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According to the IPCC, adaptation means that “in human systems, the process of adjustment to actual or expected climate and its effects, in order to moderate harm or exploit beneficial opportunities. In natural systems, the process of adjustment to actual climate and its effects; human intervention may facilitate adjustement to expected climate and its effects.” (2022)

For hospitals, HOPE mainly follows the adaptation to extreme weather events. Adaptation to other crises can be developed in the working areas on cross-border threats or cybersecurity.

In 2025, HOPE is gathering information from its members on the different local adaptations strategies.

On 19 and 20 February 2024, HOPE attended the conference on “Research Perspectives on the Health Impacts of Climate Change”.

Following the Agora in June 2023 which focused on “Climate and Environment for Hospitals and Healthcare Services”, HOPE office prepared a report on “Health in environment and climate adaptation policies” finalised in October 2023.

On 13 May 2020, HOPE attended an online discussion organised by the European Commission Scientific Advice Mechanism on “Adaptation to climate change-related health effects in Europe'”. Draft Recommendations released by the European Commission were discussed, questioning the impact of climate change on health, and to be mitigated through adaptation.

On 12 May 2020, the European Commission released a Roadmap, and on 14 May a Public Consultation, to elaborate a new strategy to help the EU adapt to the effects of climate change.

Mitigation 

According to the IPCC, mitigation (of climate change) means a “human intervention to reduce emissions or enhance the sinks of greenhouse gases”. (2022)

On 13 May 2024, HOPE office co-organised an online event entitled “Climate Resilience – the Role of the Healthcare Sector”.
On 19 and 20 February 2024, HOPE attended the conference on “Research Perspectives on the Health Impacts of Climate Change”.

Following the Agora in June 2023 which focused on “Climate and Environment for Hospitals and Healthcare Services”, HOPE office prepared a report on “Health in environment and climate adaptation policies” finalised in October 2023.

HOPE follows the Emission Trading Scheme (ETS) Directive – which entered into force on 6 June 2023 – as well as the Regulation on fluorinated greenhouse gases.

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In 2022; HOPE contributed to the consultation on the revision of the Waste Framework Directive.

Water 

The topic of water is an essential component for hospitals, both in terms of water consumption, pollution and flood risks.

HOPE is following the Water Resilience Strategy announced in the political guidelines for the European Commission 2024-2029. This Strategy should address water efficiency, scarcity, pollution and water-related risks.

On 21 July 2020, a Roadmap on the revision of the Directive on ‘Water pollution – EU rules on urban wasterwater treatment’ was launched. On 17 September, the European Parliament approved a resolution calling for new measures to tackle pharmaceutical pollution.
On 25 November 2020, an overview of the progress made in implementing the actions of the ‘Strategic Approach to Pharmaceuticals in the Environment’ showed that implementation of some actions is already quite advanced. For instance, this is the case with the adoption of the revised Surface Water Watch List and the development of new guidelines on hazardous household waste.

On 11 March 2019, the European Commission presented its ‘Strategic Approach to Pharmaceuticals in the Environment’ which identifies six action areas concerning all stages of the pharmaceutical life cycle, where improvements can be made, both for human and veterinary use.
On 12 December 2019, the European Commission released a fitness check of the ‘Water Framework Directive’, its associated Directives, and the Floods Directive which highlighted improvements and obstacles for a better implementation.

In November 2017, a Public Consultation was launched on pharmaceuticals in the environment to which HOPE responded in February 2018.

Energy 

Hospitals are high-energy environments, necessitating reliable sources of energy. As such, the energy topic is an essential one for HOPE to follow, both in terms of management, efficiency and access. Energy use goes from lights to high-operating machines such as MRIs or scanners.

HOPE followed both both the files on the Energy Performance of Buildings Directive and on the Energy Efficiency Directive.
The revised Energy Efficiency Directive entered into force on 10 October 2023, while the Energy Performance of Buildings Directive entered into force on 28 May 2024.

On 3 August 2020, the European Commission released a Roadmap on the EU ‘Energy Efficiency Directive’ to proceed to its evaluation and review. Finally, on 17 November 2020, a Public Consultation was launched to evaluate the Directive.

The 2012 EU ‘Energy Efficiency Directive’ 2012/27/EU (EED) established a set of binding measures to help the EU reach its 20% energy efficiency target by 2020. With the European Green Deal, climate ambitions have been raised upwards and the European Commission assessed how the EU’s greenhouse gas emissions could responsibly by reduced by at least 50% to 55% by 2030.

Food consumption and waste 

Hospitals are important food providers for hospital staff, patients, and visitors. As such, they are involved in reflexions on circular economy with local providers, with the importance of reducing food waste as well as food quality and safety.

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The WHO encourages HOPE to strengthen its collaboration with WHO/Europe technical units and country offices.

For HOPE the work with WHO Europe mainly started after 1989 with conferences “East meets West” and a programme of twinning’s of hospitals Western Europe/ Central and Eastern Europe. HOPE was involved from the start in the Health Promoting Hospitals network initiative and is part of the scientific Committee for the annual conference.

HOPE has been involved in various WHO initiatives: for example, the practical tool for hospital services master planning with a special focus on integrated care; the work on the WHO Global Code of Practice on the International Recruitment of Health Personnel, the consultation by the European Framework for Action on Integrated Health Services Delivery and more recently in the Primary Health Care Advisory Group.

The first collaboration HOPE envisages with the Regional Office for Europe in 2020–2022 would be on health workforce. This would involve working on the extension of the Framework for Action Towards a Sustainable Health Workforce in the WHO European Region and in addition working on the mobility of healthcare professionals, on the basis of the WHO Global Code of Practice on the International Recruitment of Health Personnel. The second area for collaboration would be on integrated care and more generally the coordination between the different health and social care actors around patients and their families. The entry point of this collaboration would be the content of the resolution on 10 evidence-based policy accelerators for strengthening primary health care in the region. Additionally, HOPE will continue its ongoing engagement and contribution to i) the consultation of the European Framework for Action on Integrated Health Services Delivery and ii) the Primary Health Care Advisory Group.

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HOPE has been involved in the activities of the Partnership for Assessment of Clinical Excellence in European Reference Network (PACE-ERN), awarded to a consortium led by the European Organisation for Rare Diseases (EURORDIS).  PACE-ERN developed a manual and toolbox for assessing ERNs addressing all the stages of the process from the call for Networks and providers to the approval of the Networks. A first draft of such documents was presented at the second conference of ERNs which took place in Lisbon (Portugal) on 8 and 9 October 2015 and completed before the launch of the call in March 2016.

Additionally, HOPE regularly follows developments of the ERNs and reports about them to its members and its network.

In September 2018, the Expert Panel on Effective Ways of Investing in Health adopted a draft opinion to which HOPE contributed on the “Application of the ERN model in European cross border healthcare cooperation outside the rare diseases area”. The Opinions of the Expert Panel on Health support the Commission to identify specific aspects to be considered as well as tangible results that should be achieved to make a real change on health systems reforms and investments at EU level. The Expert Panel concluded that, while ERNs have considerable potential to improve the care of patients with rare dis-eases across the EU, both through advice on the management of individual patients, as well as through collaboration on research and development of guidelines, it is not yet possible to ascertain the extent to which these goals will be achieved. The Expert Panel also identified several issues to address, including long-term financial sustainability and the implementation of effective IT systems.

On 25 February 2019, possible areas of cooperation between the European Reference Networks and other stakeholders, such as registries or clinical trials, have been explored during the first meeting between members of the ERNs Working group on Legal & ethical issues and relations with Stakeholders (LES) and representatives of the industry and of patients’ organisations.

On Friday 26 July 2019, the Commission adopted the Implementing Decision (EU) 2019/1269 amending Decision 2014/287/EU and launched the call for new members. It aims to:

• clarify the role of the Board of Member States in steering the ERNs,
• modify the procedure concerning the application for membership of existing European Reference Networks (ERN); and
• add provisions concerning the establishment of the Clinical Patient Management System (CPMS) and clarifies the applicable data protection rules, in compliance with the General Data Protection Regulation (GDPR).

On 24 and 25 June 2019, two statements on ERNs integration into the national health systems and cooperation with industry were adopted by the ERN Board of Member States. The ERN Board of Member States adopted updated guidance principles to frame collaboration between the ERNs and the industry, through a revision of its 2016 statement on the matter. It also adopted a new statement concerning recommendations and good practices to foster integration of the ERNs in national healthcare systems.

On 1st October 2019, the European Commission has launched the first call for new healthcare providers (HCPs) to join the existing 24 European Reference Networks (ERNs) as full members. 841 new clinical units in hospitals across Europe requested to become members of the European Reference Networks. The examination process is still ongoing.

On 17 April 2020, the Commission announced that the examination of membership applications for existing ERNs was suspended from 1 April 2020 to 31 August 2020 due to the COVID-19 outbreak.

On 14 October 2020, the Commission, in its aim to support the EU healthcare systems and clinicians at the front line dealing with the COVID-19 pandemic, announced it was funding a programme of training of healthcare professionals in intensive care skills. For this aim, a contract has been signed in August with the European Society of Intensive Care Medicine (ESICM) to develop a training programme in Intensive Care Fundamentals for Healthcare Professionals not regularly working in Intensive Care Units. The training is free of charge and is available for every doctor and nurse working in a hospital with an Intensive Care Unit, in all 27 EU Member States and the United Kingdom.

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During this cycle, the European Commission assessed the national situation of each member states (the ‘Country Reports’ in February), member states express their desires for reforms (the ‘National Reform Programmes’ in April) and the Commission and Council adopt recommendations (‘Country-Specific Recommendations’ in May/June) for each member state on where to reform social and economic policies. 

It has significantly changed under the Juncker Presidency of the European Commission. The European Semester has indeed gained importance over the years as an instrument to influence national reform programmes in the European Member States.

The adoption of proposals for country specific recommendations is a key step in the European Semester. Although Member States are responsible for their own health policy and the organisation and delivery of care, the EU can give a recommendation on certain aspects of its health system to an EU country. The rationale is that EU governments spend an average of 15% of their health budgets, making it one of the largest and fastest growing areas of expenditure. However, health is also an investment. The health sector is a major source of employment, and timely access to high quality healthcare contributes to social inclusion.

HOPE closely monitors the European Semester, regularly report on it to HOPE members and organises the discussion between on its content and accuracy.

Last Country Reports

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The EHDS – first announced by Commission President von der Leyen in her 2020 State of the Union address, followed by a Roadmap – is the upshot of a multiyear effort to develop interoperable health data exchanges. This process took concrete shape in April 2018 with a Commission Communication on enabling the digital transformation of health and care in the Digital Single Market (see HOPE Position Paper). The same year, the eHealth Digital Service Infrastructure (eHDSI, implemented through the Connecting Europe Facility) became operational and enabled the transfer of ePrescription/eDispensation data and patient summaries.

Key features of the EHDS include the following:

• It gives patients the right to easily and immediately access their health data in electronic form, free of charge, making it possible to add information, rectify wrong data, restrict access to others and obtain information on how and for which purposes data are used.
• Health data supporting primary use (i.e., healthcare provision) in priority categories – patient summaries, ePrescriptions, images and image reports, lab results, discharge reports – will be issued and accepted in a common European Electronic Health Record Exchange Format (EEHRxF).
• Interoperability and security will become mandatory requirements. Manufacturers of electronic health record systems will need to certify compliance with these standards.
• Member States will appoint digital health authorities. They will participate in the cross-border digital infrastructure (MyHealth@EU) supporting patients to share their data.
• Secondary use (research, innovation, public health) will be enabled by giving researchers, public institutions, or industry access to large volumes of health data, based on strict conditions and subject to a permit from a Health Data Access Body (HDAB), connected to a new EU-infrastructure for secondary use (HealthData@EU).

Following preliminary discussions, HOPE released its feedback on the EHDS proposal in July 2022, inter alia pointing out the high set-up costs involved, impacting an already stretched sector, the need to accommodate different national data approaches, and to ensure opportunities for co-creation. The European Data Protection Board (EDPB) and European Data Protection Supervisor (EDPS) published a Joint Opinion at the request of the Commission.

In the European Parliament, co-rapporteurs MEP Tomislav Sokol (EPP, Croatia) and MEP Annalisa Tardino (ID, Italy) from the ENVI (Environment, Public Health and Food Safety) and LIBE (Civil Liberties, Justice and Home Affairs) Committees released their draft report on the EHDS proposal, addressing concerns shared by HOPE regarding the need to increase EU funding and protect vulnerable populations. It introduced clearer language and tidied up certain provisions. Mr Sokol strengthened patients’ rights by introducing an opt-out mechanism for secondary use. Based on the report and discussions with members, partners, and policymakers, HOPE released its EHDS Position Paper in January 2023.

HOPE proposed two sets of amendments to the ENVI-LIBE report, including a request for maintaining Member States’ own health data systems for well-established national/regional purposes and calling attention to disruptive effects and administrative/financial implications. HOPE also signed two Joint Statements, supporting crucial improvements for the benefit of healthcare providers, and calling for a society-centred digitalisation of healthcare, highlighting common concerns including strengthened provisions for IP rights and trade secrets; provisions on public return on data investment and ensuring affordability of medicines; inclusion of civil society in EHDS governance; and extending the timelines to properly develop and implement it.

While the Commission defended its original proposal, MEPs were split along political lines and personal beliefs about data protection and privacy. Member States expressed concern over the high costs and expertise required. Parliament adopted its EHDS position in December 2023; in turn, the EU Council agreed on its EHDS negotiating position. It developed the regulation in several areas, including its scope, GDPR alignment, and criteria for providing access to electronic health data, setting up Steering Groups to manage the MyHealth@EU and HealthData@EU infrastructures, and expanding the Member States’ governance role.

The 2024 Belgian Presidency adopted a “finishing line” approach, paving the way for an inter-institutional agreement. In April, MEPs approved the text with 445 votes in favour and 142 against (39 abstentions). Due to an extensive legal-linguistic review, a corrigendum procedure was launched and negotiations only concluded with re-votes in December 2024/January 2025.

The final EHDS text grants the Member States more powers in line with national laws and rules. It notably includes the possibility to introduce a reversible opt-out mechanism also for primary use and strengthens the power of market surveillance authorities, which may enforce corrective actions on manufacturers of EHR systems in case of non-compliance. The implementation timelines were extended, leaving four to six years for more complex provisions.

The preparatory Joint Action towards the European Health Data Space (TEHDAS, 2021-2023) supported the Member States and Commission, proposing options on governance, infrastructure, data quality and data solidarity, and secondary use. HOPE provided inputs through its participation in stakeholder workshops. TEHDAS2 (2024-2027) builds on its predecessor and organises public consultations touching on various technical aspects via draft guidelines, which HOPE is monitoring.

Meanwhile, the Joint Action Extended EHR@EU Data Space for Primary Use (Xt-EHR) is tasked with ensuring that Electronic Health Record (EHR) systems meet stakeholders’ expectations by laying the technical, governance, and legal foundations for seamless cross-border electronic health data exchange, based on the EEHRxF. Many Implementing Acts remain to be defined through guidelines and technical specifications, and Xt-EHR will also address the integration of telemedicine, mHealth, and wellness applications.

The Commission’s Recommendation on a European Electronic Health Record Exchange Format (EEHRxF) inspired the XpanDH project (2023-24) in which HOPE was a partner. The goal was to support widespread adoption of ‘the format’ by creating a pan-European ecosystem of early adopters to ensure it is safe and reliable. Xt-EHR and the x-Share project are taking this further to ensure easy interoperability using the EEHRxF.

EU investments to support the EHDS include funding under EU4Health, Horizon Europe, and Digital Europe. Member States also benefit from the Recovery and Resilience Facility, European Regional Development Fund, European Social Fund+, and InvestEU.

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One of the most recent and relevant elements is the European Action Plan on the cybersecurity of hospitals and healthcare providers, released in January 2025. The Action Plan revolves around four pillars containing actions to prevent, detect, respond, and recover from incidents, and deter threat actors from engaging in cybercrime.  In its stakeholder response, HOPE welcomed its comprehensive, collaborative scope, but stressed the urgent need to ensure adequate funding concomitant with the size of the threat. HOPE also called for avoiding the duplication of already existing networks performing specific tasks, as well as overlapping reporting obligations.

An opinion adopted by the European Committee of the Regions in July 2025 underlines the urgent need for comprehensive measures to counter cyber-threats and argues for enhanced practices and procedures to protect IT systems and increased training across the healthcare sector.  Cyber-attacks risk delaying treatment, disrupting emergency services, and eroding patients’ trust.

The 2016 NIS Directive concerning measures for a high common level of security of network and information systems across the Union was the first EU legislation designed to boost the overall level of cybersecurity. It designated ENISA – the European Union Agency for Cybersecurity, operational since 2005 – as the secretariat of the national Computer Security Incident Response Teams (CSIRTs) network for the exchange of information on cyber threats and incident response. It also created the European cyber crisis liaison organisation network (EU-CyCLONe) for the coordinated management of large-scale incidents or crises. The NIS Cooperation Group was set up to facilitate strategic cooperation and information exchange among Member States, the European Commission, and ENISA, and to issue non-binding guidelines and recommendations to support the Directive’s implementation.

The 2019 Cybersecurity Act gave ENISA a permanent mandate, more resources, and new tasks. These included setting up and informing the public about the European cybersecurity certification framework for ICT products, services and processes, as well as increasing EU operational cooperation, including handling Member States’ cybersecurity incidents upon request. A targeted amendment adopted in January 2025 enables European certification schemes for ‘managed security services’ covering incident response, penetration testing, security audits and consultancy. In April 2025, the Commission launched a public consultation to evaluate and revise the Cybersecurity Act (see HOPE inputs).

Likewise, the NIS Directive was revised to meet evolving needs. The NIS2 Directive came into force in January 2023, containing a wider scope, clearer rules, and stronger supervision tools. It requires Member States to enhance their cybersecurity capabilities, introduces risk management measures and reporting requirements to entities from additional sectors, and stipulates rules for cooperation, information sharing, supervision, and enforcement of measures. Member States must adopt national strategies including policies for supply chain security, vulnerability management, and cybersecurity education and awareness, ensuring adherence of operators of essential services. Senior managers are held accountable for non-compliance with risk management measures. However, most Member States failed to transpose it into national law by October 2024, citing technical and other reasons.

Similarly, the Directive on the resilience of critical entities (CER), which expands the scope of the original CER Directive to 11 sectors and aims to strengthen resilience against various threats (natural hazards, terrorism, insider threats, sabotage, etc.) also experienced transposition delays, further exposing limited capacities at the national level.

Complementing NIS2 and the EU’s broader Cybersecurity Strategy (2020), the Cyber Resilience Act (CRA) enhances cybersecurity standards of products that contain a digital component, requiring manufacturers and retailers to ensure cybersecurity throughout the lifecycle. It protects individuals and entities by making it easier to identify hardware and software products with the proper cybersecurity features. The regulation applies to all products connected directly or indirectly to another device or network except for those already covered by existing rules (e.g., medical devices). Products must be CE marked to indicate compliance with the requirements. The CRA entered into force in December 2024, and its main obligations apply from December 2027 (see HOPE Position).

The Cyber Solidarity Act entered into force in February 2025, designed to strengthen capacities to detect, prepare for and respond to significant and large-scale cybersecurity threats and attacks. The Act introduces a European Cybersecurity Shield, a key element of which is a European Cybersecurity Alert System to improve the detection, analysis and response to cyber threats. This entails national and cross-border Security Operations Centres using AI and data analytics to detect and share warnings across borders. Another feature is the Cybersecurity Emergency Mechanism supporting preparedness by testing healthcare entities for potential weaknesses, creating an EU Cybersecurity Reserve made up of private providers’ incident response services deployed at the request of Member States or the Union, and fostering mutual assistance among Member States. It also establishes a Cybersecurity Incident Review Mechanism to assess and review specific incidents upon request.

Feeding into the Commission’s legislative and non-legislative work, Council conclusions on the future of cybersecurity were adopted in May 2024, inviting the Commission and Member States to step up implementation, clarify roles and responsibilities, and ensure multistakeholder cooperation. They followed previous Council conclusions including on developing the EU’s cyber posture (May 2022), the EU’s cybersecurity strategy and joint cyber unit (2021), and cybersecurity of connected devices (2020).

In relation to the implementation of the Medical Devices Regulations, HOPE joined the task force on cybersecurity created in 2018 and was invited to outline the structure of future EU guidance.

In light of an increasingly complex geopolitical environment and recognition of the defence-cybersecurity nexus, EU cybersecurity funding has been progressively increased. In June 2025 the Commission launched two new calls for proposals, the first under the Digital Europe Programme, with a budget of €55 million (€30 million of which will support the Cybersecurity Action Plan for Hospitals), the second under Horizon Europe with €90.5 million for developing generative AI for cybersecurity, new tools and processes, privacy-enhancing technologies and post-quantum cryptography.

In its 2023-2030 regional digital health action plan, WHO/Europe also stresses the importance of developing awareness and practical guidance in cybersecurity risk management and privacy-enhancing technologies. A 2025 guide, Cybersecurity and privacy maturity assessment and strengthening for digital health information systems, provides a framework for countries and organisations to develop risk assessment strategies that align with their specific needs, goals, and regulatory requirements.

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The measures presented by the Commission aim to update current rules, extending their scope to all electronic communication providers. They also aim to create new possibilities to process communication data and reinforce trust and security in the Digital Single Market. At the same time, the proposal aligns the rules for electronic communications with the new world-class standards of the EU’s General Data Protection Regulation.

HOPE released a Position Paper on ePrivacy and identified several issues related to healthcare:

• Public networks will need to comply with the new legislation;
• Healthcare providers contacting their patients by text / email using a public network will have to comply;

The main concerns are related to few provisions of the proposal that, according to HOPE, should include some restriction, for health purposes, public health and social security reasons. For example to make sure that emergency services have enough breathing space to be able to do what they need to do to respond to a person in a medical emergency or data. Also, access to some metadata (ie location data) might be needed from public electronic communications in order to see peak times and locations of A&E services for example.

In the European Parliament, the draft regulation was assigned to the Civil Liberties Committee (LIBE). The European Parliament adopted a report in October 2017 aimed at strengthening the confidentiality of communications including in machine-to-machine communications. It was presented by the initial rapporteur MEP Marju Lauristin (Estonia, S&D). The current rapporteur is Birgit Sippel (Germany, S&D).

In the Council, the discussions were blocked until July 2020, where the German Presidency published its first discussion paper. But national delegations rejected a revised version of the paper and on 23 November 2020 the German Presidency presented its progress report.

On 5 January 2021, the Portuguese Presidency presented a new draft version of the regulation. On 10 February 2021, the Council’s Permanent Representatives Committee (Coreper) agreed on a mandate for negotiations with the European Parliament.

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