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Chapter V. Impact of self-care systems on the EU health systems

V.Impact of self-care systems on the EU health systems

 

V.1 Introduction. The aim of the chapter

 

In addition to the cost benefit analysis carried out by our colleagues in Austria and Italy, which preceded this study and provided the rationale for the selection of the five minor ailments addressed here, there are a number of other studies which may assist in a review of the possible financial impact of self-care in minor and self-limiting conditions and provide part of the basis for subsequent concrete actions as policy recommendations.

 

V.2 Economic issues in European Healthcare

 

“Total spending on health goods and services absorbs a significant and growing share of total resources in the economy (about 9.6% of GDP on average in the EU in 2008 up from 8.5% of GDP in 1998). Health goods and services also constitute a significant share of public expenditure (public expenditure on health constitutes 12.3% of total government expenditure). Indeed, a large proportion of total expenditure on health is public expenditure (about 77.6% on average in the EU in 2008) and health expenditure is the second biggest component of social protection expenditure in public budgets. Total and public expenditure on health as a share of GDP have increased over time and continue to grow as EU Member States face growing pressures on their health systems. As a result, health systems’ financing – and not just pension expenditure – is at the centre of the debate on the long-term sustainability of public finances.” (Directorate-General for Economic and Financial Affairs. Joint Report on Health Systems prepared by the European Commission and the Economic Policy Committee (AWG). European Commission, 2010, p.24)

 

Growing persons’/patients’ expectations

 

«The pace of economic and technological progress is matched by the rate at which populations seek the benefits of newer, more effective and possibly expensive health technology. As national income rises the population place a greater demand on health systems. They demand more information, accountability and transparency regarding the services they consume and require evidence of value for- money in their role as taxpayers. Citizens surf the web for information on all aspects of health and health interventions and desire greater choice of provider, care setting and tailor-made treatments. They are becoming more important participants in the decision-making process in a system that they see is ultimately there to serve them.

 

Moreover, citizens have become more aware of medical errors, and are more prone to complain and litigate when they and their relatives are the victims of negligence or miscommunication, or even minor departures from the outcomes apparently achievable by leading practitioners in leading centres (OECD, 2002). Interestingly, this fact, coupled with societal changes towards a more risk-free society, has resulted in an increase in the so-called “defensive medicine”, the practice of diagnostic or therapeutic measures (tests, prescriptions, hospitalisations) conducted primarily as a safeguard against possible malpractice liability. While particularly important in the USA, where defensive medicines may account for about 25% of total health expenditure, this phenomenon is also growing in the EU.

 

Cultural factors (e.g. self-care) may reinforce or moderate such expectations. In general, while better informed consumers can improve their life-styles and encourage providers to improve service delivery, societies will have to balance their wish to increase resources for health spending with their willingness to pay for this increase. » (Directorate-General for Economic and Financial Affairs. Joint Report on Health Systems prepared by the European Commission and the Economic Policy Committee (AWG). European Commission, 2010, p. 27)

 

 

Life-styles/health behaviour

 

« According to the EPC/EC 2009 Ageing Report, in the presence of an improvement in the number of years spent in good health, the projected increase in public expenditure on health care in the EU can be reduced by 50 per cent. » (Directorate-General for Economic and Financial Affairs. Joint Report on Health Systems prepared by the European Commission and the Economic Policy Committee (AWG). European Commission, 2010, p. 75-77).

Comment: this is the basis for the huge exercise, the European Innovation Partnership for Active and Healthy Ageing. Paradoxically, the manifest aim, to increase the average active healthy life years of European populations by two years, may prove not to have been achievable, but a great deal of constructive collaboration has taken place between European healthcare providers in sharing good practices and looking for innovation, especially supported by eHealth tools, and this in itself may prove eventually to have had a positive impact cost-wise. However, the evaluation, although planned, is still in an early stage.

 

 

Health systems: possible ways to improve cost-effectiveness in the sector

 

«Simultaneous concerns over the need to improve population health status and differences in health across population groups, the need to improve the quality of services, the persistence of inappropriate incentives and ineffective and inefficient service provision, and the need to control the growth of health spending have encouraged countries to look for ways to improve value for money in the health sector. The work conducted for the WHO and OECD while showing that higher expenditure per capita is associated with higher level of health, has also indicated that there are opportunities for some countries to improve health outcomes or to improve quality of care without increasing or even reducing their current level of resources used on health. Indeed, their analysis shows that the best health status is not always found in those countries that spent the most on health and that care delivery falls short of good practices in many countries, including some where expenditure is quite high.

 

 

Improving the management of information and knowledge to help decision making in the health sector:

Several measures could be implemented to make better use of information, which is a precondition to help decision making in the health sector. Improving health sector performance is associated with an intensive use information and knowledge for planning, control and evaluation. Better strategies for the management and use of information and knowledge mean more quality and efficiency of health services. These include in particular:

 

« Improving health information for patients and motivating consumers to use performance information: patient expectations together with cultural factors (self-care) associated with health literacy, can play a role in the demand for care. Investing in information to patients on how to access the system, what is covered and why, and on the different treatment alternatives available, may align expectations with resources and lead to better informed patient decisions. Information for health can contribute to improving life-styles. Information to patients must be simple and contextual and adapted to the demand of particular users (provide context, keep it simple, help people understand meaningful differences, format in a way that is easy to follow, make it clear that information is trustworthy). There is evidence that public reporting of performance data to support patient choice of provider improves quality as providers are sensitive to their public image even in the absence of market pressure from consumer choice» (Joint Report on Health Systems, December 2010, p. 77).

 

The Economic and public health value of self-medication (2004)

 

In 2004, the European sectoral organisation of producers of self-care medicines (AESGP) commissioned a report on the effects of an expansion of the use of self-care medicines for public health and the economic effects. In this study, the effects of a 5% shift (in sales revenue) for prescribes medicines to the self-care medicines category was calculated for Austria, France, Germany, Italy, Portugal, Spain and the UK. For the purpose of support, the researchers refer to German and Italian research results which indicate that 14% and 15% respectively of all medicine prescriptions relate to minor ailments. A total potential saving of EUR 11 billion is calculated. This is about EUR 35 per capita in the countries concerned. Similar savings for the European Union as a whole would rise to more than EUR 16 billion per year.

The savings calculated were divided into savings on public funds and savings for employers and the economy as a whole. The first category concerns avoided costs of:

  • visits to doctors;
  • prescriptions by doctors;
  • personal contributions for prescriptions in some countries (net).

The second category consists of:

  • the possible substitution of GP care for specialist care in the time released, increased productivity through fewer absences with fewer visits to doctors during working hours and increased productivity through an earlier return to work ;
  • an increase in the time available through the reduction in travelling time and travelling expenses, because visits to doctors are avoided.

Although this study is now somewhat dated, and could be revisited, it provides a useful overview of the use of self-medication in a number of countries. Despite methodological issues related to assumptions made in the course of the study, it is evident that the savings potential, if self-medication is the focus of self-care for minor ailments, can be substantial.

Since the time of this report there has been considerable work at EU level to review the range of non-prescription medicines available ‘OTC’. This coincides with an expansion of the conditions considered as suitable to be treated without the intervention of a doctor, as described in more detail in pp.30-1 of the final report of the cost/benefit analysis recently completed as a precursor to this study (see below). The report of the Working Group on promoting good governance of non-prescription drugs in Europe (2013), referred to earlier emphasizes how rapidly this sector has grown in the last few years, which has prompted energetic monitoring of such safeguards as pharmacovigilance monitoring but it has meant that research data is now lagging behind the reality of the current state of the field as will be evident also from the CBA report to be considered shortly. Incidentally the last-mentioned report also stresses the importance of education of pharmacists and doctors in self-care as an important enabler for collaborative care programmes and in supporting patients.

 

Ecorys report: via empowerment to self-reliance 2011

 

The Dutch research group Ecorys carried out this interesting study of self-care on behalf of a Dutch pharmaceutical company Neprofarm that specialises in self-care products. The basis of the study was to review what was known about the economic and health consequences of self-care in the light of the recognised substantial increase in treatment of minor ailments in Dutch GP surgeries between 2003 and 2009. As they comment: ‘This is a costly trend, but we can reverse it if minor ailments are treated more often and more successfully through self-care. GPs will be able to treat more complex care needs themselves more often and will need to make fewer referrals.’

After examining definitions of self-care and the likely impact on different healthcare stakeholders of self-care being a prominent policy action, they examine what is currently known about the economic evidence.

a) Economic and public health effects of self-medication in the UK

 

A study from 2009, published by the PAGB (Proprietary Association of Great Britain) and carried out for them by IMS Healthcare, describes the potential impact of more self-care in the UK.  On the basis of a definition of minor ailments used within the UK, it was calculated that minor ailments are at issue in 57 million of the total 290 million GP consultations. 51.4 million consultations are even devoted entirely to minor ailments. Medicines are also prescribed for these. These 51.4 million consultations involve the following costs for the National Health Service (NHS): GBP 1.5 billion consultation costs and GBP 0.3 billion medicine costs. Expressed in terms of time spent, an English GP spends about one hour per day on minor ailments.

This study therefore describes the maximum potential (GBP 1.8 billion, or more than EUR 2 billion ) that could be transferred if, in theory, all visits to GPs for minor ailments could be avoided and people bought prescribed medicines independently from a pharmacy or chemist. The actual saving will be lower, but no study of the concrete possibilities for savings was conducted. The survey also contains a number of interesting observations for the UK:

 

The top ten minor ailments account for 78% of the total collective costs of treatment for minor ailments. In the top ten, the main ailments are back pain, heartburn, eczema, colds and constipation;

The over-65 age group and women visit doctors with minor ailments significantly more frequently than men aged less than 65.

b) Concrete savings potential in the Netherlands

 

The savings potential of a country depends heavily on the local regulations and culture. It would therefore be unwise to base estimates for the Dutch savings potential on measurements in other countries. Ecorys calculated the savings potential of the existing Dutch situation by making use of a validated definition of ‘minor ailments’ and reliable figures on use of GP care. The necessary research work was performed by independent researchers.

Many of the effects of a better balance between self-care and formal care provision are not of a substantive nature and/or are not easily measurable. In this study, they opted for a cautious approach to the estimates of the Dutch savings potential, exercising caution in order to avoid creating over-optimistic expectations. The savings potential of rebalancing self-care and formal care provision calculated below is a (potentially severe) underestimate of the actual potential.

NIVEL defined the time spent by GPs in connection with minor ailments.  The data gathered relates to all health problems (expressed in ICPC codes), of which professionals estimate that on average, more than 50% of the complaints presented to GPs could be satisfactorily addressed through self-care. NIVEL published an assessment based only on the ICPC codes, in which 75% of the complaints are ‘self-treatable’. They based their calculation on all ICPC codes following from the Delphi rounds of the experts, because this provides a better picture of the overall scale of the health care use in question. If an ICPC code has a ‘low self-care score’ (between 50 and 75%), this does not always mean that there are doubts as to whether this is self-treatable. A low self-care score may also be caused by the fact that the relevant ICPC code is very broadly defined, and as a result, covers a heterogeneity of more and less self-treatable ailments.

Patient contacts of GPs

 

In 2009, Dutch GPs had 12.5 million patient contacts in connection with minor ailments. They saw patients in surgery hours about 6.8 million times, wrote 3.5 million repeat prescriptions and conducted almost 1.8 million consultations by telephone. In addition, there were smaller numbers of visits and consultations by e-mail. In 2006, there were more than 9.2 million patient contacts in all related to minor ailments. The total care costs for these contacts rose from EUR 71 million in 2006 to almost EUR 96 million in 2009. About 12.5% of the number and costs of patient contacts of GPs in 2009 related to minor ailments, compared with about 10.8% of the number of contacts in 2006. The total number of patient contacts of GPs (i.e. not only for minor ailments) was about 100.9 million in 2009 and 85.2 million in 2006.  The total costs involved were about EUR 770 million in 2009.  The increase in the number of contacts and in the costs of GP care for minor ailments amounted to 35% in comparison with 2006 and 45% in comparison with 2003. The highest increase took place in repeat prescriptions (+95% in comparison with 2003). Use of GP care for minor ailments is therefore not only growing, but is growing even faster than the total use of GP care. GPs are therefore contacted for minor ailments in a growing share of their working time.

Table 3 Volume and costs of patient contacts in connection with minor ailments

  2003 2006 2009
Consultations <20 min. Number 5,354,701 4,995,917 6,170,985
  Costs € 48,192,311 € 44,963,255 € 55,538,867
Consultations > 20 min. Number   282,415 671,164
  Costs   € 5,083,467 € 12,080,953
Visits <20 min. Number 261,031 201,562 237,333
  Costs € 3,523,921 € 2,721,081 € 3,203,996
Visits > 20 min. Number   74,973 53,086
  Costs   € 1,686,894 € 1,194,424
Telephone consultations Number 1,169,782 1,090,621 1,789,553
  Costs € 5,264,020 € 4,907,795 € 8,052,989
E-mail consultation Number   2,777 5,880
  Costs   € 12,496 € 26,461
Repeat prescription Number 1,810,539 2,594,166 3,530,594
  Costs € 8,147,427 € 11,673,746 € 15,887,673
Total GP consultations Number 8,596,054 9,242,431 12,458,595
  Costs € 65,127,679 € 71,048,735 € 95,985,363

 

Source: NIVEL 2011, processing by Ecorys.

Prescribed medicines in connection with minor ailments

The total use of prescribed medicines in connection with minor ailments cannot be defined precisely on the basis of the NIVEL data. For this reason, no savings potential was assigned to this. One of the problems in determining the self-treatable share of the medicine prescriptions is the fundamental question of whether a particular ailment can be self-treatable if a GP has decided to prescribe a medicine for it. This question went beyond the scope of this study. The total value of the use of prescribed medicines (pharmacist’s costs plus medicines) is therefore high.

Further to the NIVEL analysis, which reports that a medicine is prescribed in 55% of consultations for complaints with a self-care score of more than 75%, Ecorys calculated that a total of 37 million prescriptions were issued in 2009 for the 55 ICPC codes with a self-care score of at least 50% (22,495 prescriptions per 10,000 registered patients). Given the total of 12.5 million GP contacts in connection with minor ailments in 2009, this raises the question, so far unanswered, of how it is possible that about 3 prescriptions are issued per contact.

Conclusion

In theory, the economic effects of an optimal balance between self-care and care provision can be predicted with some accuracy. However, the availability of usable data on empirical measurements is limited. International comparisons are possible only to a limited extent, due to differences in health care systems and methodological issues in the available publications. Furthermore, the scope of the ailments concerned is often not clearly defined.

Ecorys felt that they had made a cautious estimate of the quantifiable benefits of optimizing the balance between self-care and care provision. The savings potential of self-care on the use of GP care in the Netherlands in 2009 amounts to EUR 96 million if all minor ailments were treated other than by the GP. The costs of pharmacy care and the costs of prescribed medicines are not included here. The medicine costs that are also covered under the basic health insurance are a multiple of EUR 96 million.

They comment: the potential health risks of self-care medicines attract a great deal of attention from researchers and are consequently a regular subject of publications. However, the actual negative effects occurring are poorly measured and the measurements that exist are therefore surrounded by considerable uncertainty. The fact that the risks are under control is shown by the recent evaluation of the classification of self-care medicines, in which the Minister of Health, Welfare and Sport (the Netherlands Department of Health) saw no reason to change the classification.

Comment: although this is a report carried out by the industry for the industry, the data adduced is helpful, if only to recognise the economic extent of the impact of minor ailments. Although mention of self-care that the citizen might carry out without recourse to medication, which includes prevention and sensible hygiene, there is no data available, it would seem, to allow assessment of either its extent or what impact there would be if better education of the population led to greater spread of such behaviours.

 

A cost benefit analysis of self-care systems in the European Union

This report (Ostermann et al 2014) EAHC contract N° EAHC/2013/Health/26A ‘Cost/benefit analysis of patient self-care oriented health systems in the European Union and the current frameworks in place to enhance self-care oriented heath care systems and patients’ empowerment is the sister project and precursor of the present one. It was the one on which basis the five minor conditions were chosen that form the basis of the present study.

Following an extensive literature review and analysis of added value from self-care in the 5 conditions, a short list of interventions was drawn up, two health information website systems, from France and the Netherlands, two telephone helpline systems, from Latvia and the UK (NHS 111), a further UK health information system (NHS Choices) and two model prescribing systems introduced as part of UK NHS policy developments. Following an initial analysis it appeared that the quality of information that could be found on their functioning prevented use of the first four, so that only the last three, all based in the UK were used for the main study.

The Minor ailment scheme

«Community pharmacy minor ailment schemes (MAS) are locally tailored schemes to provide public access to NHS treatment and/or advice via a pharmacist or pharmacy personnel, or, where appropriate, to refer to other health professionals. The idea is to encourage patients to use community pharmacies as first access point for minor ailments rather than a general practitioner (GP). Their establishment as well as their management is up to the four different regional entities (NHS 2000). »

 

As far as physicians are concerned, the implementation of a MAS effectively leads to reduced physicians’ time hence leaving the physician in total worse off at the amount of ₤ 36.27 for each shift case. The immediateness of this impact, however, is depending on the payment mechanism applied: if, for instance, GPs are paid on a fee-for-service (FFS) basis or receive lump-sum payments for every patient contact, then a reduction of the physician’s consultations, due to self-care initiatives, immediately results in a reduced income. If, on the other hand, physicians receive fixed budgets or salaries for performing their services, a reduction of GP consultations must not immediately lead to a net negative benefit for physicians. However, on the medium term, the health system is likely to adapt the capacities of GPs and use the freed resources for alternative uses (with a higher benefit) ultimately resulting in a net negative benefit for GPs if regarded as a whole. »

Non-medical prescribing / pharmacist independent prescribing

Concerning the introduction of non-medical prescribing, the net benefits for each case shifted are summarised in Table 23 from various perspectives. Regarding the societal level it has to be noted, that under the assessed effective shift rates of 5%, 10% and 20% of the minor ailment only GP consultations, net societal benefits is always negative ranging from ₤ -8.22 to ₤ -12.02. It is also remarkable, that even at an assumed rate of shift cases at the level of all (i.e. 100%) minor ailment GP consultations avoided, net societal benefits would still be negative (₤ -7.21).

«With regard to the providers’ perspectives, pharmacists are facing substantially higher costs due to the implementation of non-medical prescribing as consultation time increases and training costs have to be factored in. Overall, pharmacies are affected by a net negative benefit ranging from ₤ -14.45 to ₤ -16.22 for each case in which a patient decided to consult a NMP/PIP pharmacist instead of seeing the GP first. As pointed out above, evidence for the remuneration of NMP/PIP pharmacists on a case-base was insufficient, which could in theory counterbalance the net negative impact to pharmacies on the account of the system’s perspective, as this would most likely result in a transfer of funds from the health system to the pharmacies.

NHS Choices

«NHS Choices (www.nhs.uk) is Europe’s most popular health website and the third biggest government website in the UK (NHS Choices 2012b). It is run by the NHS, thus a programme of UK’s Department of Health and accessible across all parts of the UK. In case of non-availability of services, users are referred to other equivalents (e.g. NHS 24 for Scotland). NHS Choices was established in 2007 (Nelson et al. 2010a) to provide comprehensive medical and lifestyle information to both the public as well as healthcare professionals. Its aim is “to develop a world-leading, multi-channel service that will create a ‘front door’ for everyone to engage with the NHS and social care.” (NHS Choices 2013b). Therefore, it compiles the knowledge and expertise of various healthcare organisations (e. g. NHS Evidence, Health & Social Care Information Centre, Care Quality Commission, etc.). »

«Concerning the introduction of an internet-based information portal such as NHS Choices, Table 24 shows that from a societal perspective a positive net benefit is generated for all the assessed levels of shift cases (5%; 10%; 20%) ranging from ₤ 0.83 to ₤ 5.33 for each shift case. In fact, a minimum shift rate of 4.4% is required in order to result in a positive net benefit. »

«Concerning the providers’ perspective, pharmacists are facing slightly higher costs (₤ -2.13 loss of net benefit) due to the implementation of an internet based information portal as the time needed for consultations increases (see Table 13). With regard to the results of the sensitivity analysis it has to be kept in mind, though, that for the lower boundary no additional consultation time is assumed hence leaving the pharmacists unaffected. »

«With regard to the physicians’ perspective, the introduction of NHS choices again leads to reduced physicians time in the case of shifts from GP + pharmacy (option 1) to pharmacy consultations only (option 2) hence leaving the physician in total worse off at the amount of ₤ 36.27 for each shift case.»

«As far as the system’s perspective is concerned, it can be shown, that the health system benefits from the effective introduction of NHS choices quite substantially (in fact exceeding the net benefits attainable by the implementation of MAS or NMP/PIP). This is mainly due to two mechanisms: first, and as for all the other initiatives assessed the health system benefits from reduced GP time resulting in lower expenditure for GP services and/or higher efficiency of service delivery. Second, for the particular case of NHS Choices, the health system saves expenditure on medication, if a patient exempt from prescription charges decides to consult a pharmacist directly without corresponding prescriptions hence paying the full price for the OTC products handed out. Moreover, overall fixed operating costs for running the NHS choices service regress with increasing participation rates ultimately resulting in a range of net benefits to the health system between ₤ 22.22 (urinary tract infection for patient not exempt from prescription charges at an overall shift rate of 5%) and ₤ 43.70 per shift case (athlete’s foot for exempt patients at 20% shift rate). »

Results of the Cost-Benefit- Analysis (CBA) 

«With regard the results of the cost-benefits analysis, a number of key findings have to be discussed:

The status of the patient in terms of exemption from prescription charges or not has an essential impact on the results of the CBA for MAS and NHS Choices. As it is assumed, that patients in general receive 1 OTC and 1 Rx product if they decide to visit a GP (option 1) and 2 OTC products if they decide to opt for self-care with medication (option 2), patient not exempt from prescription charges tend to benefit more from a shift to pharmacy consultation only as on average OTC products are priced below the level of current prescriptions charges for England. With regard to the MAS, it has to be borne in mind, though, that patients not exempt from prescription charges are explicitly targeted only by some schemes and that the rational of minor ailment scheme is rather geared towards the avoidance of GP consultations, which are currently held as the patient exempt from prescription charges needs a prescription in order to obtain the medication needed free of charge (Baqir et al. 2011). For the case of NMP/PIP, a shift case under this self-care initiative does not lead to a change in medication; consequently patient exempt from prescription charges as well as patients obliged to pay prescription charges benefit from time savings but not from reduced (co-)payments for medication.

Third, the availability of Rx and/or OTC medication for specific minor ailments as well as for the case of OTC medication the question, whether this medication can be reimbursed for exempt patients – if prescribed or handed out under a MAS – has an impact on the fact, whether a patient is prone to higher or lower out-of-pocket payments for pharmaceuticals (see medicine costs as listed in Table 19 and 20). Generally speaking, NHS choices lead to the highest increase in out-of-pocket payments for pharmaceuticals for the population exempt from prescription charges whereas this effect is somewhat mitigated within the MAS as reimbursable OTC-products are usually covered by the scheme. For the case of patients not exempt from prescription charges, medicine costs except for the case of cold, for which no Rx medication is available, tend to decrease if they shift from GP consultation to self-care with medication.

Fourth, evaluations of self-care initiatives (including cost-benefit analysis) are rather scarce. For the development of the CBA the authors mainly relied on the methodological approaches devised by Farnfield 2008, Latter et al. 2010, Nelson et al. 2010a, with the latter two representing officially mandated evaluation studies of a broader scope whereas Farnfield 2008 can rather be classified as grey literature representing an internal CBA to the Department of Health (DoH) with regard to the introduction of a nationwide MAS. Even though the authors finally felt quite confident for the CBA and were able to identify at least two different sources for most cost components (at similar scales), it still appears that the conduction of a cost-benefit-analysis as well as an overall evaluation in general is rather the exemption than the norm if a particular self-care initiative was to be implemented.

Fifth, with regard to the overall identified societal benefit of the self-care initiatives assessed, it can be concluded, that the more elaborated an initiative appears to be in terms of handling at a pharmacy level as well as in terms of its governance, the less likely the initiative will achieve a positive net societal impact. In terms of the minor ailment scheme, it appears to be possible, that increased patient benefit tends to outweigh relatively modest training and operating costs on a pharmacy level with increasing levels of shift rates. With regard to the “brake-even” participation rate of 27.5% it has to be borne in mind, however, that almost half of the patients exempt from prescription charges would have to decide to participate in the MAS and effectively shift from GP contact to self-care with medication if they would exclusively suffer from a minor ailment next time.

Regarding non-medical prescribing handling costs and in particular time and training costs to pharmacies currently appear to be too high in order to promote widespread adoption of pharmacist independent prescribing but also in order to contribute to a positive net societal benefit as a whole. For the case of NHS Choices, however, net societal benefit appears to be positive even at a low rate of shift cases. This is mainly due to the fact, that NHS Choices does not require a high amount of adoption and/or investment at the pharmacist level on the one hand and features relatively low operating costs. Moreover NHS Choices appears to be the most attractive policy option from a system’s perspective as it leaves the prescription mechanism including the exemptions untouched hence resulting in average savings up to ₤ 43.70 per shift case (in the case of athletes’ foot).

Limitations

The authors comment: these limitations have also to be taken into consideration for our results: as pointed out in the methods section, the developed CBA is – as any other CBA – based on a number of assumptions, which are important in order to come up with an operational framework, but must not necessarily be met in practice.

The first fundamental assumption relates to the fact, that all the assessed minor ailments are self-limiting by nature and that the effectiveness of the medication handed out is the same regardless whether Rx or OTC products are used. In fact, as sickness leaves due to minor ailments are excluded in the model and as we have decided in line with Farnfield 2008 not to monetise non-monetary patient benefits or costs (such as harm caused by longer periods of pain), it is irrelevant in terms of the health outcome, whether a patient suffering from one of the selected minor ailments choses to visit a GP (option 1) or decides to rely on self-care with (option 2) or without medication (option 3).

The second assumption which has to be scrutinised is included in the conceptualisation of the model: As indicated above, a patient suffering from a minor ailment faces three treatment options: (1) physician contact, (2) self-care with medication and (3) self-care without medication. In the case of the implementation of one of the analysed self-care initiatives, a change in the patient’s behaviour only takes place from option 1 to option 2. This can be reasoned by the mere mechanism of the initiatives assessed, which for the case of MAS and NMP/PIP effectively intends to replace GP visits caused by prescription considerations with pharmacy encounters. However, as pharmacy encounters may be easier to access for patients (no need to arrange appointment, fewer waiting times), self-care initiatives might also exert some impacts on patients, who originally decided to conduct self-care without medication hence resulting in shift cases from option 3 to option 2. Ultimately, the internet information provided by NHS choices might have a similar impact incentivising patients to consult a pharmacy instead of doing nothing, as patients are informed on treatment options they would not have considered prior to consulting NHS choices.

From a methodological point, thus, the authors were also well aware of the relevance of this second shift scenario (from option 3 to option 2). With regard to the available data, however, it was not possible to extract sufficient and/or consistent information of the prevalence of minor ailments in general and the share of each treatment option in particular, which would have been a prerequisite for integrating this second scenario in the cost-benefit analysis. Consequently, the authors decided to only include shifts from treatment option 1 to treatment option 2 in the CBA, as valid information could be identified for the number of patients visiting a GP due to minor ailments only allowing for the calculation of a minimum share of shift cases required for each initiative in order to generate a societal net benefit (if feasible).

The third fundamental assumption of the CBA conducted is related to the average number and type of pharmaceuticals prescribed or handed out if one decided to visit a GP (option 1) or a pharmacy only (option 2). Based on the (scarce) evidence presented in literature (Ashworth et al. 2005; Fischer 2003; May/Bauer 2013; Pillay et al. 2010) we reasoned that on average 2 products are dispensed to the patient in case he or she suffered from a minor ailment. Moreover, we assumed, that if the patient visited a GP (or an independent pharmacy prescriber), 1 Rx and 1 OTC product would have been prescribed instead of 2 OTC products if he or she had contacted the pharmacy only (all assumption for the case, that OTC and Rx products are available for a particular minor ailment; for details see table 15).

In the first draft, the authors also considered to ailment-specifically adjust the number and type of medication. However, due to lacking data in particular on the medication handed out in pharmacies for a particular minor ailment we decided to rely on the approximation of 2 items prescribed or handed out bearing in mind, that both different (co-)payments and their mere number for a particular medication has an impact, in particular, on the net benefits generated on the patients’ and system’s level.

The fourth relevant assumption is also linked to the issue of medication and becomes evident when presenting the results of the CBA from a patient’s perspective. With regard to the average savings a patient would generate if he decided to shift from option 1 (GP visit) to option 2 (self-care with medication), the authors compare two different shift scenarios: without and with the initiative assessed in place This differential analysis of the effects of a particular self-care initiative from a patients’ perspective is of relevance when it comes to the interpretation of the results and takes into consideration the fact that a patient is free to opt for self-care with medication instead of a GP consultation even if there is no self-care initiative in place. Consequently, if one wants to assess the additional benefit a particular self-care initiative might have for a patient suffering e.g. from athlete’s food, one cannot simply derive this effect by solely regarding a shift from option 1 to option 2 with the particular self-care initiative in place. Instead, it has to be assessed how much the patient may be better or worse off, if he or she performs the shift under the conditions of the particular self-care initiative as opposed to a shift in scenario of no self-care initiative in place.»

 

V.3 Interpretation of the results and possible ways forward

 

The potential for cost-benefit of self-care seems to be evident from these studies in the UK, the Netherlands and EU25. The conclusions however are derived almost solely from consideration of self-medication whereas further investigations need to show the cost-benefit for the healthcare system given the full range of interventions of self-care. Furthermore, while exploring possible scenarios for change, the evidence that self-care is actually taking place is largely derived by inference, and undoubtedly further work needs to be done in this area, particularly via deriving data from citizens, rather from other stakeholders.

Possible ways forward require an integration of the existing evidence in the policy formulation stage of EU self-care policy, communication via the European Semester and other cross-ministerial for a to underline self-care benefits for the system and for the person/patient.

Furthermore, health promotion, prevention and measures to reduce health inequalities may show, in parallel with the cost-benefit for healthcare systems, the benefits for the persons/patients together with increased patient satisfaction may also result in a shift from defensive medicine to proactive medical interactions.