Who is shaping the future of European health systems?

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What are the commitments for each country?PortugalThe programme for Portugal aims to reduce expenditure by €1bn (£835m; $1.3bn) in 2012 and €375m in 2013.2 3 This is equivalent to a total reduction of 0.8% of gross domestic product from a previous health spend of around 6.5% of GDP.4 There are 33 commitments affecting the health system, including a target to limit public spending on pharmaceuticals to 1.25% of GDP by the end of 2012 (around the current level4) and about 1% of GDP by 2013, plus detailed measures on hospital services (especially acute care services) and primary care services (box).Measures taken in Portugal3 Electronic prescription has been made mandatory for medicines and diagnostic tests, in part to enable better monitoring Doctors are being required to prescribe by generic name rather than brand Copayments have been expanded to cover more services Overtime has been cut Fees paid to private providers were reduced by 12.5% in 2011; a further 10% reduction is planned for 2012 The measures seem likely to have a substantial impact on both patients and healthcare workers. Patients will have to pay more towards their care and will get reduced tax allowances for healthcare. The scope of specific healthcare schemes for public sector workers is also being tightened and the maximum number of patients per general practitioner has been increased. Healthcare workers can expect reductions in overtime, more flexible working rules, and requirements increasing mobility of staff throughout Portugal. Hospital performance will be assessed annually and the prescribing practices of individual doctors monitored quarterly. The cost of drugs and other medical products is particularly targeted, with a new centralised purchasing system plus requirements for lower prices and distribution margins and stronger guidelines on prescribing and use of generics.There are also requirements for restructuring of the health system. These include moving some hospital outpatient services to primary care, increased specialisation and concentration of hospital and emergency services, and reduction of hospital management staff. The aim is to reduce operational costs of hospitals by at least 15% by 2013 compared with 2010. Taken as a whole, the objectives would profoundly challenge any health system.GreeceThe programme for Greece perhaps goes the furthest in setting an overall framework for the health system because it includes an explicit objective of keeping public expenditure on health capped at 6% of GDP (around its current level).5 Greece already has one of the lowest levels of health system expenditure relative to overall resources within the EU—for example, the UK spends 8.2% of GDP, Germany 8.9%, France 9.2%, Portugal 6.5%, and Ireland 7.2%.4The changes in Greece are principally focused on how the health system is managed and administered. They include consolidation of health insurance funds, more use of e-health such as electronic prescribing, and general strengthening of data collection and central monitoring. So far success has been limited. The task force commissioned to review overall policy has still not issued its main recommendations, though it is likely to include hospital reorganisation and a reduction in the healthcare staff contracted with the health insurance funds.6 Prescription guidelines have been developed but not yet formally adopted; targets for increased use of generic drugs and reductions in hospital budgets have not been met.7 Tools are being developed for the future—for example, diagnosis related groups are being piloted. IrelandThe economic adjustment programme for Ireland is the least directive of the three bailout agreements on health.8 Nevertheless, it includes explicit actions “to remove restrictions to trade and competition in sheltered sectors including […] medical services.” It will eliminate restrictions on the number of GPs qualifying and remove restrictions on GPs wishing to treat public patients if they are not contracted to the state to do so. Restrictions on GPs advertising their services will also be removed, and there will be changes in fees for pharmacists.

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