Dutch government encourages the use of E-mental health

Ladies and gentlemen,
Minister Klink was delighted to have been invited to open this ‘First International E-mental Health Summit 2009’, which brings together so many internationally renowned experts in the field of e health services. Unfortunately, Minister Klink is unable to address you today, as his presence is required at an urgent debate in the Dutch parliament.
I would like to begin by congratulating those responsible for organizing this event, at which new alliances can be forged and new knowledge shared. I hope that the mental health sector as a whole will benefit from the impetus that this conference will provide.

To host such an important conference is a great honour for the Netherlands. I do not wish to brag, but I think I can claim that our country is a world leader in ‘e health’ services. Our first online mental health programme was launched already some ten years ago.

And this month, the World Health Organisation (WHO) in Geneva commissioned the Trimbos Institute - which is the Netherlands' Institute of Mental Health and Addiction - to launch a collaborative project. The project's aims are to
• develop,
• disseminate, and
• evaluate,
an E-Health Portal to curb hazardous and harmful drinking. Here it should be mentioned that excessive consumption of alcohol is one of the leading causes of disability and premature death, globally. It is expected that E-Health interventions to curb alcohol use can be effective, cost-effective and very scalable. The project will be conducted by the Trimbos Institute with several WHO Collaborating Centres across the globe. The start of the project is co-funded by the Ministry of Health, Welfare and Sport.

Although the Netherlands is already very active in e health services, we shall not rest on our laurels. In addition to introducing further applications in e mental health, we wish to play also a very prominent part in new developments which address all somatic conditions.
Our national Healthcare Innovation Platform will no doubt make a significant contribution in this respect. It will promote further cooperation between market parties, will fast-track the introduction of innovations, and will help to overcome any obstacles. The platform exists to establish a fully sustainable healthcare system in the Netherlands, with due regard for quality, accessibility and affordability, both today and in the long term.
In pursuing these aims, the current focus is on patients with chronic diseases and the elderly. Innovations must address certain key requirements:
1. A greater focus on people, whereby the position of both patients and professionals is enhanced.
2. Better use of the possibilities of ICT and other technology.
3. ‘Smarter’ organization and more entrepreneurship in healthcare.

Dutch healthcare insurers and other commercial partners recognize the potential of e health applications.

Indeed, Menzis, Achmea, TNO, Philips, KPN and Rabobank recently approached the Minister of Health, Welfare and Sport and his colleague, State Secretary Mariëtte Bussemaker, asking them to expand the scope of e health programmes, remove the current obstacles and ensure that solutions become available to all.

On 1 October, we therefore launched the ‘open e health platform’. Its website can be found at www.eHealthNu.nl.
Working alongside the partners responsible for the various individual projects, we wish to force a real breakthrough in e health services. The Dutch government encourages developments like this because we recognize their importance and necessity. It is no coincidence that Minister Klink and State Secretary Bussemaker are chair and vice chair of the Healthcare Innovation Platform, respectively.
The combined efforts of the healthcare sector, private parties and government are already bearing fruit. Just two weeks ago, the Euro Health Consumer Index awarded the Netherlands an excellent score for the implementation of e health applications, using that term in its broadest sense.

Given the nature of today’s event, it will be appropriate for me to confine my remarks to mental health issues. After all, that is what you are here to discuss.
Each year, some 740,000 people in the Netherlands suffer from depression. Approximately 1.7 million, nearly ten per cent of the total population, suffer from some form of anxiety disorder. Almost one in ten of the working population has alcohol-related problems.
Although these are clearly and firstly serious problems at the individual level, in many cases the consequences extend beyond the individual to affect the entire family or social circle. Moreover, the costs to society are very significant.

But treatment of depression alone – whether clinical or subclinical – costs the public approximately two-and-a-half billion euros every year. That is the direct financial cost. The social cost is even greater, since people with depression are unlikely to perform to the best of their ability while at work, or may not be able to attend work at all.
There is therefore every reason to take the problems of depression, anxiety disorders, alcohol abuse and other psychological conditions extremely seriously, and to take appropriate action. One significant way in which we can do so is by means of e health applications.

Depression offers a good example. There are great gains to be made if an online programme can prevent someone with mild depression going on to develop a more serious form of this unfortunate illness.
That person will have received the help he needs in time, rather than being unable to function well for several months and eventually becoming unable to work at all.

We must remember that the numbers involved are by no means trivial. In the Netherlands, from the total of 740,000 who suffer, some 590,000 people are aged between 18 and 65, with 240,000 new cases reported each year. Imagine the difference we can make if an online mental health programme can reduce this number, for all the individuals and society as a whole.

Such programmes have long since proven themselves to be very effective, even for those who are not currently experiencing any health problems. Just as you might go to the gym to keep your body in tip-top condition, so you can rely on mental fitness programmes to keep your mind in shape. People in good mental health enjoy a better quality of life than those who lack the resilience to ward off impending problems.

There are also online mental health programmes which address the relatively ‘minor’ problems.
You may not be depressed as such, but are experiencing problems sleeping or tend to worry too much. These programmes help you to restore the balance.

E-mental health applications have great preventive value. They reduce the demand on healthcare services and hence cut costs. But there are other aspects which make e-mental health very interesting. I shall cite just three, all of which are closely interrelated: accessibility, content and anonymity.

When help is available online, people suffering from depression can actually do something about it themselves, rather than relying on someone else such as a healthcare professional. One highly effective form of care is the self-help group. This is a specific type of assistance which does not rely on professional intervention. Rather, it unites people who find themselves ‘in the same boat’ whereupon they can tackle their issues together. Each member of the group can decide when and where he makes contact with others, and can decide for himself whether to seek further therapy.
Today, over ninety per cent of the Dutch population has Internet access. The potential outreach of an e mental health programme is therefore huge. Well designed, ‘low threshold’ programmes will encourage people to seek assistance at an early stage.
This is precisely why the Ministry of Health, Welfare and Sport is pleased to support the ‘Mentaal Vitaal’ programme run by the Trimbos Institute. It includes various specific campaigns and services which will help over forty thousand people in the three-year period to 2010.
The programme devotes extra attention to young people, members of ethnic minorities, and those with a low socioeconomic status.

Ladies and gentlemen,
Many people do not wish it to be known that they suffer psychological problems, or that they are addicted to alcohol or drugs. This can be a source of great shame and embarrassment, also among the more highly educated who perhaps feel that they ‘ought to know better’. For these people, walking into one of the mainstream facilities to seek help may be a ‘bridge too far’. A stigma attaches to the walk-in mental healthcare organizations, even more so in the case of addiction centres. For this particular group, anonymous online prevention or treatment programmes are of immense value.

Most of the online programmes are entirely anonymous, but this does not mean that they are also impersonal. In many cases, the user and the care provider develop a relationship of trust. There is direct contact without the distractions of non-verbal communication. Some users actually find it very reassuring to avoid personal face to face contact with a professional, yet the networking which many sites encourage is an excellent form of social interaction.

Receiving the information they need and having contact with others encourages users to adapt their behaviour. This is amply demonstrated by the fact that people within the networks often search out, collate and publish information about the other care services available. Often, they do so based on their own experiences. They gather not only medical information about a particular condition, but also tips on how to maintain control of one’s life or how to promote social contact between people afflicted with the same condition. This can greatly increase the user’s sense of personal responsibility for his own health and wellbeing. It is a question of ‘self management’.
That is very useful not only for those patients already receiving care, but also in terms of prevention. With prompt help at an early stage, some people will never require professional assistance at all.

The patient - or potential patient - has therefore been empowered. He is at the very hub of his own care process. ‘Information therapy’, whereby the right information is made available when and where it is needed, enables him to make informed decisions.
Those decisions are more likely to be the right ones. The overall result will be reduced costs. The relationship between care provider and patient is changing. It is now far more a partnership of equals.

Ladies and gentlemen,
As I mentioned a few moments ago, many online mental health programmes are entirely anonymous in use. Unfortunately, this raises another problem, that of financing. Let me explain. When someone goes to his GP with a psychological problem, he will of course receive the treatment he needs.
He will be referred to an independent psychiatrist, psychologist or the local mental health service, and the costs involved will be covered by his health insurance. But who is to pay the bill in the case of anonymous treatment that is provided online? The insurance companies are perfectly willing to pay for programmes which have been proven to be effective, but only in respect of their own policy holders.
That is now the dilemma, the bone of contention. The strength and success of e-mental health programmes is that they are often anonymous. This is what gives them such a high outreach.

To date, many of the programmes have been entirely free of charge. Some are still ‘in development’ or receive government subsidies during their start-up phase. However, there are also programmes which offer paid assistance without compromising the user’s anonymity. The internet alcohol reduction programme ‘Alcohol de baas’ is a good example. A company can opt to pay for a set number of employees to take part – say, twenty people – and inform its staff of the possibility to participate.

Workers who may wish to enter the programme, but who do not want their colleagues or employer to know about their alcohol problem, are then able to obtain a log-in code anonymously.
I think that it would be worthwhile to explore other, more permanent, solutions. The Ministry of Health has recently brought up that issue with the
national Health Care Insurance Board.
There are, after all, some analogies in the world of clinical medicine: treatment for STDs or HIV/AIDS is made available anonymously in order to encourage people to come forward.

Ladies and gentlemen,
Clearly, we must find a solution to the problem of financing the anonymous use of e health programmes. However, there remain two further obstacles. Given the increasing demand for care services due to population ageing, and the fact that medical technology is offering more possibilities by the day, we have to keep costs under control.
If at all possible, we must avoid merely passing the costs on to the patient by means of higher insurance excesses or any significant reduction in the cover provided by the standard health insurance policy.
It would be equally inappropriate to cut hospital budgets or reduce the salaries of healthcare professionals. The Minister considers it his duty to concentrate on improving quality before asking the consumer to dig yet further into his pocket.

I firmly believe that e health, the use of the Internet and other ICT applications in the healthcare sector will do much to ensure that healthcare costs remain manageable. In fact, I would go so far as to state that it is now impossible to achieve modern healthcare which is accessible, of the highest possible standard and affordable without the use of ICT and web-based applications.
I am therefore looking forward to hearing the results of the most recent evidence-based studies and trial projects in e-mental health. At this conference, we will join forces in seeking solutions to challenges such as extending the outreach of cost-effective web based prevention and treatment programmes.

I wish you all an inspiring and fruitful conference. Thank you for your attention.