Recommendation Rec(2006)17
of the Committee of Ministers to member states
on hospitals in transition: a new balance between institutional and community care

(Adopted by the Committee of Ministers on 8 November 2006
at the 979th meeting of the Ministers’ Deputies)

The Committee of Ministers, under the terms of Article 15.b of the Statute of the Council of Europe,

Considering that the aim of the Council of Europe is to achieve a greater unity between its members and that this aim may be pursued, in particular, by the adoption of common rules in the public health field;

Bearing in mind the provisions of the Convention for the Protection of Human Rights and Fundamental Freedoms (ETS No. 5) and of the revised European Social Charter (ETS No. 163);

Recalling Article 3 of the Convention on Human Rights and Biomedicine (ETS No. 164) on equitable access to health care of appropriate quality, its Article 4 on intervention in the health field, including research, which must be carried out in accordance with relevant professional obligations and standards, and its Article 10 stipulating that everyone has the right to information about his or her health;

Recalling its recommendations to member states: Recommendation No. R (97) 17 on the development and implementation of quality improvement systems (QIS) in health care, Recommendation No. R (99) 21 on the criteria for the management of waiting lists and waiting times in health care, Recommendation No. R (2000) 5 on the development of structures for citizen and patient participation in the decision-making process affecting health care, as well as Recommendation Rec(2001)13 on developing a methodology for drawing up guidelines on best medical practices;

Considering that hospitals are an integral part of the whole health care system and that they are a sum of their functions;

Considering the increasing interest among member states in improving their health care systems by modernising hospital services and improving integration across the health care system;

Conscious of the need to respond to challenges and pressure for change, as hospitals are faced with a strategic repositioning of their place in the whole care system, particularly in caring for chronically ill people;

Considering that this can be achieved by introducing systemic innovation to develop integration and coherence between hospital functions and other parts of the health and social care system. This includes other options for hospital care such as day surgery, multi-disciplinary teams in the community, case management approaches for patients with serious conditions, support for patient self management, clinical networks, telephone and on-line services, and so on;

Bearing in mind that consideration of other options does not necessarily mean substituting hospital services;

Considering that any modernisation and reconfiguration between providers must continue to work towards equal access to care and treatment for patients and citizens, and ensure continuity and quality of care;

Recognising that health care systems and the position of hospitals in them varies depending on the country because of the complex environments of ethical, economic, social, legal, cultural, educational and other factors in which health care systems operate;

Noting that hospital care is evolving in most countries, in line with the efforts to increase efficiency and continuity of care within the framework of health and social services;

Considering that new developments in information and communication technologies may improve access to care, bring it closer to the citizen, enhance quality and increase performance,

Recommends that governments of member states:

i. develop a coherent and comprehensive national policy framework as part of the wider agenda for health and social care that explores a range of alternative options to traditional hospital care. This framework should respect values of equity, accessibility and patient-oriented care;

ii. ensure that continuity of health care and of its funding is put at the core of all health policies, in particular as a foundation for developing networks of health services;

iii. develop a new balance between primary, community and institutional care that is organised around the patient and provides services closer to the community;

iv. ensure that appropriate resources are made available and are used to support changes and introduce incentives for such changes;

v. ensure that new approaches are relevant and appropriate to local situations, respecting multicultural, ethical, social and economic backgrounds;

vi. consider the added value of new information, communication and management systems to support patient-centred care and continual care;

vii. plan for and invest in securing sufficient human resources, in terms of numbers of staff and their educational and training needs, to address the impact of the new balance on health care personnel;

viii. ensure that services introduced in the framework of the new balance are monitored and assessed for efficiency, cost-effectiveness and quality;

ix. encourage building on and learning from national and international experience, and stimulating international co-operation in the field covered by this recommendation.

When considering the above recommendations, member states should take into account the principles included in the appendix.

Appendix to Recommendation Rec(2006)17
of the Committee of Ministers to member states
on hospitals in transition: a new balance between institutional and community care

A. General considerations

1. All health reform policies should be based on the provision of continuous, patient-oriented care to meet the demands of populations that are undergoing changes in socio-demographics and epidemiology.

2. Hospitals should not be considered as a set of buildings but as a sum of their functions. Those functions can be delivered in different settings.

3. Member states seeking to implement health reforms should consider the context within which their health systems are operating. Europe is facing similar changes and challenges, although at different rates. In addition, within each country there are separate challenges, particularly associated with resources.

4. Member states should improve integration between social and health care.

B. Alternative options to traditional hospital care

1. Member states should consider what sort of health care is needed to support their citizens and to define the most appropriate place for this care and the best service provider

2. Member states should consider how they can develop and support the transformations needed to deliver effective health care.

3. Stakeholders in member states should participate in defining a clear health strategy that strikes a better balance between traditional models of episodic care and alternative options that provide preventive, systematic and integrated care to our increasing chronically ill populations.

4. Member states are encouraged to introduce incentives to facilitate reforms of their health care systems.

5. In developing policy and implementation plans, member states should consider the following options:

– action to encourage patients to manage their chronic conditions themselves, for example, through expert-patient programmes;
– the possibility for patients to have access to information and advice through telephone and on-line support services;
– stand-alone treatment centres, testing and diagnostic facilities;
– intermediate care: rehabilitation centres, step-up and step-down facilities;
– enhancing the role of primary care;
– better joint co-operation with social workers;
– home-based care;
– palliative care and hospices;
– the benefits of telemedicine and distance learning.

6. Member states should develop health policy strategies, which take these innovations into consideration and implement them in the appropriate way.

C. Reconfiguring hospitals

1. Member states should take into account the need for improving the health care system through a reconfiguration of hospitals that places them within the context of the overall health care system.

2. Member states should reconfigure hospital services in order to offer patients with the best possible services in the most appropriate settings, while taking into consideration the relevance of hospitalisation.

3. Member states should develop and improve safety and quality assurance systems to ensure that services are consistent and of high quality, wherever they are delivered.

4. Member states should define conditions for private and public provision of services.

D. Systemic innovations

1. Member states should consider implementing efficient systemic innovations, which are described in this document as examples of good practice. Key themes include:

– introducing clinical networks where all organisations who deliver part of a specified patient care cycle or are engaged in delivering services to specified populations come together as a whole to improve service integration, for example, cancer, psychiatric, paediatric or geriatric services. These networks occasionally have common management arrangements and/or pooled financial arrangements;

– introducing integrated and co-ordinated care cycles that start from diagnosis and follow through all treatments and care for as long as it is needed by the patient;

– ensuring close co-operation across organisational boundaries and encouraging changes in behaviour at those boundaries. This calls for significant changes in the management and flow of information as well as communication between stakeholders. Although current innovations in information technologies can allow for improved communication, the context of each country should be taken into consideration before introducing major systemic changes;

– the importance of encouraging patient self-care and self-management. Efforts should be made and funds invested when necessary to provide patients with access to factual information, advice and support with regard to adopting a healthy lifestyle, to make tools and techniques available to them and to allow them to manage their own medication;

– monitoring and evaluation of the reform and change to the system. It is important to consider making adjustments in the light of the outcomes.

E. Education and training

1. In proposing reform and change, member states should take into account the impact on human resources. Human resources are the main asset in the health sector and can help or hinder reforms, depending on how people are involved in and supported through the process.

2. Member states should consider the skills needed for managing services that cross organisational boundaries.

3. Member states should consider a variety of options for putting appropriately skilled health personnel in place including education and continuous development, accreditation, moving professionals from areas which are overstaffed to areas which are understaffed.

4. Member states should put in place communication strategies to educate patients, their carers, their families and communities about the changes in services and the role of different people in implementing them.

F. Impact of system changes on equity, access, continuity of care and the wider system

1. Policy makers, planners, health service purchasers and the organisations providing health care must ensure that patients and the public are at the heart of services.

2. Member states, when considering alternative options to traditional hospital care, should ensure:

– equal access to health care;
– equity in receiving health care services;
– continuity of care;
– quality of care.

G. Centres/models of excellence

1. Member states should agree, in co-operation with other bodies, on a set of criteria and an evaluation process for identifying evidence-based best practice. This should take into account the country context and circumstances of each member state.

2. When considering best practices, the following areas are important: patient and clinician satisfaction; cost-effectiveness; good collaboration between clinicians and support staff across the whole system; and an adequate time interval between implementation and evaluation of reforms.

H. Information gap

1. Member states need to review existing arrangements for managing data and information and upgrade them to meet the demands of a more patient-oriented, preventive and integrated approach to health care.

I. Monitoring and evaluation

1. Clinical practice guidelines for alternative approaches to traditional hospital services, based on the best available evidence, should be developed in a systematic way, with the participation of patients.

2. Continuous feedback on existing practices in the form of an audit is essential.

3. Alternative approaches to traditional hospital services should be evaluated using proven scientific methods, both qualitative and quantitative in nature. Such studies should above all be patient-focused.

4. Collaborative research in this field, both at national and international level, should be encouraged.

J. Role of the patients/citizens

1. Member states should increase the role of patients and citizens in shaping future health care services.

2. Public debate should be more widely used to strengthen participatory mechanisms in all health care reforms.

K. Financing

1. Member states have a responsibility to ensure that all parts of the health care system have appropriate financing to fulfil their role in the new balance.

2. Member states should consider the value of developing the private sector to contribute to the health care agenda.



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