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BMJ No 7095 Volume 314 Editorial Saturday 7 June 1997 Health priorities for the European intergovernmental conference Long term, multisectoral issues rather than knee jerk political responses Last month, Britain's new prime minister, Tony Blair, called on the European Community to become less obsessed with itself and its institutions and to focus instead on the issues that matter to people. These included, he said, public health, fraud, and the environment. From the start, public health has held only a tenuous foothold within the community, and there had been reports that the community's remit in public health, set out in article 129 of the Maastricht treaty in 1993, would be abandoned. But as a result of the crisis about bovine spongiform encephalopathy (BSE), article 129 is now safe, at least in some form, and it will figure on the agenda of the intergovernmental conference on treaty reform this month in Amsterdam. Unfortunately, the outcome of any review of the community's role in health may be only a short term response to the problem of BSE. Such knee jerk action is already evident in the European Commission's proposal earlier this year to revise article 129, which tacked on a highly visible reference to actions in the veterinary and phytosanitary fields, even though this duplicated powers existing elsewhere in the treaty.(1) Instead, the community needs to fundamentally change the way it deals with health matters. The community's current role has been based on a limited definition of public health, restricted to specific areas such as "prevention," "major health scourges," and "drug dependence." This disease based approach was outlined immediately after Maastricht in the commission's framework document.(2) While it may have proved politically successful, such an approach has reduced the community's ability to make a substantial contribution to the health of European citizens. Rather than this disease based strategy, we need greater focus on risk factors associated with diseases and determinants of health. This calls for a multisectoral approach that incorporates subjects such as poverty, unemployment, agriculture, transport, housing, and education. Such an approach has recently been highlighted by Tessa Jowell, Britain's new minister for public health, in her message to the World Health Assembly on 7 May. This longer term, risk based approach may be less politically appealing but is likely to be more effective in health terms. Many other areas of European Community policy (such as agriculture and industry) can and do impact on health, and there is great potential for an integrated approach to health at community level. Since the Maastricht treaty, health protection must be integrated into other areas of community policy, but this has not happened effectively. The most substantial product has been an uncritical annual report by the commission's public health unit(3) instead of initiation and facilitation of policy changes and development. There is also an urgent need to define where the European Community can act in public health and which areas should remain the preserve of member states, as the present lack of clarity may lead to disputes over the community's role. A clear framework for setting priorities is needed: to define the criteria for community actions, where they can be performed more cost effectively for the community as a whole, where there is a need for the coordination of activities at European level, where other community policies have health implications, and where there are issues that cross national boundaries. Such areas include communicable disease surveillance, the free movement of people and goods including drugs and medical devices, the collection of comparative data, the standardisation of definitions, health technology assessment, environmental health policies, and exchanging information on best practice in health care. Another fundamental definition that needs clarification is that of "added value." This is supposed to guide community action, but there is little understanding of what it actually means in practice. Given the differences between member states in the development of their public health policies, health systems, and socioeconomic status, what constitutes added value is not necessarily the same for all member states. Action by the European Union must take into account these different needs and levels of development. Implementing a new framework for setting priorities must go hand in hand with reforms of European Community institutions and decision making to redress the relative weakness of those responsible for health, particularly in the commission. Currently, health related activities are scattered throughout the commission without any effective central focus for health. This was obvious in the BSE crisis, in which agriculture and not health officials took the lead both in the commission and the Council of Ministers. Health related policies are also discussed by ministers of transport and industry at European level, for example, but omitted from the agenda of meetings of health ministers. This is not altogether a bad practice as it enhances a multisectoral approach, but there is currently no effective mechanism to bring together all health related discussions. The commission's public health unit does not have the resources to lead this integrated approach to public health policy, and the newly created directorate general for consumer policy and consumer health protection will mainly focus on food safety. The intergovernmental conference provides an important starting point to overhaul the way the European Community deals with health. Government representatives at the conference must discuss in a comprehensive way the future of public health in the European Community rather than responding to short term political considerations arising from the BSE crisis. With its expertise in public health, Britain now has the opportunity to contribute meaningfully to the discussions on the future shape of public health in the European Community. This opportunity should not be missed. Paul Belcher European research officer Elias Mossialos Director LSE Health, London School of Economics and Political Science, London WC2A 2AE References 1 McKee M, Mossialos E, Belcher P. The influence of European law on national health policy. J Eur Social Policy 1996;6(4):268-9. 2 Commission of the European Communities. Commission communication on the framework for action in the field of public health. Brussels: EC, 1993. (COM (93) 559 final of 24 November 1993.) 3 Raynor M. European Union policy and health. BMJ 1995;311:1180-1. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline