International Journal of Integrated Care, 1 March 2002 - ISSN 1568-4156
Looking back from 2015

It is the year 2015, and it is now 15 years since this journal was launched. In the last 15 years, there have been many changes that impact on integrated care.

The main killer diseases of the past centuries, such as smallpox, cholera and measles are no longer the threat they were. The development and widespread use of vaccines and medicines have contributed to this success, as have improved hygiene, environmental and social conditions. Nevertheless, it would be wrong to conclude from these achievements that no serious health problems remain.

People in the Western world are now living longer and leading healthier lifestyles than ever before. And, because of falling birth rates and lengthening life expectancy, populations are ageing. A range of indicators ranging from life expectancy, infant mortality and maternal mortality confirm this trend. In Western Europe it is estimated that in another 5 years, i.e. by 2020, there will be 40% more people aged 75 and above than in 1990.

A consequence of the lengthening life expectancy is the increase in the number of persons suffering from diseases and conditions related to old age, such as Alzheimer's. With more people living into their 80's and 90's, there will be increased pressure on social and health care and treatment services.

Over the next few years, because of demographic changes alone, Governments will be placed under increasing pressure to raise their health care expenditure. This could force rises in the health budget of 1–3% of Gross Domestic Product. The decline in family size and the increasing number of small and single parent households is likely to reduce the contribution traditionally made by family members to the care of the elderly. The question of how to pay for the increasing costs is made more difficult because the total dependency ratio (the ratio of dependants to workers) is likely to continue to rise from its current levels.

Health care systems are subject to conflicting pressures. Rising costs due to demographic factors, new technologies and increased public expectations are pulling in one direction. System reforms, greater efficiencies and increased competition are pulling in another. Governments have to manage these conflicting pressures without losing sight of the importance of health to people's wellbeing and the economic importance of the health systems.

But health care spending is continuing to increase and in some countries, it has already reached 10% of Gross Domestic Product (GDP). In response, Governments have been undertaking a wide range of structural reforms and cost containment measures to improve the efficiency and effectiveness of their health systems.

There is an ever-present concern that overall standards must be improved, while at the same time ensuring that health costs are controlled so as to obtain the best value for money. The various initiatives in the field of care and the growth of evidence-based medicine, quality assurance and health technology assessment are all responses to these developments.

Health is one of the fastest growing sectors of the economy and is linked to full employment, as unemployment reduces the total funds available for health care and treatment. This is because in many countries a significant proportion of the finances for health and social protection systems is linked to income-related contributions. In parallel the globalisation of trade and industry and the pressures of competition have affected health systems, like other areas of the economy.

In response to this situation, a number of international bodies, notably the World Health Organisation, the World Bank, the United Nations Population Fund (UNFPA), the Council of Europe and the Organisation for Economic Co-operation and Development (OECD) have been and will continue to be active within their respective remits. The doubling in size of the European Union (EU) has been a significant development in the last few years. Initially the health situation in the countries of Central and Eastern Europe compared poorly with the other countries of the EU. In general, there was lower life expectancy and poorer health status in these countries. And they had fewer resources to spend on health to improve their situation. However, with support from the European Community they have been able to improve their situation substantially. This included, inter alia, the action programmes of the European Community in the field of public health. These programmes helped to improve the health status of the population and contributed to a reduction in premature deaths in the EU. They were aimed at tackling the underlying causes of ill health, through effective health promotion and disease prevention measures. These measures were directed at improving health information and knowledge, responding rapidly to health threats, and addressing health determinants. Of particular interest has been the setting up of a comprehensive health information system to provide policy makers, health professionals and the public with key health data and the information they need. This was in line with the Feira European Council in June 2000 which endorsed the ‘e-Europe 2002 Action Plan on An Information Society For All’ which under Health Online urged Member States to develop an infrastructure of user-friendly, validated and interoperable systems for health education, disease prevention and medical care. This high quality, peer reviewed scientific journal, that is published only on the Internet, is also in line with this endorsement.

It is quite clear that there will continue to be pressures on the financing of health care systems and that all those involved will seek to control any increases to a minimum. The ways and means of achieving such controls will need to be carefully evaluated to ensure that they do not reduce the levels of prevention, care or treatment. Integrated care is not the only means of doing this, but it certainly has a role to play as it is one of the most efficient currently available.

The articles published in this edition of IJIC are an illustration of the importance and global interest in integrated care. We can expect that, in 15 years time these articles will remain as topical as they are today.

William Hunter