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Document 14
     
EUROPEAN COMMISSION 
HEALTH & FOOD SAFETY DIRECTORATE-GENERAL  
Health systems, medical products and innovation 
Performance of national health systems 
EXPERT GROUP ON HEALTH SYSTEMS PERFORMANCE ASSESSMENT
12TH MEETING 
7 DECEMBER 2017, 09:00-16:30 
VENUE: JUSSIEU- ZAMANSKI TOWER ROOM 
PARIS, FRANCE 
MINUTES 
Participants: Austria, Belgium, Cyprus, Estonia, Finland, France, Germany, Greece, Hungary, 
Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, 
Slovakia, Slovenia, Sweden, United Kingdom, European Observatory on Health Systems and 
Policies, WHO Europe, OECD, European Commission. 
* * *
1.
OPENING OF THE MEETING
After opening the meeting by the 
 (Ministry for Solidarity and Health) 
welcomed the participants on behalf of French hosts. She stressed the importance and 
usefulness of HSPA in policy making in France as well as need for co-operation and mutual 
learning in Europe.  
The agenda was approved.  
2.
DISCUSSION ON THE DRAFT REPORT ON PRIMARY CARE
 (DG SANTE) presented the general structure of the report and 
recommendations inquiring how the report could be made more useful for Member States. 
The HSPA Group's members were invited to express their views on how to make HSPA a 
triggering factor of change in primary care. Question of using HSPA as a basis for on-going 
reforms was raised too. 
There was broad agreement on the conclusions and recommendations of the report. It was 
suggested that the report puts more emphasis on some challenges faced by primary care in the 
shift to the performance-based models: pressure on primary care to take more responsibilities 
and the impact on working conditions of primary healthcare practitioners and on capacities to 
deliver according to higher and new expectations (attractiveness of primary professions, 


 
esteem for primary care professionals and recognition of their importance, staff and skills 
deficit, new approach to training through contextualisation, insufficient resources 
accompanying the change, etc.). The impact of the transformation of primary care on other 
segments of care was highlighted. Ideally this should be grasped by the primary care report.  
The HSPA may be also a powerful tool to deal with challenges at subnational level. To put a 
right accent on the discussed challenges for primary care, a suggestion was made to cluster 
indicators in the report around: accessibility, outcomes and capacities of primary care. There 
is a need to distinguish what should and what could be measured when HSPA of primary care 
is concerned.   
It was concluded that the recommendations will be made more focused and punchy, building 
a strong case for primary care and stressing how HSPA can support a stronger primary care 
with spill-over effects for the overall healthcare. The recommendations will also be slimmed 
down to highlight the main challenges.  
Revised draft of the report, including discussion in Paris, will be sent out to the group. 
Possible comments are expected until January 8th, 2018. 
 
3. 
REPORTING ON COUNTRY EXPERIENCES 
This agenda item saw two presentations delivered to the group.  
The first presentation by 
 (FR) provided an overview of the governance of the 
health system in France and its barriers to fostering accountability in care. The presentation 
highlighted the complexity of the governance of the French health system: management 
responsibilities are shared between the state and social health insurance (SHI), the former 
having a stronger role than is usually the case in systems based on social insurance. The 
system is considerably centralised, and relies on territorially organised state entities to 
coordinate the implementation of national policies at the local level.  
As per accountability, 
 pointed out that the French healthcare system has been 
designed, for various reasons, in a way that puts pressure almost exclusively on the supply 
side. Since 2011, a pay-for-performance scheme called ROSP (rémunération sur objectifs de 
santé publique
) was implemented. According to this scheme, GPs receive a bonus on top of 
their normal fee-for-service income, taking into account the amount of people treated by the 
doctor and a number of other quality indicators. Data from 2012-2016 shows that while the 
scheme has improved performance in some areas, for others (e.g. preventive medicine) no 
changes and even slight regressions seem to have occurred. In hospitals, an analogous system 
called IFAQ (incitation Financière à l’Amélioration de la Qualité) was expanded in 2015, 
together with an initiative called "E-SATIS" which uses metrics of patient satisfaction and 
experience in hospitals. These HSPA frameworks are used to rank and reward the best 
performing hospitals, both via financial and non-financial incentives (i.e. reputational 
rewards).  
On the "demand" side (i.e. patients) for care, 
 highlighted the existence of an 
"asymmetry of responsibility" for which it is difficult to implement provisions based on a 

 

 
"carrot and stick" approach to moderate demand for care in France. 
 provided a 
telling example of a 2014 court ruling establishing the unconstitutionality of a clause that 
would see the SHI stop paying for the cost of CPAP devices for patients with sleep apnea 
whose devices' utilisation rate falls below a certain level. In this context, developing a system 
of patient accountability faces hurdles of political, technical and even cultural/philosophical 
nature.  
Comments from members of the group touched upon i) the role of practitioners in educational 
programmes and the potential of non-financial incentives, ii) nudges and reputation as 
instruments to enhance health systems' performance, iii) the possibility that providing care 
services completely free at the point of access may lead to their inefficient use, and iv) the 
need to bear in mind that data collection is a labour burden, and that its intended target 
audience must believe in the reliability of data for rankings to have the desired effect.  
The second presentation for this agenda point saw 
 and 
 from a 
Medical and Diagnostic centre in Siedlce (PL) present the design features of a performance 
assessment tool that their medical centre has developed to track the performance of their 
primary care facilities and provide GPs with financial incentives for good performance. 
Primary care physicians in Poland are typically the entry point into the health system, and 
their role has considerably grown in the last years. The main design features of the 
performance assessment tool which was presented showed the importance of categorizing 
patients in different clusters based on their disease burden.   
Additionally, the stratification became a helpful tool for creating the individual treatment 
plan. Thank to this solution, every medical professional can easily apply the standardised 
treatment plan. 
MDC’s performance assessment tool for GP’s takes into account several factors such as: 
1. 
number of patients in each age range for GP’s population  
2. 
number of issued green charts 
3. 
number of different health check-ups  
4. 
number of DRG visits with thorough medical examination etc. 
Every GP receives the Monthly GP’s score card. Remuneration base is calculated on the basis 
of number of patients in each age range for GP’s population. Bonus is dependent on several 
factors part of the listed above. GP’s scorecard also contains comparison of actual working 
hours and working hours calculated statistically on the basis of size of GP’s population. 
Included information reflects the general aims. Each element must be systematically 
measured.  Thanks to that GP receives additional incentive reinforcing directly his individual 
involvement. 
In line with expectations as a result of the implementation of redesigned financial settlement 
for GP’s the proportion between the base and bonus remuneration has significantly changed. 
Initially, in 2003, it was 95% for base and 5% for bonus. In 2017, it is 65% for base and 35% 
for bonus.  

 

 
 
Similar solutions were introduced for non-physician professionals (nurses, midwives, 
paramedics and medical assistants). The financial incentive depends on individual 
involvement in work. This system is more complicated comparing to the one for GP’s, due to 
the fact that work of this group of professionals can be measured on the level of each basic 
procedure. The system is structured on the basis of the listed principles. This system consists 
of many single procedures which are performed by this group. Every procedure has got 
priority and standard execution time assigned. Target is calculated for each employee on the 
basis of working time and it is reduced proportionally to non-working days. There are three 
priorities of the procedures: green (the lowest), yellow and red (the highest). What is more, 
initial calculation of bonus is adjusted during Quarterly, annual and Internal Audit assessment 
of employee’s performance. Each professional has got a guaranteed bonus for all the points 
performed, but calculated on the basis of the lowest rate. Reaching target is a precondition for 
achieving additional bonus for yellow and red points that represent high priority crucial 
procedures. The system gives incentives for professionals to combine procedures in order to 
create comprehensive chain of procedures, thus deliver a complete high quality medical 
service. 
As a result of non-physician motivational system implementation, s significant increase share 
of “red” points has been noticed. This trend is beneficial for patients, employees and company 
due to the fact that red procedures contribute highest value for health and generate positive 
financial impact for both professionals and company. What is more a positive shift from 
yellow points to red points can be seen. The share of green points is slowly decreasing. These 
are necessary basic procedures that cannot be reduced in delivering medical service. 
 
 
4. 
ASSESSMENT OF EFFICIENCY OF CARE  
(OECD) presented a summary of the findings of the "Tackling Wasteful 
Spending on Health" report.  
The report recommends that strategies to curb wasteful spending must reflect two principles: 
i) to stop spending on services and processes which are either harmful or do not deliver 
benefits  – for example, unnecessary surgeries, and to ii) swap inputs when less costly 
alternatives of equal value exist – for example, by encouraging the use of generic drugs, 
developing advanced roles for nurses for chronic patient management, or ensuring that 
patients who do not require hospital care are treated in less resource-intensive settings.  
By linking actors to key drivers of "waste", the report identifies three main categories of 
wasteful spending:  
I. 
Wasteful clinical care,  which  covers (avoidable) instances when patients do not 
receive the right care. This includes duplicate services, preventable clinical adverse 
events – for instance, infections acquired during treatment – and inappropriate care – 

 

 
for instance, medically unnecessary C-sections, imaging for uncomplicated lower back 
pain and prescriptions of antibiotics for viral infections.  
II. 
Operational waste, which occurs when care could be provided using fewer resources 
within the system while maintaining the benefits. In other instances, costly inputs are 
used instead of less expensive ones, with no additional benefit to the patient. This is 
often the case when patients seek care in emergency departments, end up in hospital 
due to preventable exacerbation of chronic disease symptoms that could have been 
treated at the primary care level; and 
III. 
Governance-related waste, which pertains to resources that do not directly contribute 
to patient care. This category comprises unneeded administrative procedures, as well 
as fraud, abuse and corruption.  
 
 (European Observatory on Health Systems and Policies) presented publication 
Observatory's publication "Health system efficiency: How to make measurement matter for 
policy and management
".  
The study observes that while the basic idea of efficiency is easy to understand – maximizing 
the "outputs/inputs ratio", in practice it is difficult to operationalize this concept in real-life 
management situations. While the desire for greater efficiency in healthcare motivates a great 
deal of decision-making, the routine use of relevant efficiency metrics to guide decisions is 
often lacking. The study therefore provides a framework for thinking about health system 
efficiency which aims at facilitating the development of indicators that are relevant for both 
policy-makers and managers.  
While there are relatively few indicators for measuring allocative efficiency, policymakers 
arguably have more levers related to allocation of expenditure rather than technical efficiency 
– as a matter of fact, it would be perfectly possible to have a technically efficient institution 
(e.g. clinic) operating within an inefficient system in terms of allocative efficiency.  
 
 (DG SANTE) presented a background paper on efficiency of health systems, 
which was circulated to the group's members in advance of the meeting. The objective of the 
presentation was to start a discussion on how to structure the group's work on this topic in 
2018 and to gather feedback from the group as to: 
1)  what should be the value added by the HSPA Expert Group to the discussion on health 
systems' efficiency, and what should therefore be the main thematic area of focus of 
next year's report; and  
2)  how the group should organise its work (i.e. whether the organisation should reflect 
the one from previous years, setting up a sub-group and a summer course to work on 
the development of the group's report).  
Proposals from members of the group ranged from focusing on the further development of 
methodologies to measure efficiency, to producing a summary of "country examples" with the 

 

 
potential of showcasing and exchanging best practices. Other specific proposals from the 
brainstorm included further exploring the concept of "waste", developing a methodology for 
assessing the efficiency of disease prevention policy, assessing the efficiency of mental health 
care, assessing the impact of inactivity/long-term unemployment on health, and further 
studying the interplay between health system efficiency and quality of care.  
The Group agreed that the choice of focus of the next report should ensure maximising value 
added in relation to the previous reports: on quality of care, integrated care and primary care 
(forthcoming). The report should be devised also as an instrument of advocacy for promoting 
HSPA as a tool for policymakers.  
The Group agreed on setting up a sub-group similarly as it was the case when the previous 
reports were prepared. The deadline for members interested in joining the sub-group was set 
for January 12th, 2018.  
 
5. 
STATE OF HEALTH IN THE EU  
Andrzej Ryś (DG SANTE) presented the State of Health in the EU (SoH) initiative, a multi-
annual project by the Commission that aims at providing policy makers, interest groups and 
health practitioners with factual, comparative data and analysis of health and health systems 
in EU MS. He presented the Companion Report, which draws cross-cutting conclusions, links 
common policy priorities across EU MS and explores the scope for mutual learning. 
 (OECD) and 
 (European Observatory) took the floor to walk the 
Group through the extensive process of research and co-ordination that took place to develop 
the 28 Health Profiles and to present their methodology.  
 
6. 
PREPARATION OF THE JOINT MEETING WITH EIT HEALTH  
 (FR) presented an account of the history and mission of EIT Health, a 
knowledge and innovation community established by the European Institute for Innovation 
and Technology (EIT), an independent EU body set up in 2008 to promote innovation and 
entrepreneurship across Europe. The EIT Health network brings together academia, research 
institutions and private sector entities to form cross-border partnerships that foster the 
development of new products and services. 
 mentioned that the following day's 
joint seminar would see about 120 participants from academia, industry and policymakers 
from the French institutions and three working roundtables.  
 
7. 
CONCLUSIONS OF THE MEETING, A.O.B.  
The Chair thanked all members for their participation and reminded the group that the next 
meeting will take place on February 23rd in Brussels.