly in need with assistive devices,transportation, housing adaptations, handicap aids and support for informalcaregivers. Services are provided after a care assessment process. Somemunicipalities have however started to provide services such as home alarms toall persons over 65 that want one, without care assessment.The service user pays fees and co-payments for the different services, but thecosts are highly subsidized. Fees may vary between municipalities and regions.For people living in institutions, the cost of board and lodging is covered, with aco-payment based on the income of the recipient.Assistive technology at home for elderly in Sweden54 Labour market actors such as labour unions and employer ́s organizations.5 Information from The Swedish institute of Assistive technology, webpages in English– 657 –II WG homework 3 – Answer from SwedenThe Swedish Institute of Assistive technology (SIAT) writes that assistivetechnology includes traditional products such as those which assist with bathing,dressing and eating, walkers, wheelchairs as well as ICT-based assistivetechnology. Assistive technology makes it possible for elderly to age in theirhome.Examples of ICT- based assistive technology that can support older persons toage in their home (often called welfare technology in Sweden) include socialalarms, video communication via TV and memory support devices to remindpersons to take necessary medication or to organize their day and remind themwhen to carry out activities. SIAT writes that such products are available on themarket but not yet commonly used in Sweden. Some municipalities however,have begun to use ICT-based services, and have seen that by doing so they canefficiently deliver service to their clients by reducing travel time and have morecapacity to support those who are in most need of support from a career on site.The Swedish Institute of Assistive technology (SIAT) was commissioned by thegovernment to manage two large programs, “Technology for Elderly” and“Growing Older – Living Well”, that aimed at promoting innovation anddevelopment of products and services that can enable older persons to age inplace. More than 220 projects were funded in the programs and involved morethan one hundred municipalities, groups of senior persons, professionals,decision makers and researchers.The following are some examples of technology for elderly included in the“Technology for elderly”-project:Housing• Care IP – Alarm Unit with GSM-backup• Accessibility – CAD-tools for building design• Outdoor training for elderly– Preventive training with outdoor equipmentInformation of and accessibility to products and technology• Doro – Mobile phone designed for elderly• ELSA 85 – 85-year old persons’ perception of home technology ineveryday life• Nintendo WII Sport – Computer games as an activity for fun and joy ofmovement within the domain of elderly-care in SwedenTechnology for elderly and their relatives• ACTION – ICT for the elderly, caregiver support and communication insparsely populated areas in Sweden• Caredo – Wireless home care safety system• Call Centre for relatives – Videophone support to relatives fromSource: The Swedish Institute of Assistive Technology– 658 –