Future Health Scenarios – serie

9. 1 311 9. 2 The results in the four areas 313 9. 3 Likely causes of the growing demand for services 314 9. 4 The dominant perception of mental health problems 315 95 A shifting balance 317 9. 6 Mental health problems as a policy issue 319 311) 9. 7 Culture-dependence as an approach 9. 8 Culture-dependence and the four tbemes 322 9. 9 The value of a socia-cultural approach 323 9. 10 Two core notions: normality and identity 325 9. 11 Conclusions and policy options 328 Bibliography 333 Appendix Basic ~ssumptions in the exploratory and target-seuing sccnanos 368 v Preface This study of mental health issues breaks new ground. The task set by the Steering Committee on Future Health Scenarios was twofold, encompassing issues relating both to mental health and to mental health care. Discussions of mental health normally narrow down immediately to a focus on its care; this study, in contrast, seeks to deal with mental health as a theme in its own right alongside that of mental health care. This task led to the establishment of a broadly based committee whose members possessed a wide range of knowledge and experience in the field. The study was carried out by an equally expert team from the Netherlands Institute of Mental Health. In the course of the study over a hundred people with wide­ ranging expertise took part in consultative panels.

How can the public health system best be organised in the future and which factors are the main determinants thereof? These are key questions in the scenario report The Future of Public Health: a Scenario Study. The report is the result of a study commissioned by the Steering Committee on Future Health Scenarios and carried out by a research team of the TNO Institute of Preventive Health Care and the STG Scenario Committee on the Future of Public Health. The report focuses on activities in collective prevention of diseases, generally known as primary prevention. The future images developed make use of two examples, the control of infectious diseases and public health for the elderly. In designing those scenarios, two sets of possible trends were combined: centralisation versus decentralisation and nationalisation versus privatisation. These combinations resulted in three scenarios; a local government scenario, a central government scenario, and a private enterprise scenario. The consequences of these future alternatives were developed in terms of their effect on organisation, policy control, financing, information supply, expertise and effectiveness. Although the report primarily focuses on the public health system in the Netherlands, the analysis of the processes examined, and the alternative scenarios based on them are also thought-provoking for readers throughout the world.

In March 1983 the Secretary of State for Welfare, Health and Cultural Affairs appointed the Steering Committee on Future Health Scenarios (STG). The task of the STG is to advise the Minister on the future of public health and health care in the long term in the Netherlands with a view to increasing the anticipatory capacity of government policy. Since 1983 the STG has set up a number of committees, including the Scenario Committee on AIDS, with a view to mapping out possible scenarios in their particular field of interest. The committees report in the form of scenario reports, which are of relevance not just to the national government but also to others involved in policy development and opinion formation in the field in question. What proportions will the HIV/AIDS epidemic assume and how many new HIV infections can be averted by HIV/AIDS prevention campaigns? How much care and support will people with HIV and AIDS need and what successes can be expected within the care sector? What will be the social consequences of AIDS and how can ostracism and the social isolation of people with HIV and AIDS be avoided? These and other related questions form the subject of this book, which examines the sociocultural and economic impact of AIDS in the Netherlands up to the year 2000. The book presents a study carried out by the Netherlands Institute of Mental Health (NcGv) and the National Institute of Public Health and Environmental Protection (RIVM), under the direction of the STG Scenario Committee on AIDS. The researchers look back at the epidemiological, sociocultural and economic impact of AIDS in the Netherlands during the first decade of the epidemic and, on the basis of this, use scenario analysis to project the impact of AIDS up to the year 2000. The future projections relate both to the impact of AIDS and the maximization of efforts to combat the disease. In addition to a scenario exploring the impact of AIDS if developments continue unchanged, alternative scenarios are also put forward. These focus on the impact of significant changes in such diverse fields as sexual behaviour, injecting drug use, the effectiveness and organization of HIV/AIDS prevention programmes, and the demand for delivery of care. The book concludes that the impact of AIDS will only become fully apparent in the second decade of the epidemic. The authors consider the implications of this conclusion for HIV/AIDS prevention programmes, research, care and the efforts to counter the socially undesirable impacts of AIDS.

Aims and approach In order to chart the way for long-tenn policies in the field of public health, the Dutch government needs to have the best possible insight into potential future trends and the problems to which these could give rise. It was with a view to compiling a number of long-range studies that the independent Steering Committee on Future Health Scenarios was set up in 1983. In 1988 this body appointed a board of experts to sUivey the future of Chronic Diseases. Three chronic diseases have been selected: diabetes mellitus, CNSLD (chronic non-specific lung disease) and rheumatoid arthritis (a chronic disorder of the joints). In close consultation with this board, the study has been conducted by the Department of Epidemiology of the National Institute of Public Health and Environmental Protection in Bilthoven. This report contains the results of the research into CNSLD. The report on diabetes mellitus was published in March 1990, while that on rheumatoid arthritis followed shortly (1991). The series has been concluded with a fmal report (spring 1992), in which, among other things, the results of the three reports have been brought together with a view to arriving at an overall picture of chronic diseases. The research had two main objectives: 1.

CARE AT HOME -HOME CARE Health care in the Netherlands looks to be a well structured system. Supplementing the vital level of self-care and informal care are four levels of professional care: the public health service (known in the Netherlands as basic health care) is mainly concerned with preventive work aimed at the population at large; individuals with problems can contact their general practitioner or other primary care provider, who can -depending on the problem -refer them to specialists in the cure-oriented and hospital-centred secondary sector; where necessary, patients can then be referred on to the institutions of the tertiary sector with their role in mainly long-term care. On paper this pyramidal structure appears to work well; in practice, and in particular where complex forms of care are involved, the boundaries become blurred. Medical advances and social and economic developments may delay death to ever greater ages, but disease is not defeated; and since the risk of developing chronic conditions rises with age, more and more people become incapacitated and those who do remain so for longer. This leads to a growing demand for care and compels us to reconsider patterns of provision. The need for such reconsideration is reinforced by users' changing needs and aspirations, as patients increasingly wish to be nursed and cared for in their own surroundings if at all possible. Technological advances mean that wish can often be accommodated.

Which developments can be expected to take place in the dental health of the Dutch population in the decades to come, and what are the influential factors? What effects might the changing supply of dental professionals, the additional substitution of responsibilities from dentists to dental hygienists and the possible reforms in health care insurance have on the nation's oral status? These are some of the central questions discussed in this report by the Scenario Committee and the research group. For this purpose, the Committee developed a computer simulation model of dental health care which was used to analyze future scenarios. The future scenarios described in this report clearly show that a number of crucial decisions must be taken if dental health care is to remain accessible and available for all sections of the population in the future.

This book is an edited and updated version of the report 'Arbeid, gezo- heid en welzijn in de toekomst; toekomstscenario's arbeid en gezondheid 1990-2010' commissioned by the Steering Committe on Future Health Scenarios and published by Bohn, Stafleu and Van Loghum, Houten/- Antwerp in 1991. The authors wish to express their grateful thanks for the constructive comments they received from many people during the writing of this book. The following persons, however, deserve to be mentioned by name: E.W. Bergsma M.A., Prof. F.J.H. van Dijk, Dr. C.L. Ekkers, Prof. F. Huygen, Dr. M.A.J. Kompier, Prof. J.P. Mackenbach, Dr. P.A. van Wely and Dr. J.H.B.M. Willems. SUMMARY Aim and scope of the study The main aim of this book is to show how the field of work and health will develop until the year 2010 under certain economic and other con- ditions. This is done on the basis of a Delphi study carried out with the cooperation of 120 leading experts in the Netherlands. A secondary aim was to investigate the present state of work and health in the Netherlands with the aid of available statistical sources.

The first STG report to embody scenarios on population ageing, health and care appeared in 1985. This report describes developments since 1985, reviewing the current position and setting out updated scenarios. The 1985 report set out three scenarios, in which the central focus was on the developing future patterns of demand for care by the elderly. The present report also sets out three scenarios, centring on the demand for care, in which account is taken of a variety of factors; it also details four strategic scenarios whose central focus is the developing supply of care, and which set supply and demand one against the other. Three of the strategic scenarios - emphasizing, respectively, intramural, extramural and informal care - suppose the demand for care to be met in full; the fourth scenario, which rolls current policies on the care of the elderly forward into the future, pinpoints discrepancies between the need for care and the extent to which that need is likely to be met, making clear in so doing that a review of long-term policy for the elderly is urgently needed.

The report Scenarios on Rheumatoid Arthritis 1990--2005 is the third specialized report of the Chronic Diseases Scenario Project. An exploration has been made of the likely trends in the number of patients, the number of severity of consequences and complications, the quality of life and the demands likely to be made on the health system as a result of rheumatoid arthritis up to the year 2005. Rheumatoid arthritis is a growing problem. Key issues therefore include the need for expansion of health care facilities and health care innovations and the prospects to prevent the disease itself and to cope with its consequences and complications. The report is therefore of relevance to all groups involved in the care of rheumatoid arthritis patients and for society as a whole.

The future place of medicines in health care is both exciting and uncertain. With an aging population, an increasing number of chronic sick, a growing range of treatment options and a developing European market, the one certainty is that medication patterns will change radically over the next 15 years or so. How the future might look, in terms of quality, volume and cost of pharmacotherapy, is the subject of this report. Four scenarios for the future are set out, all of which take account of already visible trends. Sobriety in sufficiency envisages rational and restrained consumption patterns. Risk of avoidance is dominated by fears of iatrogenic harm and hence minimal drug use. The central feature of Technology on demand, in contrast, is confidence in technological progress. Free market unfettered, finally, is marked by a Europe without frontiers and minimal state intervention. The reader is encouraged to reflect without preconceptions on the future of medicines in health care. No ready-made answers are offered; rather, a wealth of information and analysis is provided which serves to underpin decision making and policy development, not just by central government but also by every institution concerned with the role of medicines in health care.

As noted in the Foreword, this report is the second of several volumes resulting from this study of future health care technology. The purpose of the study, as formulated by the STG, was to analyze future health care technology. Part of the task was to develop an 'early warning system' for health care technology. The primary goal of the project was to develop a list or description of a number of possible and probable future health care technologies, as well as information on their importance. Within the limits of time and money, this has been done. This report is the description of anticipated future health care technologies. However, given the vast number of possible future health care technologies, complete information on the importance of each area could not be developed in any depth for all technology. Therefore, four specific technologies were chosen and were prospectively assessed. These future technologies were examined in more depth, looking particularly at their future health and policy implications. Subsequently, the project was extended to September 1987, and two additional technologies are being assessed.

As noted in the Foreword, this report is one of several volumes resulting from this study of future health care technology. The purpose of the study, as formulated by the STG, was to analyze future health care technology. Part of the task was to develop an 'early warning system' for health care technology. The primary goal of the project was to develop a list or description of a number of possible and probable future health care technologies, as well as information on their importance. Within the limits of time and money, this has been done. However, given the vast number of possible future health care technologies, complete information on the importance of each area could not be developed in any depth for all technology. Therefore, four specific technologies were chosen and were prospectively assessed. These future technologies were examined in more depth, looking particularly at their future health and policy implications. Subsequently, the project was extended to September 1986, and two additional technologies were chosen for assessment.

This publication represents the report of the Scenario Committee on Ageing. The draft report was discussed with a wide range of experts, inter alia during the symposium 'Growing Old in the Future' held on October 27th, 1984. In addition to the scenario report, a background report containing the basic analysis employed in the scenarios on ageing has been prepared. The scenario report has been written in such a way that it can be read independently of the background study. Scenarios are a relatively new phenomenon in health care and related policy. For this reason it might be useful to furnish the reader with a few suggestions. As a first step, perusing the summary will provide the reader with an ~verall picture of this application of the scenario method in policy preparation and policy implementation in the sector health of the elderly. As a second step, we would recommend that the scenario report be read in its totality. It might be useful to note down points on which the reader would like to make additions or variations.

This report, Anticipating and Assessing Health Care Technology, is the first report from the STG Commission on Future Health Care Technology. The STG (Stuurgroep Toekomstscenario's Gezondheidzorg) was established in 1983 as an independent advisory group to the State Secretary for Welfare, Public Health, and Cultural Affairs (WVC) to assist in long-range health planning efforts. Thus far, STG commissions have examined cardiovascular disease, cancer, aging, and life styles as issues of importance to the health of the Dutch population in the future. Obviously, health care technology is of great concern to the government. On the one hand, technology is one of the major tools to promote a healthy population. On the other hand, the costs of health care have been rising at an alarming rate in recent years. It was these two facts, along with the social consequences of certain technologies such as genetic screening, that led the STG to establish the Commission on Future Health Care Technology in 1985. The European Office of the World Health Organization (EURO) cosponsored the project. The Health Council (Gezondheidsraad) agreed to cooperate with the project by furnishing space and intellectual and logistical support. The goal of the Commission's work is to develop sufficient information on future technological developments in health and health care to assist planning for their consequences. Subsequent reports will give more detail on future health care technologies and will provide in-depth assessments on a few specific technological areas.

As noted in the Foreword, this report is one of several volumes resulting from this study of future health care technology. The purpose of the study, as formulated by the STG, was to analyze future health care technology. Part of the task was to develop an 'early warning system' for health care technology. The primary goal of the project was to develop a list or description of a number of possible and probable future health care technologies, as well as information on their importance. Within the limits of time and money, this has been done. However, given the vast number of possible future health care technologies, complete information on the importance of each area could not be developed in any depth for all technology. Therefore, four specific technologies were chosen and were prospectively assessed. These future technologies were examined in more depth, looking particularly at their future health and policy implications. Subsequently, the project was extended to September 1986, and two additional technologies were chosen for assessment.

As noted in the Foreword, this report is one of several volumes resulting from this study of future health care technology. The purpose of the study, as formulated by the STG, was to analyze future health care technology. Part of the task was to develop an 'early warning system' for health care technology. The primary goal of the project was to develop a list or description of a number of possible and probable future health care technologies, as well as information on their importance. Within the limits of time and money, this has been done. However, given the vast number of possible future health care technologies, complete information on the importance of each area could not be developed in any depth for all technology. Therefore, four specific technologies were chosen and were prospectively assessed. These future technologies were examined in more depth, looking particularly at their future health and policy implications. Subsequently, the project was extended to September 1987, and two additional technologies were chosen for assessment.