Never too early tackling chronic disease to extend healthy life years

Never too early

Tackling chronic disease
to extend healthy life years

A report from the Economist Intelligence Unit
Sponsored by Abbott


Never too early: Tackling chronic disease to extend healthy life years

Contents
Introduction

2

About this research

4

Executive summary

5

Heading off chronic disease: New approaches to prevention

7

l A preventable scourge

7

l Changing incentives14
l Market-driven prevention16
The role of employers: Workplace initiatives to tackle chronic disease18
l Mission: Healthier workers19
l Healthier companies, too

20

l What works?

21

Managing chronic disease: Rethinking provision of care

23

l The separate worlds of acute and chronic care

23

l Managing chronic care: keys to success

25

l High touch and high tech

26

Conclusion

28

Appendix: Interview programme and expert panel participants

29

© The Economist Intelligence Unit Limited 2012




Never too early: Tackling chronic disease to extend healthy life years

Introduction

“We are in the age of the old. Let’s celebrate,” says Mary Baker, president of the
European Brain Council. The premise of her statement, especially for Europe, is
indisputable. The United Nations Population Division reports that life expectancy
in Europe has risen by an average of ten years since 1960 and two years in the past
decade alone. It forecasts that average life spans across Europe will rise from 75
years currently to 82 years by 2050.
This is of course good news, but even good news can have a dark side. In the case
of Europe’s longevity, the sunny outlook is clouded by the fact that not all those
extra years will necessarily be healthy ones. The advanced years of many Europeans
will be prematurely burdened by the need to cope with one or more chronic
diseases, the incidence of which is climbing alarmingly. Moreover, the rising tide
of chronic illness is threatening the viability of Europe’s healthcare systems, which
are ill-equipped to cope financially, operationally or strategically with increasing
numbers of long-term patients.

That said, increased longevity promises opportunities too, as the swelling ranks
of older Europeans represents a largely untapped human resource. To raise
awareness of those opportunities, the European Union has established the
European Innovation Partnership (EIP) on Active and Healthy Ageing, part of
a broader programme aimed at improving co-ordination between the EU and
member states to encourage innovation. The specific aim of the EIP on Active and
Healthy Ageing is to find ways to add an average of two healthy life years for each
European by 2020.
Like much of the debate around extending healthy life years, the EIP focuses
almost exclusively on improving care for Europeans over the age of 65. Yet better
care for the aged is only one aspect of ensuring healthy ageing; the other is
ensuring that people arrive at old age in a healthy condition in the first place. The
health practices of people in their 40s and 50s—and much earlier as well—has a


© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

significant impact on their health in their later years. Indeed, some health experts
suggest that the focus on health should begin at birth, and perhaps even before—
in other words, that it is never too early to start taking steps that result ultimately
in a healthier and longer old age. “The strategy for healthy ageing should be a
continuum from birth,” says Desmond O’Neill, president of the European Union
Geriatric Medicine Society. “The challenge is not to take the foot off the pedal.”
This study hopes to make a contribution to European efforts to extend healthy
life years by focusing on what can be done well before retirement to increase the
odds for healthy longevity. The focus is in particular on measures to prevent and
manage chronic diseases, since these have the greatest impact on the health of

older Europeans. The research considers the effects of poor co-ordination among
healthcare providers, governments, civil society, private employers and the public
on making the necessary changes to the healthcare system to improve the healthy
longevity of both individuals and the system. It identifies best practice initiatives
in prevention, early intervention and management of chronic diseases that can
contribute to healthy ageing. In addition, it highlights effective ways to shift the
focus from reactive, hospital-based care of the sick towards a proactive, preventive
and patient-centred approach to improving health.

© The Economist Intelligence Unit Limited 2012




Never too early: Tackling chronic disease to extend healthy life years

About this
research

In late 2011, with a view towards contributing to the debate surrounding the EU’s
European Innovation Partnership on Active and Healthy Ageing, the Economist
Intelligence Unit undertook this study of ways to manage the rising tide of chronic
disease. This research, which was sponsored by Abbott, focuses on tackling chronic
disease as one of the chief ways of extending healthy life years in Europe.
As an initial step, the Economist Intelligence Unit convened a panel of experts on
November 21st in Brussels to discuss the focus of the study. This report is based
on the insights gained in that discussion, as well as on extensive desk research
and subsequent in-depth interviews with 35 experts in chronic disease and
healthy ageing. We would like to thank all participants in the expert panel and the
interview programme, who are listed in the Appendix.

The Economist Intelligence Unit bears sole responsibility for the content of this
study. The findings and views expressed in the report do not necessarily reflect the
views of the sponsor. Paul Kielstra was the principal researcher of this study. Delia
Meth-Cohn and Aviva Freudmann were the authors. Conrad Heine, Trevor McFarlane
and Stephanie Studer contributed research and interviews.



© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

Executive
summary

The promise of healthy ageing in Europe is
clouded by the rising incidence of chronic
disease. These diseases, whose hallmark is
a gradual and long-term deterioration of
function rather than a sudden acute event,
increasingly threaten both the quality of life of
older Europeans and the ability of healthcare
systems to cope with their demands. In the
absence of reforms in both the care of individual
patients and the overall design of healthcare
systems themselves, the rising tide of chronic
illness threatens to overwhelm the resources of
healthcare by mid-century, ensuring that ageing
is a burden and not an opportunity for Europe.

Most of the work on healthy ageing, including
the European Union’s Innovation Partnership
on Active and Healthy Ageing, focuses on how to
improve care for the aged. This study refocuses
attention on getting people to old age in a
healthier condition by looking at what can be
done throughout people’s lives to increase the
odds for healthy longevity. Here are some of the
key findings of this research:
l Chronic diseases threaten to overwhelm
Europe’s healthcare system. Between 70% and
80% of European healthcare costs are spent on
chronic care, amounting to €700bn in the EU.
Chronic diseases account for over 86% of deaths
in the EU.

l This scourge is largely preventable. Scientists
believe that much of the disease burden can be
prevented, or at least substantially delayed,
through a combination of primary prevention
measures, screening and early intervention.
l An ounce of prevention is worth a pound of
cure. The “four basics” of primary prevention
are already well known: a healthy diet, regular
exercise, avoiding tobacco and eschewing
excessive alcohol intake.
l Prevention also includes early diagnosis and
intervention. While primary prevention focuses
on healthy living, secondary prevention (early
screening and diagnosis) and tertiary prevention

(early intervention to slow the progress of
diseases identified) also play important roles in
reducing the burden of chronic disease.
l It is never too early to tackle chronic diseases
such as cardiovascular and respiratory illnesses,
Type 2 diabetes, cancer, dementia, kidney and
liver diseases, obesity and being overweight.
Indeed, healthy practices begun in infancy—and
perhaps even earlier, in vitro—can help to
forestall the onset of disease.
l Care of chronic conditions has distinct
needs compared to acute care, and must be
refashioned accordingly. To ensure appropriate
care for chronic disease sufferers as well as free
up medical resources for acute-care patients,

© The Economist Intelligence Unit Limited 2012




Never too early: Tackling chronic disease to extend healthy life years

communities and healthcare systems should
direct more resources to wellness, prevention and
disease management programmes for chronic
patients.
l Healthcare should be integrated and
patient-centred to the greatest extent
possible. Integration of medical services and

other services such as mental health, in-home
sanitary care, and instruction in self-monitoring
and self-care methods are crucial components of
creating an integrated, patient-centred chronic
care system. This is particularly important for
patients suffering from more than one chronic
disease, who often must co-ordinate their own
care among silo-like specialised care providers
under the current system.
l Healthcare should be devolved as far as
possible down the provider chain. As part of
patient-centred healthcare, patients should
be encouraged to do as much as possible for
themselves, with appropriate support from a
variety of providers—not all of them necessarily
specialised doctors. Pharmacists, nurses,
community workers, home care workers and
others can all play a part, and are often in a



© The Economist Intelligence Unit Limited 2012

better position than doctors and hospitals to
provide time-intensive coaching and personal
attention to patients.
l Employers and health insurers have major
contributions to make in fighting chronic
disease. Health and wellness programmes
are increasingly being offered by progressive

employers as a way to ensure that older workers
are able to remain on the job longer. Health
insurers are also increasingly sponsoring health
and wellness programmes as incentives to
encourage healthy lifestyles and practices.
l Mental healthcare is an important part of the
mix in the prevention and treatment of chronic
illnesses. Researchers have found that isolation
and loneliness among those whose function is
impaired owing to chronic disease aggravates
their condition. Several promising initiatives aim
at reducing that loneliness through individual
case management and personal health coaching.
In general, healthcare providers are increasingly
incorporating mental health services as part of
treatment for chronic-care patients.


Never too early: Tackling chronic disease to extend healthy life years

1

Heading off chronic disease
New approaches to prevention

“An ounce of prevention is worth a pound of cure,” wrote
American statesman Benjamin Franklin in the 18th century.
Although his dictum was meant to apply to all facets of
life—and not only to medical cures—his wisdom is nowhere
more applicable than in 21st century Europe. Today in Europe,

many pounds of cure are being expended to fight chronic
illnesses that in many cases could have been prevented in
the first place.

who have reached retirement age have had at least two chronic
conditions. Although Europeans are increasingly living longer
on average, the high incidence of chronic disease at retirement
age suggests that for far too many this longevity will not
necessarily mean many years of healthy, full functioning.
For Europe’s healthcare systems—and the national budgets
that largely support them—this trend also suggests an
unhealthy future. According to the European Public Health
Alliance (EPHA), between 70% and 80% of European
healthcare costs are spent on chronic diseases. This
corresponds to €700bn in the EU, and this figure is expected
to rise in the coming years, according to the EPHA. Worldwide,
the figures are even more dramatic. The World Economic Forum
calculates that the global economic impact of the five leading
non-communicable diseases (NCDs)—cardiovascular disease,
chronic respiratory disease, cancer, diabetes and mental illhealth—could total US$47trn by 2030 (see Chart 1). Unless the
rising tide of chronic disease is reversed, such costs—which

A preventable scourge
Chronic disease is shaping up as a modern-day scourge.
According to the European Chronic Disease Alliance, a
coalition of medical professional organisations, over 100
million European citizens—or 40% of the population above
the age of 15—have a chronic disease. That proportion rises
progressively through the age ranks, with the result that
Europeans reaching retirement age are more likely than not

to suffer from at least one chronic condition. According to the
World Health Organization (WHO), two out of three Europeans

Chart 1
Doubling the burden by 2030
Chronic disease cost burden, 2010 and 2030 (VSL estimates*)
(US$ tr)

2010: total 22.8
14.8

0.5

5.1

2.4

High income

Upper middle income

Lower middle income

Low income

2030: total 43.4
19.7

1.0

17.4

5.3

*The VSL approach is used to estimate the economic burden of NCDs in 2010 and to project that burden in 2030. The VSL data are taken to be the value of life of a representative
median-aged member of the corresponding national population. Constructing the VSL estimates/projections requires the estimation of DALYs in 2010 and 2030.
Source: 'The Global Economic Burden of NCDs', World Economic Forum and Harvard School of Public Health, 2011.
© The Economist Intelligence Unit Limited 2012




Never too early: Tackling chronic disease to extend healthy life years

include output loss as well as direct healthcare spending—
could have a severe impact on national economies and their
healthcare systems.

found that eating a Mediterranean diet, regular exercise, not
smoking, and maintaining a healthy weight collectively added
15 years to an average woman’s life span and 8.5 years to an
average man’s life span.

One of the main reasons healthcare systems around the world
are ill-suited to dealing with chronic disease is that they
were designed to respond to acute, short-term illnesses and
injuries, rather than to prevent and manage the gradual, longterm deterioration that characterises chronic disease. Indeed,
the rising ride of chronic disease represents a sea change in
the type of illnesses affecting people worldwide. More than
60% of deaths worldwide are due to NCDs, killing 36 million

people each year, according to the World Economic Forum.
Chronic diseases account for over 86% of deaths in the EU,
according to the Chronic Disease Alliance.

“These measures are so well known as to be almost banal,” says
Professor James Vaupel, founding director of the Max Planck
Institute for Demographic Research in Rostock, Germany, and
head of its Laboratory of Survival and Longevity. “The bottom
line is, you are more likely to reach age 80 if you listen to what
your mother told you.” But the trend towards healthier living
is weak, at best. “People think they need expensive food to
have a good diet, but the Mediterranean diet is cheap and
smoking costs lots of money,” notes Piet van den Brandt,
professor of epidemiology at Maastricht University and author
of the Dutch study. A 2010 study by the OECD and the European
Commission found that over one-half of adults living in the EU
are overweight or obese, and that the rate of obesity has more
than doubled over the past 20 years (see Chart 2). Similarly,
although smoking rates have fallen, smoking is still very much
part of the culture in many parts of Europe.

Astoundingly, scientists believe that much of this scourge
is preventable—or at least can be substantially delayed.
According to the WHO and the NCD Alliance, simple measures
that fall under the rubric of “primary prevention”, such as
eating a healthy diet, avoiding tobacco use and excessive
alcohol, and increasing physical activity can prevent 80% of
premature heart disease, 80% of Type 2 diabetes and 40% of all
cancers. A recent large longitudinal study in the Netherlands

Prevention is not only a matter of healthier living. Early
diagnosis and the right kind of early intervention and disease

Chart 2
Growing girths
Overweight and obese populations in Europe, males (representative sample of countries)
(%)

Overweight

Obese

50

50

Bulgaria

Denmark

England

Finland

France

43.5

45.0

39.2

30

Germany

Italy

Poland

Note: Overweight defined as % Body Mass Index 25-29.9; and obesity defined as % Body Mass Index 30+.
Source: International Association for the Study of Obesity, 2011.
© The Economist Intelligence Unit Limited 2012

Russia

Slovakia

Spain

10

8.3

14.8

13.4

17.8

20

10.3

15.7

10.5

0



40

30.7

41.0

42.5

45.5
20.5

16.1

14.9

11.8

13.4

22.1

20
10

41.0

40.1

39.6

30

43.7

40

51.5

60

44.8

60

Sweden Switzerland

0

Never too early: Tackling chronic disease to extend healthy life years

management—known as secondary and tertiary
prevention—can also make considerable
contributions to reducing mortality from chronic
diseases. (For fuller definitions of primary,
secondary and tertiary prevention, please see
box, “Prevention: Three lines of defence”.).

Shifting priorities
Although policymakers are well aware of the shift
in the nature of the burden on the healthcare
system, that knowledge has yet to be translated
into an overhaul of the system. Funds are still
directed in the same way they have been all
along—to caring for hospital-bound patients,
and to treating diseases after they occur rather
than trying to prevent them from occurring.
Much of healthcare spending is still oriented

towards single-organ and single-occurrence
events—such as heart attacks or acute
appendicitis—rather than on the less dramatic
long-term deterioration of function associated
with chronic disease.
As a result, most funds expended in the
healthcare system are directed towards solving
yesterday’s problems rather than today’s and
tomorrow’s problems. In particular, vast sums

are directed towards fighting diseases when
they are close to killing patients rather than
earlier in life when they are not immediately life
threatening. “About 27% of [US] Medicare spend
is in the last year of a patient’s life,” notes Dr Paul
Keckley, executive director of the Deloitte Center
for Health Solutions. “The policy debate is, is it

Prevention: Three lines of defence
The medical system has developed a typology
for the wide range of practices covered by
the general term “prevention”. Preventive
measures are carried out by both individuals and
healthcare providers, and fall into three general
categories:
l Primary: Primary prevention aims to protect
healthy people from developing a disease in
the first place, through such measures as good
nutrition, regular exercise, avoiding tobacco
and alcohol, and receiving regular medical
check-ups. Primary prevention may also extend
to population-wide measures such as improving
air and water quality, mass immunisation, and
strengthening family and community ties to
promote mental health.
l Secondary: After risk factors have been
found to be present, and/or signs of an illness
have actually appeared, secondary intervention
consists of screening for illnesses, particularly
when risk factors are present, and early

intervention measures to slow the progress of
the disease while it is still in its early stages.
For example, a patient with signs of a heart
condition might take daily low dosages of

aspirin to prevent a first or second heart attack.
Alternatively, secondary prevention might
consist of an enhanced regimen of screening
and monitoring to track the progress of the
disease as well as monitor response to therapies
and track any required adjustments in dosing.
In some cases, drug therapies can be introduced
to delay or slow down development of a disease
such as Alzheimer’s.
l Tertiary: For patients who already have
illnesses such as diabetes, heart disease,
cancer or chronic musculoskeletal pain, tertiary
prevention consists of measures to slow down
physical deterioration. Such measures might
include participating in cardiac or stroke
rehabilitation programmes, joining chronic pain
management groups, or participating in support
groups for patients with mental or psychological
problems. While these measures are technically
no longer strictly preventive—the patient has
already been diagnosed with the disease—they
do help to limit the debilitating effects of the
illness, and thereby improve quality of life and
extend life years in comparative health.

© The Economist Intelligence Unit Limited 2012




Never too early: Tackling chronic disease to extend healthy life years

better to reinvest those resources in preventative
management of chronic disease, or is it better to
spend an inordinate amount of resources on endof-life care.”
Similarly in Europe, the Organisation for
Economic Cooperation and Development has
determined that only 3% of current health
expenditure in Europe is invested in prevention
and in public health programmes (see Chart
3). This shows the extent of the difficulty of the
shift from curative to preventive investment.
And yet for healthcare professionals, the link
between early prevention and intervention,
on the one hand, and healthy longevity, on
the other, is clear. “Every single measure of
prevention—say, reducing smoking or obesity
or cholesterol—means that during the ageing
period your quality of life will be much better,”
says Bernat Soria, a former minister of health
in the Spanish government. Clearly, the healthy
longevity of both individuals and healthcare
systems would be well served by a reordering of
the current spending priorities.

Available data on the benefits of early diagnosis
and intervention point in the same direction as
that on the impact of healthier lifestyles. In the
case of many chronic diseases, the onset of the
disease can be delayed, and its progress slowed,
by secondary and tertiary prevention measures
as well as primary prevention measures.
Advances in genomics are helping doctors to
identify risk factors, which in turn helps them
to identify vulnerable population groups, as
well as population groups likely to respond
to specific treatments. Various screening and
diagnostic devices are then used to identify
individuals at risk or showing early signs
of disease. Identifying risk factors and/or
biological markers—any protein or other
substance in the blood whose concentration
can indicate the presence or future onset of a
disease—provides a powerful incentive for both
patients and doctors to take further action
to prevent the onset of the disease or slow
its progress.

Chart 3
Prevention: Making a start
Proportion of European health expenditure invested in organised public health and prevention
programmes, 2008
(%)

6.0

6.0
5.0

4.9

0.7

0.7

1.4

1.4

1.6

1.6

1.8

2.0

1.0

2.0

2.1

2.3

2.4

2.7

2.7

2.8

2.9

2.0

3.0

3.0

3.6

3.7

3.0

3.9

4.0

4.1

4.0

4.0

5.0

5.7

7.0

6.0

7.0

Sources: OECD Health Data 2010; Eurostat Statistics Database, 2010.

10

© The Economist Intelligence Unit Limited 2012

Italy

Lithuania

Denmark (2007)

Latvia (2007)

Iceland

Austria

France

Norway

Poland

Switzerland (2007)

Spain

Belgium

Czech Republic

Estonia

EU average

Slovak Republic

Sweden

Germany

Slovenia

Hungary

Bulgaria (2007)

Netherlands

Finland

0.0
Romania

0.0

1.0


Never too early: Tackling chronic disease to extend healthy life years

“The latest statistics from the International
Diabetes Federation show that 50% of people
with diabetes do not know that they have it,”
notes Dr Maha Taysir Barakat, medical director
at the Imperial College London Diabetes Centre
in Abu Dhabi. “The challenge is how to increase
the chance that those who don’t know they have
diabetes will take the test and go to a health
provider who can help them. The sooner you
start managing someone with diabetes, the
better the long-term outcome. That will have an
impact on extending healthy lives.”

From diagnosis to treatment
There is also promising clinical work under way
to identify the biological markers—such as the

build-up of plaques and tangles in the brain—
that point to the likely future development
of Alzheimer’s disease, the principal form
of dementia. Many doctors argue that early
screening to determine if such markers are
present can lead to a regimen of exercises, diet
changes and possible drug therapies, which
together can delay the onset of the disease and
slow its progress once it appears. Researchers
are also trying to develop a clearer view on
what biological markers, and especially in what
concentrations, would prove the effectiveness of
different therapies in fighting the disease.
Similarly, clinicians generally believe that
measuring certain biological markers in the
blood or urine can identify patients at risk of
kidney diseases, can detect diseases in the
earliest stages, and through early detection
can be treated effectively. A clinical trial,
published in the Clinical Journal of the American
Society of Nephrology Studies in 2007, showed
promising results in terms of lower death and
hospitalisation rates after participation in
an early intervention programme. The trial
compared results obtained for around 1,000
hemodialysis patients enrolled in such a
programme, and another 1,000 patients in a
control group. By the end of one year, the death

rate of early-intervention patients was around

43%, compared with 56% for the control group
of long-term hemodialysis patients. Within the
first 90 days, the mortality rate for participants
in the early intervention programme was 20%,
compared with 39% for the control group.
“Screening is a very good idea for renal disease,
because when we are effective, we are very
effective,” says Johannes Mann, professor
of medicine and head of the Department of
Nephrology, Hypertension and Rheumatology
at Schwabing General Hospital in Germany.
“Screening is especially effective when we
prevent people from going on to dialysis. I see no
negative aspects to screening for kidney disease.
For other diseases, the case can be different.
There has been a long debate about prostate
cancer, for example, where you might be able to
recognise the disease earlier but not necessarily
change its course.”
Improving the links between diagnosis and
treatment is crucial if preventive healthcare is
to be effective. Among other things, it would
provide a needed incentive to shift resources
from treating the sick to preventing illness.
However, this process is not simple. In particular,
there is a thicket of conflicting scientific studies
on the costs and benefits associated with
screening and early intervention. For example,
mammography to detect breast cancer in
women—once considered an obvious health

measure—has fallen into controversy. Some
respectable research institutes have found an
unexpectedly strong probability that, in some
populations, mammography could yield false
positives or highlight pre-cancers unlikely
to become full-fledged cancers, but which
nonetheless lead to interventions. These studies
suggest that, for the populations in question,
if a highly sensitive test is used, the probability
of a false positive may exceed the likelihood of
finding real cancers and saving lives—in effect
saying that, statistically, the costs of the test
exceeds its benefits in such cases.

© The Economist Intelligence Unit Limited 2012

11


Never too early: Tackling chronic disease to extend healthy life years

The same questions have been raised in screening
and early intervention for respiratory and for
cardiovascular illnesses. To ensure they detect as
many real cases as possible, clinicians may use
a highly sensitive measurement, which may also
yield some false positives. “The classic example
is asthma: we tend to diagnose twice as many
asthmatics as those that actually have asthma,”
says Mr Keckley of the Deloitte Centre for Health

Solutions. “So we are not particularly good at
doing these things. There are some great studies
that show that our primary care system is failing
to adequately apply the evidence to diagnostics.”

12

towards a solid economic case for redirecting
funds from treatment to prevention. The absence
of hard data linking specific prevention measures
to reduced incidence of specific diseases is
slowing the process of acting on that knowledge
to change spending priorities and overhaul an
outmoded healthcare system.
Changing this state of affairs requires three
things.

Blanket screening does not just carry the
potential danger of adding unnecessary costs
to healthcare systems, it also carries the risk
of creating psychological risks to the people it
is trying to help. Joep Perk, cardiologist and
professor of health sciences, and chairman of
the Joint European Societies’ Task Force for
Cardiovascular Prevention in Clinical Practice,
points to a programme to screen men over 65 for
abdominal disease. “The psychological effect
has not been sufficiently studied. In much of our
screening work we do not pay enough attention
to the unrest that we create in people,” he says.

“I am a national co-ordinator for cardiovascular
disease prevention, and it is part of my duty
to speak to doctors about their prevention
methods. One once said to me about screening,
‘I do not want to make healthy people sick!’
This is the reverse side of the coin. It needs
more attention.”

First, public health officials need to measure
systematically the returns on investment
of various health prevention measures,
particularly for more expensive screening
and early intervention programmes. Walter
Ricciardi, president of the European Public
Health Association, believes that his profession
is partly to blame for the lack of evidence-based
medical care so far. “Before, public health people
said, ‘prevention is beautiful, let’s do it,’ but
did not look at the costs and benefits,” he says.
“It is possible for prevention programmes to
generate significant savings, but certain ones
might also be costly and yield little benefit. The
problem is that too often evidence is simply
not collected either way.” Professor Ricciardi
believes that these programmes need to be able
to demonstrate value so that policymakers can
decide whether to adopt them. (Please see box,
“From sickness to health: Abu Dhabi’s radical
refocusing initiative” for an innovative attempt to
collect this evidence systematically and translate

it into a new healthcare financing model.)

While these concerns over how best to implement
screening require attention, the overall case
for pursuing prevention over cure is clear and
urgent. Scientists have concluded that most
chronic disease is preventable, or at least can
be held at bay for much longer than it is today.
Yet for such knowledge and clinical insights to
be translated into a reorienting of spending
priorities towards prevention, policymakers
must be persuaded of the overall applicability
of the selected clinical trials, which would point

Second, healthcare policymakers need to move
away from talking broadly about prevention,
screening or treatment for chronic diseases and
start taking a more differentiated and focused
view of the efficacy of specific measures for
preventing or delaying the onset of specific
diseases, for specific groups of people, and
identifying those who are most likely to benefit
and those who are likely to be non-responders.
Ironically, the successful push for recognising
chronic disease management as a separate focus

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

for healthcare in Europe is now creating an
obstacle for its better diagnosis and prevention.
“EU policy does not include any disease-specific
policies except for cancer. This is a huge barrier
for cardiovascular disease,” says Sophie O’Kelly,
head of European affairs for the European Society
of Cardiology and a founder of the Chronic
Disease Alliance. Diseases are bundled together
as ‘chronic disease’–“which is a start, but it’s

not enough. It makes it difficult in turn for EU
member states to adopt specific prevention
strategies to address cardiovascular disease.”
Third, healthcare officials will need to find a
way of overcoming the problem of short-term
costs versus long-term benefits. Investing in
prevention requires waiting a decade or two
to determine the effect of measures and enjoy

From sickness to health: Abu Dhabi’s radical
refocusing initiative
Abu Dhabi may be best known in healthcare
circles for its alarmingly high and rising rates
of obesity and diabetes—and for having lots
of money to throw at the problem. But the
emirate is actually testing one of the first totalpopulation action plans on chronic disease,
built around screening, planning and action.
The Weqaya prevention programme was
launched in 2008 by a group of international

health experts within the emirate’s
government. Weqaya began with a simple 15minute opt-out screen for cardiovascular risks.
This covered 95% of the population in its first
few years and in 2011 moved into the second
screening round (screening will be repeated at
least every three years, more often for those at
the highest risk). Each screened person receives
an individual report, which outlines in a simple
traffic light form the main risk areas, like high
blood pressure and high body mass index, and
a set of personalised actions, from diet changes
and exercise, for example, to visiting the doctor
to receive therapy.
“Now we’ve started the second round of
screening, we can start to assess trends
across the population and over time, plus see
what really works in our population,” says
Oliver Harrison, Director of Public Health and
Policy at the Government of Abu Dhabi. One
big success was to get people with problems
going to see doctors. “In the first round of
screening we found that one-third of people
with diabetes didn’t know they had it, one-half
with hypertension and two-thirds with high
cholesterol. Assessing Weqaya overall, we’ve

seen a 40% improvement in blood glucose levels
and a 45% improvement in lipids, plus the costs
of the programme are very modest—less than
US$20 per person per year.”

With all health data collected and stored in a
universal health database (again developed inhouse), Abu Dhabi is now taking the individual
results and bundling anonymised data for
target groups, such as employers and local
governments. Bundled data help to set local
priorities and to measure the level of impact.
This form of benchmarking can be used to
identify (and praise) best practice which can be
disseminated, and identify those who are not
putting in the effort. Of course, the data can
also be aggregated to the population-level to
project the level of demand for health services,
and strengthen the case for policy interventions
such as tobacco control and improving the
walkability of Abu Dhabi.
Dr Harrison also plans to use the data to
revolutionise healthcare financing—an issue
even in oil-rich Abu Dhabi as chronic diseases
skyrocket along with costs. By calculating the
expected cost of disease over the next decade,
based on the measured risk factors, Abu Dhabi
is planning to reimburse disease management
companies directly for improvements in
measured health over time. “This allows us to
transfer risk with a new financing model,” he
says. “We have geared the numbers so the more
we pay for health, the more we save on future
health spend.”

© The Economist Intelligence Unit Limited 2012

13


Never too early: Tackling chronic disease to extend healthy life years

the benefits in lower healthcare costs. “We
have elections every four years, but medical
complications [in the absence of prevention] will
appear in 15 to 20 years,” notes Dr Soria. “So
today’s politicians will not pay the future price
for poor prevention measures.”

Changing incentives
In the case of the medical system, incentives are
at the core of the short-term bias. Despite the
rising tide of chronic illnesses, the incentives
for practitioners are still to treat the sick
rather than keep them out of the system.
Healthcare in Europe developed as a sickness
system rather than a health system, and this
is where, generally speaking, it remains. “It’s
a global phenomenon—the urgent crowds out
the important,” says Derek Yach, senior vicepresident of global health and agricultural policy
for US-based Pepsi-Cola. “Prevention is always
sacrificed in face of the curative load in front
of people.”
In the absence of comprehensive evidence
linking preventive measures to significantly
retarded rates of chronic disease development

and therefore lower future costs for healthcare,
“the prevention case often sounds vague and
fluffy—but there are specific actions with big
positive outcomes,” Mr Yach says. “Part of the
problem is that we lump many types of actions
under the term ‘prevention’. But some of these
are done within the health service by doctors and
nurses, such as screening and vaccination; then
others are population-wide measures such as
tobacco taxes, marketing controls, and efforts to
reduce salt intake, and for these you need broadbased partnerships.”
This broad approach was articulated 25 years
ago in the intergovernmental Ottawa Charter
for Health Promotion, which concluded that,
for change to occur, “healthy choices need
to be the easy choices—for individuals, for
healthcare providers, and for a wide range
of other stakeholders who have an impact on
public health.”
14

© The Economist Intelligence Unit Limited 2012

Putting that insight into practice means a
broader reconfiguration of incentives—one that
goes well beyond the healthcare system. “The
real thing we need to crack is how to move the
non-communicable diseases discussion outside
of the healthcare sector, as no one single sector
alone will be able to address its complexity,” says

Dr Jané-Llopis, head of healthcare programmes
at the World Economic Forum. “We need to align
the incentives currently in place for healthy
living. For example, subsidies for agriculture
should incentivise crops that are beneficial for
health; incentives should be aligned to promote
walking. Unless we work this out between
government, industry and individuals, there is no
way we will manage to change our behaviours.”
“It has to come from the whole of society to make
it work,” notes Ms O’Kelly of the European Society
of Cardiology. “If you just have a campaign to
promote fruit and vegetables, but still have
advertising for chocolate bars, one will offset
the other. What is needed is comprehensive,
consistent and cross-sectoral co-operation, as
recommended by our prevention experts.”
In addition to joining up the dots to promote
what is healthy, researchers are finding that peer
support is far more effective than education
and proscription in getting people to change
behaviour. Generally, Professor Ricciardi says,
“The approach has been to say ‘smoking is
dangerous’, ‘drinking alcohol is dangerous’,
but few interventions have understood the
psychology behind those behaviours.” In
contrast, simple reinforcement of healthy
choices, given by an observer or peer group,
makes behavioural change much more likely.
Much of the evidence of this in Europe comes

from the Nordic countries, where smaller and
more homogenous populations make such
personalised, community-based interventions
easier than in larger, more heterogeneous
populations. The most famous example comes
from the Karelia region in Finland, which
dramatically reduced its high rate of heart


Never too early: Tackling chronic disease to extend healthy life years

disease over the past 30 years through concerted
community action (please see box, “North
Karelia: Joining the dots”).
Mr Perk of the European Society of Cardiology
tells of a successful Swedish programme involving
all 26 primary healthcare centres of Kalmar
County in south-eastern Sweden. Each centre
has a nurse who acts as a ‘lifestyle counsellor’
for patients, providing a half-year of ‘lifestyle
training’. “It’s been hugely successful, chiefly
because we extended it to primary care centres,”
Dr Perk says. “If you see after half a year that
target levels (such as blood pressure, blood lipids
and glucose) are still elevated, then the doctor
says, ‘OK, let’s see what else we have in the
cupboard. Is it now time for drug treatment?’”

rather because of the attention they give to the
individuals’ health and well-being.

Such one-on-one interaction, together with
peer group communication through word of
mouth, social media and the like, can be far more
effective in promoting healthy choices than topdown exhortations from governments, doctors
or any other authority figures. Experiments in
behavioural economics have shown that the very
act of tracking and measuring—for example,
recording blood sugar readings for pre-diabetics,
or tracking athletic performance levels for a
person prone to overweight—creates an incentive
system that changes behaviour.

Market-driven prevention
Insurers, among others, are starting to build
programmes around these insights as a way to
reduce their future disease burdens. For example,
as a supplement to care provided by medical
professionals, Techniker Krankenkasse, a German
insurer, has offered its “TK-Gesundheitscoach”

Similarly in Denmark, a programme of visits
by nurses to all citizens over the age of 75 at
least twice a year has had a positive impact
on the target population—not because of any
medical services that the nurses perform, but

North Karelia: Joining the dots
A key to ensuring well-targeted intervention
is to involve a wide range of public and private
sector organisations in a joint campaign. A case

in point is the North Karelia Project in Finland.
In 1971 the representatives of this Finnish
province petitioned the national government
for help in dealing with the high level of heart
disease. The result was a five-year pilot scheme,
later extended for several decades, which
focused on reducing risk factors, in particular
smoking and poor diet.

professionals provided anti-smoking assistance,
and food stores made healthy options available.

Much of the work involved campaigns giving
people information on why and how to change
their own behaviour. These efforts required the
co-operation of health services, community
groups, schools and non-governmental
organisations (NGOs), as well as supermarkets
and other relevant companies. Healthcare

The keys to the project’s success, according to
Finland’s National Public Health Institute, were
community commitment and organisation, the
flexible use of multiple strategies, and, above
all, the collaboration of numerous players
including health providers, industry and
government.

The pilot proved so successful that it was
rolled out across Finland. In North Karelia,

meanwhile, improvements continued for many
years: between 1972 and 2002, average serum
cholesterol levels dropped by around 18%.
Deaths from coronary heart disease fell by
87% between 1972 and 2002, compared with a
decline of 75% in the entire country.

© The Economist Intelligence Unit Limited 2012

15


Never too early: Tackling chronic disease to extend healthy life years

programme since 2008. All insureds with chronic
diseases who meet certain criteria are eligible
for a personal coach, who contacts the insured
by telephone and, on a voluntary basis, supports
the patient’s therapy, monitors its success,
and increases the patient’s abilities of selfmanagement. The key is the ongoing relationship
built on trust between the coach and the patient,
which creates an incentive for patients to
co-operate.
The results are tangible. When the programme
began, the Techniker Krankenkasse launched
a longitudinal study to track results and the
outcomes so far are positive. For every chronic
disease, participants report significantly better
subjective health than the control group. These
better results are saving the company money.

For patients with cardiac disease, lower rates
of heart failure and heart attack could mean
a very significant reduction in costs. The final
evaluation of the project’s outcome is planned for
July 2013.
In addition to creating incentives through
personal reinforcement of healthy choices,
insurers are starting to offer financial incentives
for healthy behaviours, such as visiting doctors
for screening purposes, and disincentives for
unhealthy ones, such as smoking. In Germany,
several health insurers (Krankenkasse) are
starting to offer rebates on healthcare premiums

16

© The Economist Intelligence Unit Limited 2012

to subscribers who prove they have made regular
visits to a gym.
Similarly in South Africa, the US and Canada,
the Discovery insurance company offers a
points-based system of rewards for insureds who
exercise, buy healthy foods or reach specified
goals for athletic performance. Participants
earn points for specified healthy behaviours
and thereby rise through various levels, from
blue to gold—with rewards adjusted to starting
levels of fitness. As they rise through the
fitness measurement system, participants are

given rewards, ranging from reduced insurance
premiums to expenses-paid holidays. To support
the programme, Discovery formed alliances with
various partners, such as supermarkets to offer
discounts on certain healthy foods, and with
airlines to offer discounted flights.
This type of short-term reward, along with the
reinforcement offered by measurement and
personal attention, support a shift to healthy
habits more decisively than do the promise of
a healthier life decades from now. This insight
underlies the development of healthy lifestyle
and early diagnosis programmes among
insurers and employers. Policymakers, too, are
experimenting with both carrots and sticks such
as smoking bans, high taxes on unhealthy foods
and subsidised rates for sports facilities.


Never too early: Tackling chronic disease to extend healthy life years

2

The role of employers
Workplace initiatives to tackle chronic disease

Employers, too, can play a crucial role in tackling chronic
disease early and an increasing number of companies are
focusing on improving employee health. A recent survey by
Towers Watson, a human resources consultancy, found that

while only 30% of companies in Europe, the Middle East and
Africa (EMEA) had a global health strategy in place, a further
47% intended to introduce one in the next five years. Although
these strategies include numerous elements, in 77% of cases
they currently or will involve wellness and health promotion.
The reason for the spread of employee health programmes
is not altruism. Chronic diseases exert a high toll on labour
productivity (see Chart 4). The World Economic Forum
estimated that high-income countries lose US$26trn in

economic output each year as a result, and that translates into
a concern for all large companies. “What employers are really
interested in is a healthy workforce today,” says Natalie-Jane
Macdonald, UK manager of BUPA. “But the things they do also
help individuals to be healthier as they move into old age.”
The main hurdle with relying on businesses to be an integral
part of the health puzzle is that healthcare is still relatively
low on the business agenda—and companies are certainly not
incentivised to invest heavily in employee health for the sake
of a healthier retired population in the future. Nevertheless,
companies are increasingly seeing the business value of taking
a more proactive approach to maintaining health. A Harvard
Business School study found that the return on investment of a

Chart 4
Output suffers
Total economic cost of chronic disease, US, 2003
(US$ bn)

Treatment expenditures (Total = US$277 bn)

Lost economic output (Total = US$1,047 bn)

300

300

280

271

250

250

200

200

171

150

150

100

105

50

48
0
Cancers

33
Hypertension

65

46
Mental
disorders

Heart
disease

100

105

94

50

45
Pulmonary
conditions

27

Diabetes

14

22

0

Stroke

Source: The Milken Institute, 2009.

© The Economist Intelligence Unit Limited 2012

17


Never too early: Tackling chronic disease to extend healthy life years

comprehensive, well-run programme could be as
high as 600%, while the World Economic Forum’s
head of health programmes, Dr Jané-Llopis, says
“the most conservative figures are a return on
investment of US$3-4 for every one US dollar.”

Mission: Healthier workers
There are three main driving forces for companies
to introduce healthcare programmes, weighted
differently across countries: the rising cost
of covering employees’ healthcare costs; the

shortage of skills and the need to retain workers
as they get older; and the growing burden of
absenteeism and low productivity through
ill health.
US companies tend to be the most advanced in
providing healthcare because they pay directly
for medical costs. “The US has the ‘advantage’
of being saddled with medical costs at corporate
level, giving companies an incentive to
improve the health of their employees,” says
Sean Sullivan, president and chief executive
of the Institute for Health and Productivity
Management. “Keeping employees out of hospital
has a direct impact on the bottom line.” (For an
example of a comprehensive corporate approach
to preventive health, please see box, “Dow: A
focus on prevention”.)

German companies also feel the impact of
rising healthcare costs passing through the
system and raising employer contributions. In
addition, they are strongly motivated to tackle
the growing skills shortage by keeping a steadily
ageing workforce healthy and productive. In
the past, “companies fired people who were sick
rather than working on improving the labour
environment,” notes Professor Norbert Klusen
of Germany’s Techniker Krankenkasse, a health
insurance fund. “That has changed completely.
Employers ask us to analyse absenteeism and

create prevention programmes. We have done so
for thousands of companies and they are working
quite successfully.”
Klaus Böttcher, head of the department of
performance and contract management for
KKH Allianz, a German health insurer, has seen
a similar change in attitudes as businesses
recognise the implications of ageing populations.
Until very recently, companies encouraged
early retirement as a way to maintain healthy
workforces. “Now company leaders realise that
this was not a good idea,” he says. “They are
not able to find enough young, highly qualified
workers, so they ask us to collaborate and offer
prevention programmes.”

Dow: A focus on prevention
Dow is a global leader in corporate healthcare. It
started developing healthcare programmes ten
years ago and has developed a comprehensive
and strategic approach to preventive health.
A team of health promotion managers runs a
broad variety of activities and initiatives all
feeding into each other. Dow Health Days, for
example, focus on a specific issue (Walk at Dow
Day, Dow No-Tobacco Day). There are opt-in
six-week group programmes focusing on areas
like stress resistance or weight management.
In addition, there is more targeted outreach
through a Health Assessment Programme, which

begins when employees join the company and
18

© The Economist Intelligence Unit Limited 2012

continues throughout their career, assessing
health risks, followed by counselling and
referral where necessary.
Dow has rolled out preventive health
programmes for all its employees worldwide and
claims the payback is substantial. It has seen
a 23% reduction in smoking among employees
since 2004 and an improvement in weight at
a time when the rest of the country is getting
heavier. Its targets are to reduce key indicators,
such as average levels of smoking, body
mass index, blood pressure and so on, by ten
percentage points over ten years.


Never too early: Tackling chronic disease to extend healthy life years

BMW has embraced this shift as a way to ensure
that it remains competitive. In 2007 the luxury
German car company realised that the average
age of its workers in its Dingolfing plant in
Bavaria would rise from 39 to 47 over the
next decade. Rather than seeking to find and
train younger workers, the company looked at
redesigning production to help older workers

keep working and remain healthy.
The first step was research. BMW created
Line 2017, with 41 volunteer employees who
collectively matched the demographics that
were expected to exist at the plant in that
year. They employed a research team to collect
information from the employees on all the
aches and pains they experienced on the job,
as well as suggestions on how conditions might
be improved to reduce or eliminate these.
Employees on the experimental line also voted
on which of these changes they thought would
be most desirable.
None of the innovations was huge: they included
items such as softer flooring, adjustable
worktables, easy exercises and lighter work
shoes. The health implications were, however,
dramatic. Absenteeism due to sick leave dropped
from 7% to 2%. The company also benefited
financially. Although the speed of the line was
reduced by one-third, productivity increased
by 7% and had an almost zero error rate. When
the experiment ended, the volunteers returned
to their old lines, but BMW is rolling out the
changes—and researching new ones—across all
its Bavarian plants.
“Enabling older employees to be productive
longer is not just about helping workers stay
healthy; it’s about creating an environment
conducive to health, activity, and continuous

learning,” says Dr Michael Hodin, executive
director of the Global Coalition on Aging. “The
result will help extend active and healthy years
in employment and, more importantly, is the key
to winning the competitiveness race of the 21st
century,” he says.

Healthier companies, too
Reducing absenteeism has been one of the major
focuses of corporate healthcare programmes
in the UK and France, where companies feel
less direct pressure from rising medical costs.
Unilever has led the way in the UK with the
launch of a pilot “Fit Business” programme in
2009, which was rolled out across the UK in 2010
after showing a decline of 19% in sick leave, a
reduction in obesity of 26% and reduced risk
of developing cardiovascular diseases. At a
cost of only £35,000, the returns from lower
sick leave alone were threefold. Unilever’s
programme focuses on free health checks with
clear explanations of what is being measured,
and easy-to-use advice on nutrition and exercise.
The programme is evaluated on three criteria:
absenteeism, employee involvement and a survey
on the impact on attitudes towards work and life.
A French railway operator. SCNF. is also focusing
on reducing absenteeism through its new
healthcare scheme. Average days lost to nonwork-related illness has been rising steadily,
growing by 14% between 2007 and 2010. So the

company launched a “Healthier Life” scheme
in February 2012, following a successful pilot
project in Brittany. All workers will be screened
for body mass index and those regarded as
overweight will receive advice on diet and
exercise and will be monitored on a monthly
basis. The company has set a target to reduce sick
leave by 32%.
The focus of the programmes can vary depending
on the needs of the staff. One particularly serious
concern for many firms is stress, which the Towers
Watson survey listed as the leading health issue
among EMEA companies. KKH-Allianz developed
an anti-stress programme for a hospital in
Hannover where nurses faced high stress levels.
A multi-pronged approach, which combined
advice on how to work in a way that reduced or
eliminated stress, how to live with heightened
stress levels and programmes in muscle
relaxation, has reduced the number of sick days
markedly, and let people stay on the job longer.

© The Economist Intelligence Unit Limited 2012

19


Never too early: Tackling chronic disease to extend healthy life years

What works?

Not all plans are successful. The key is that
“company leaders and department leaders
want to collaborate,” says Mr Böttcher of KKHAllianz. “It works only if you go top down into the
company.” Mr Sullivan of the Institute for Health
and Productivity Management stresses that
although top executive leadership needs to make
health into a corporate priority, ‘champions’ are
needed to keep it a priority. “You need to have
mid-level management champions who help to
build it into a culture, reinforce practices and
values, with ‘cheerleading’ and encouragement,
to get these policies down to employee levels,” he
says. He also emphasises the need for systematic
screening. “If you just rely on health risk
assessments, you will miss half the people who
don’t know they actually have a health problem,”
he says.
Beyond that, the keys to success are:
l Agree on simple measures and evaluate
them with clear targets and key performance
indicators.
l Make initiatives simple and convenient for
participants.
l Be consistent and ensure that goals are
supported by the work environment.
l Make it part of the culture of the business with
support from the top.
l Allow flexibility—to recognise differences and
the need to adapt.
l Make the programme long-term, be persistent

and make sure it lasts.
l Ensure confidentiality.

20

© The Economist Intelligence Unit Limited 2012

For enlightened firms where executives
understand the utility, corporate wellness
programmes can improve profits while helping
employees to a healthier old age. But for
companies to become an integral part of national
prevention and healthy ageing strategies,
policymakers need to encourage workplace
initiatives. “The corporate employee is a
representative of individuals in the community
who are at risk of developing diabetes,” says Dr
Barakat of the Imperial College London Diabetes
Centre in Abu Dhabi. “We frequently see patients
who were very fit at school and university, but
as soon as they get a desk job find it difficult
to include exercise within their day-to-day
activities. The outcome is that weight begins
to creep up, and then blood pressure begins
to creep up, and then blood sugar levels begin
to creep up.” Among the remedial solutions
discussed to help solve this growing problem
include sponsorship of football tournaments,
walkathons, fitness challenges and nutrition
coaching, among others.

Companies are also a crucial piece of the puzzle
because they have an incentive to finance
preventive services. “You won’t get wellness
and health promotion through a national health
service, because they are focused on paying for
illness—not on keeping people healthy,” says Mr
Sullivan. “But at the corporate level, they have a
direct incentive to head it off.”


Never too early: Tackling chronic disease to extend healthy life years

3

Managing chronic disease
Rethinking provision of care

In the long term, the sustainability of Europe’s healthcare
systems will depend on two factors: reorienting its focus
from treating illness to promoting health, and improving
the management of chronic diseases to make it both more
effective and more cost-efficient. Far from reducing the quality
of healthcare, reforms that achieve these two goals will also
help to extend healthy lives for all Europeans—allowing for a
better allocation of medical resources and the continued use
of expensive therapies where needed, while ensuring that
chronic care addresses the real needs of the patients rather
than that of specialised practitioners and hospitals.

The separate worlds of acute and chronic care

What would it take to reorient the healthcare systems around
the management of chronic diseases rather than treating
them as just a species of acute care? Researchers have been
working on ways to differentiate chronic care from acute care
since the late 1990s, when three US institutes, the McColl
Institute for Healthcare Innovation, the Robert Wood Johnson
Foundation and Improving Chronic Illness Care (ICIC), created
and developed a Chronic Care Model, designed as a support
system for individuals with impaired functioning. The approach
requires care to revolve around interaction between an
informed, active patient and a prepared, active practice team,
drawing on resources from both the community and healthcare
systems.

and pathways. Level 3 patients are the most complex cases
requiring active disease management by medical teams.
In 2010 the RAND Corporation think tank evaluated 51 sites
that had reorganised care in line with the model and found a
much better chance that patients in such facilities received
the correct therapy and saw improved outcomes. For example,
congestive heart failure patients treated in Chronic Care model
facilities reduced the duration of their hospital stays by 35%
on average.
There is a growing body of evidence in Europe too that a
combination of medical and “social” care—the latter often
involving both in-home visits and community-based activities
for those able to participate—is more beneficial for patients.
A 2008 review of chronic care by the European Observatory
on Health Systems found “sufficient evidence that single or
multiple components of the model improve quality of care,

clinical outcomes and healthcare resource use”. The benefits

A variant of the model was created by Kaiser Permanente, a US
health insurance group. It is based on the Kaiser Triangle, a
notional, three-tiered pyramid with low-intervention patients
at its base and high-intervention patients at its peak (see
illustration). Level 1 patients, the vast majority of chronic
disease sufferers, mainly need support for self-management.
Level 2 patients are higher risk, either because of multiple
diseases or poor abilities to manage their own care, but
can still be supported by teams using common protocols
© The Economist Intelligence Unit Limited 2012

The 'Kaiser Triangle', illustrating different
levels of chronic care

Case Highly complex patients
manage
Disease
management

High-risk patients

Supported self care

70-80% of people with
chronic conditions

Population-wide
prevention

Source: NHS and University of Birmingham.

21


Never too early: Tackling chronic disease to extend healthy life years

Chronic care in Denmark
A good example of integrated care, involving
doctors and community organisations, comes
from Denmark. The Østerbro Health Centre
in Copenhagen is a joint venture of the city’s
health administration, a large municipal
hospital and local general practitioners. It
provides one-year rehabilitation programmes
for patients with a range of chronic conditions.
This programme may include physiotherapy
and co-ordination of various specialists a
patient may need to see. Central to the clinic’s
offerings is the effort to teach the patient how
are measurable in terms of improved levels
of functioning, slowing down the progress
of diseases, and reduced demand for acute
intervention by doctors and hospitals. (For an
example of such an approach, please see box,:
“Chronic care in Denmark”.)
With the weight of increasing evidence, it is an
apparent paradox that chronic care facilities,
based around improving the functioning of
patients and reducing demand for expensive

acute care, are still an exception. As a British
general practitioner, Dr James Morrow, explains:
“A lot of patients are stuck in hospital beds as
bed blockers, and a lot of hospital admissions
are triggered by a lack of readily available care
in the community.” Improving the options for
affordable care outside of hospitals could go a
long way toward alleviating this problem.
There are three main constraints to expanding
chronic care, none of which is insurmountable
but all of which need concerted effort by many
players to overcome.
The first is the need for task-shifting from doctors
and hospitals to the patients themselves, as
well as nurses, pharmacists, community workers
or trained laypersons. Creating this division of
labour will, as a first step, require giving doctors
and hospitals incentives to separate chronic from
22

© The Economist Intelligence Unit Limited 2012

to self-manage, including education specific to
the disease, dietary counselling, and smoking
cessation courses where necessary.
Early assessments of results showed that 86% of
patients had started to exercise more and 42%
had changed their diets. Over 90% of general
practitioners in the area have referred patients,
and 96% of those thought the programme

valuable to their patients.

acute care, and turn more of the former over to
others. Some European countries are already
experimenting with such a shift. The UK, for
example, is experimenting with paying doctors
based on their success in keeping patients out
of hospital, and penalising hospitals whose
discharged chronic-care patients are back within
30 days after being treated for an acute episode.
Patients, too, need help to understand that this
shift of care responsibilities does not amount to
“passing the buck” to less qualified personnel. On
the contrary, it tends to bring appropriate care
closer to patients and make delivery of that care
more personal. Many of the needs of chronic-care
patients, particularly older ones whose diseases
have progressed, have to do with combating
isolation, lack of mobility, and difficulty with
simple chores such as shopping, cooking and
bathing. Support in carrying out such everyday
tasks, as well as personal contact with a care
provider, can go a long way towards improving
patients’ functioning and their quality of life—
while also relieving the burden on the medical
system. Among other benefits, individual followup by non-medical providers can boost adherence
to doctors’ prescribed therapies.
A transfer of care responsibilities to other
medical professionals and to laypeople requires
a supportive policy framework to avoid uneven

Never too early: Tackling chronic disease to extend healthy life years

levels of service and gaps in needed services.
A clearer division of labour between medical,
paraprofessional and non-medical personnel
could usefully be spelled out at national or
regional level, with standards of care and
clear protocols accompanying the transfer of
responsibilities. In a 2010 study for the University
of Birmingham’s Health Services Management
Centre, researchers Professor Jon Glasby and
Kerry Allen identify a core of services that can
be provided locally, such as co-ordinating
and managing care programmes, recording
performance and monitoring statistics. But
they also suggest a wider set of responsibilities
at regional or national level to ensure a wellfunctioning system of care, including producing
equipment, setting aims and objectives,
developing and maintaining information
management systems, and assuring quality at
every stage.
The second obstacle to introducing chronic care
on a broad scale is the difficulty of integrating
many different players within and beyond the
healthcare system, in the absence of incentives
for them to co-operate. In Europe, some of the
best examples of well-functioning community
care come from small, homogenous communities,

like Østerbro, where achieving consensus and
working together is relatively simple. In some
rural regions, particularly in southern Europe,
institutions such as pharmacies already play
an active role in dispensing medical advice to
individuals, acting as a parallel support system.
With proper training and standard-setting,
this approach could be used on a broader scale
throughout Europe, not only in the case of
pharmacists but also with nurses, community
workers and others.
The third obstacle is embedded in the financial
incentives surrounding caring for chronic
disease sufferers. Any change in the status
quo is bound to have winners and losers. And
although patients may ultimately be the winners,
in the short term opening up community-based

chronic care facilities can mean closing down
hospitals, or reducing their funding. This is
a political decision, and requires politicians
and policymakers who are willing to take
responsibility for the impact on current players.

Managing chronic care: keys to success
Several important lessons about what works best
have already emerged from the early experiments
with restructuring the care of chronic disease
patients away from the acute care model. One is
that chronic-care patients should be as involved

as possible in designing and carrying out their
own care, avoiding medical “diktats” wherever
possible. This approach has a practical
side: ultimately, patients will be in charge of
taking their medicine or not, doing their exercise
or not, avoiding harmful foods or not, calculating
their insulin requirements or not. A patient
who has been involved in the planning of a care
regimen, and who understands the reasons for
the health measures prescribed as well as their
practical implementation, is a patient more likely
to do what is necessary to slow the progress of
their disease.
Beyond that, a range of practical support
for patients should be readily available
when needed. For example, a diabetic who
has difficulty calculating the total calories
associated with various foods may benefit from
a simple calculator with built-in calorie counts
for different foods. A more maths-challenged
diabetes patient may require an implanted
“glucometer” to measure glucose levels and
receive alerts from a remote support person—
perhaps a nurse on duty—concerning how much
insulin is required. Access to advice and support
can be made available through telephone
hotlines, e-mail and social media forums,
instant-messaging systems, and drop-in centres
for those who prefer consultations in person.
Improving adherence to a medical regime is one

of the key goals set by the European Innovation
Partnership for improving healthy ageing—and it
is not just a problem for the aged.

© The Economist Intelligence Unit Limited 2012

23


Never too early: Tackling chronic disease to extend healthy life years

Patients may also need ongoing support to
ensure that medications they take for one chronic
disease does not aggravate the symptoms of
another disease. It is increasingly common for
patients, particularly in advanced years, to suffer
from more than one chronic disease. In such
cases, general practitioners, community-based
nurses and other caregivers may be in a better
position than medical specialists—who tend
to focus on one disease at a time—to instruct
patients on how to ensure appropriate responses
to several medical issues simultaneously. Coordination may also involve calling upon different
resources—transport, in-home care, access to
rehabilitation facilities, among others—where
the patient may not have the wherewithal to do
that for himself or herself.
New technologies play an increasingly important
role in facilitating the transfer of chronic care
from doctors’ offices and hospitals to community

centres and patients’ own homes. In particular,
telematics and e-health systems are increasingly
coming into play. Telematics technologies lend
themselves to remote diagnosis—as, for example,
when sensors transmit readings of patients’
vital signs, blood sugar levels and the like to a
medical professional who can alert the patient to
respond to dangerous levels. Electronic health
systems—which can share individual patient data
and population-wide health information across
various healthcare settings—can help to improve
tracking of treatments for different diseases. This
is an especially useful tool when more than one
disease is present in a single individual.
At a more sophisticated level, imaging
technologies can aid in identifying indicators
of disease, as well as helping treatment and
monitoring. As noted above, the fast-developing
science of genomics is helping doctors to
identify at-risk populations, while screening
technologies are increasingly sophisticated
in detecting disease indicators in individuals.
Moreover, telecommunications—online or by
videoconference or simply by mobile phone—can
24

© The Economist Intelligence Unit Limited 2012

help to reduce the isolation of those whose
illnesses limit their mobility, thereby supporting

their mental health.

High touch and high tech
The risk associated with some of the new
technologies is that time-pressed caregivers
will substitute medical devices and drugs for
personalised care, perhaps out of a wish to
use the latest and best technology available
even if a lower-tech solution might be more
appropriate. “There is a real danger of overmedicalising normality, and creating dependent
patients—patients who believe they are ill when
they are normal for their age,” says Dr Morrow.
“The medical profession has always had the
ability to encourage dependency. It requires a
dedicated team to avoid dragging patients into
medical need.”
Clearly, the solution is to focus on providing
the right treatment at the right dose for each
patient, but in the context of personalised
attention wherever possible—in effect combining
high touch and high tech. There is growing
evidence that the high-touch, personal approach
is a crucial and often neglected part of the
package. Social psychologists are making strides
in understanding the links between maintaining
health—or at least avoiding rapid deterioration—
and maintaining good connectedness with
others, whether family members, friends, work
colleagues or the broader community. Staying
active and connected is increasingly seen as a

necessary component of a healthy lifestyle, and
one that contributes to extending healthy life
years. The obverse is also true: isolation and
loneliness aggravate many disease symptoms.
The effort to promote connectedness is a
broad-based one, involving local government,
community leaders, urban planners and many
others. The aim is to design communities —
including housing, transport, shopping areas and
public gathering places—in a way that promotes
activity and interactions with others. This trend