Unique features including a microwave integrated into lower cabinet Read today's Portuguese stories delivered to your email After the success of the international triples tournament at Alvor Bowls Club 1st October saw the start of the domestic season with the annual Ladies v Gents triples competition We had a good turn-out of both players and supporters and this year the gents turned the tables on the ladies with a dominant win to reclaim the trophy It was good to see everyone coming together and enjoying the competition and then socialising over lunch and drinks afterwards The Club is currently hosting a number of touring clubs from the UK before the Bowls Algarve Winter League starts later in October Alvor Bowls Club welcomes visitors and new members playing both flat green and crown green bowls, and full details can be found on our website (www.alvorbowlsclub.com). Tuition and equipment can be provided for new bowlers. 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PortugalChevron AlgarveChevron Set the sceneFrom a distance, one could be forgiven for mistaking the Longevity Health & Wellness Hotel in the Algarve for a hospital Perched on a secluded hilltop overlooking the coastal town of Alvor white exterior bears the hallmarks of a top medical institution Longevity Alvor has raised the wellness tourism game to new and robust heights partnering with a hospital group to produce a spa that brings full meaning to ‘holistic’ Its state-of-the-art diagnostic facilities draw mid-lifers wanting in-depth health MOTs for early-stage niggles or for intense detox there’s the lure of complimentary spa facilities and fitness and beauty treatments under glorious Mediterranean sunshine that leaves one feeling cleansed and re-energised What's the backstory?Owners Longevity Wellness Worldwide have partnered with the HPA hospital group to create a 5-star medical spa – a first in Portugal – that vies with Spain’s SHA for supremacy in the Iberian peninsula It is the third and newest of Longevity Group’s three health retreats in the region: while their Vilalara Thalassa Resort and Vilamoura sites focus on medical and wellness respectively Longevity Alvor does both on a dialled-up level What’s the wellness concept?As its name suggests anti-ageing though prevention and diagnosis are the aims here at Longevity environmental and lifestyle factors may affect long-term health it combines a variety of treatments to combat stress Its hospital connection means there’s state-of-the-art equipment to offer a plethora of diagnostic tests including genetic screening to measure telomere length of chromosomes (to gauge cellular aging which is linked to cardiovascular diseases and cancer) Guests may be whisked away for an electrocardiogram (ECG) immediately on arrival before even being shown to their rooms There are also osteopathic examinations to assess vertebrae function to deal with the neck and back problems Solutions for any imbalances run the gamut from osteopathic massages to intravenous therapies for detoxing and re-energising; to teeth whitening All this is combined with holistic lifestyle advice which guests can apply in their everyday lives to prevent the onset of diseases What are the signature treatments?Longevity is the only spa in Portugal that’s licensed to give intravenous treatments including ozone and oxygen injections for immunity boosts and glutathione infusions to hike up energy levels These and other personalised detox strategies are designed to combat a range of autoimmune conditions the Venus Legacy machine tackles cellulite and there are cryotherapy sessions to burn fat and manual lymphatic drainage to remove excess fluid and toxins from the legs Which therapist should I book?Internationally renowned osteopath who counts the Kuwaiti royal family among his international clients uses surface electromyography (sEMG) to measure the relative electrical activity generated when muscles contract Red bar graphs on a computer image of the torso show areas of excess muscle activity on the back and neck Rosa then manipulates those regions with dramatic improvements/effects – and stays that way Rosa’s magic touch is accompanied by advice about root causes such as lifestyle and psychological considerations Longevity’s Clinical Director Dr Joana Santos specialises in aesthetics Her know-how ranges from face sculpting to providing chemical peels and telomere-length evaluations and treating mineral deficiencies based on the results of blood analysis What makes it different?Alongside the unique intravenous treatments a biophysical evaluation scans the palm of the hand to identify health markers such as visceral fat levels of antioxidant protection or heavy minerals in the blood High-tech gadgets include a thermography machine for genetic screening an infrared Iyashi Dome sauna that rids the body of toxic heavy metals and helps shed weight What else do they offer? The food at the rooftop Pure Café is organic Mediterranean fare that aims to combat autoimmunity by being low glycaemic and gluten-free (and washed down with local Most dishes are vegetarian but the chefs also cater to committed carnivores; vegan dishes can be ordered off-menu too The menu allows some gluten-free naughtiness like chocolate brownies and panna cotta opens in high-season and offers a segregated space for guests on shake diets who might be tormented by the lure of solids A conscientious diet can be complemented by sessions with a fitness instructor who creates a personalised plan that includes guided walks in the vicinity For those wanting to dip back into the real world Alvor fishing village with its seafood restaurants and beach The largely whitish interiors channel the reassuring clinicality of a medical spa but are softened by taupe and blue accents The effect is a neutrality that tranquillises the senses makes for a notably calm atmosphere in all spaces be it the sun-drenched garden by the basement spa area whose floor-to-ceiling windows flood its interior with glorious sunlight and views of the hills Adjacent to the dining area a rooftop infinity pool merges into the twinkling waters of Alvor Bay Anything else to mention?There’s a holistic therapist who doubles as a physio and Traditional Chinese Medicine (TCM) practitioner, with qualifications in acupuncture. All listings featured on Condé Nast Traveler are independently selected by our editors. If you book something through our links, we may earn an affiliate commission. up-to-the-minute voice in all things travel Condé Nast Traveler is the global citizen’s bible and muse We understand that time is the greatest luxury which is why Condé Nast Traveler mines its network of experts and influencers so that you never waste a meal or a hotel stay wherever you are in the world Tivoli Hotels & Resorts opens its fifth resort in the Algarve and the first all-inclusive taking its elegance and experience to a new destination in the Algarve in the south of Portugal Tivoli Alvor Algarve Resort is situated next to the picturesque village of Alvor and close to the city of Portimão The resort offers dedicated facilities and entertainment for all ages providing an unforgettable family experience The all-inclusive offering goes beyond the resort to include access for guests to some of the best local restaurants and theme parks The Tivoli Alvor all-inclusive offer allows guests to enjoy the best of life in a spacious resort with 491 contemporary guest rooms spread over 27.5 acres including 56 two-bedroom Premium Family Rooms and four Premium Suites the resort has reopened as Tivoli Alvor with newly decorated rooms inspired by Tivoli's contemporary classic style There are five outdoor pools (one adults only three for families and one for children) and one indoor pool a peaceful adults-only swimming pool and bars for an evening drink There is an entertainment programme just for adults and partner restaurants outside the resort where guests can dine as part of the all-inclusive experience For golfers there are several courses close by making the most of its facilities including a swimming pool with slides full of games and challenges for the little ones padel or tennis and join daily activities prepared specially for them Tivoli Alvor Algarve Resort offers two all-inclusive options one standard and a more exclusive with extra premium services Both allow guests to discover the best of the destination with access for the family to a choice of local theme parks for one day per person included (with a minimum stay of seven nights): Zoo Marine the resort also offers the choice of dinner at a selection of local restaurants (included within the all-inclusive rate subject to availability and booking 72 hours in advance) such as the renowned Restinga Praia (Praia do Alvor) Sky Bar Carvoeiro and The One Restaurant (both at Tivoli Carvoeiro) Oregano Restaurant and Purobeach Vilamoura (all located at Tivoli Marina Vilamoura) The Premium All-inclusive rates also include check-in and check-out in the VIP area breakfast in a dedicated area and a free 30-minute massage per adult/stay For an easy trip to the nearby sandy beaches or to Alvor village the resort offers a regular complimentary miniature train transfer exclusively for guests The gastronomic offering in the resort includes options throughout the day The Essenze restaurant is the meeting point for the whole family For dinner there are three additional restaurants available by reservation with a mix of buffet and à la carte service Roastic is a steakhouse and Mad Med offers fresh Mediterranean flavours high-quality organic ingredients and local produce including seafood For those who want a light meal or drink by the pool Bar offers evening entertainment and cocktails is located just 600 metres from the sea and close to the charming village of Alvor cobbled streets and fishing boats moored along the banks of the Alvor River the location is perfect for connecting with nature making the most of the beaches nearby and discovering the local caves near Portimão and Lagos such as the Benagil cave or the cliffs of Ponta da Piedade marina and nightlife is just a short distance away Hotel website Brand OwnerMinor International (MINT) Alvor Bowls Club ran its annual Crown Green Bowls Tournament from 24th to 28th February with a prize fund of 1505€.  Alvor Bowls Club welcomes visitors and new members playing both flat green and crown green bowls and full details can be found on the website Tuition and equipment can be provided for new bowlers Crown green bowls takes place at the Club every Tuesday afternoon We appreciate that not everyone can afford to pay for our services but if you are able to we ask you to support The Portugal News by making a contribution – no matter how small You can change how much you give or cancel your contributions at any time Send us your comments or opinion on this article Reaching over 400,000 people a week with news about Portugal Alvor Bowls Club will soon be finishing the construction of two new pickleball courts to expand the sports facilities available at this local family-owned Club.  For those who have yet to learn about pickleball it is a fast-growing sport which is also fun It is an easy game to learn but can also be a fast-paced competitive game for more experienced players Family members José Guerra and Alexandre Martins have already made an impact on the local pickleball scene with successes at the Vilamoura Pickleball Tournament in April 2024 In order to mark the completion of the new courts the Club will be holding an open day on Saturday 29th June from 10:00 to 17:00 when anyone interested can come along to try out the game balls and rackets will be available and someone on hand to introduce you to the basics but you are asked to register in advance and book a time slot to ensure that you do not have to wait to play You will need to wear comfortable clothing and suitable sports footwear for moving around the courts and make sure that you are using sun protection The Club will have light refreshments available and the bar will be open for drinks You will get a warm welcome and the opportunity to make new friends If you would like to attend the open day or want more information about the future use of the courts, please contact Alex (+351 966 991 153) or José (+351 939 505 811) or email pickleballclubealvor@gmail.com 15 watchtowers for lifeguards are now in operation on the beaches of Praia da Rocha and Alvor, following a protocol established between the Vodafone Portugal Foundation and the Portimão City Council.  The measure is the result of the “Healthy Beach” program with the location and placement of the towers being carried out by a company hired by the municipality with the collaboration and monitoring of the Rocha Rescue Association This website is using a security service to protect itself from online attacks The action you just performed triggered the security solution There are several actions that could trigger this block including submitting a certain word or phrase You can email the site owner to let them know you were blocked Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page Lawn bowls is a sport that evolved 5000 years ago in Egypt and is now played all over the world It was notoriously known as an old person's game Portugal does not recognise it as a sport and luckily some expats brought the game to the Algarve.  Portugal has few options and activities for the retired aged population and it has been proven that lawn bowls helps prevent Alzheimer's which is a large concern for the citizens of Portugal Alvor Bowls Club would like to grow the game for all its benefits Alvor Bowls Club is holding an open day on Sunday 26th May It is an activity suitable for all ages and whilst many think of it as a British sport it is fully international The only thing you need on the day is flat-soled shoes The club will provide equipment and tuition free of charge and refreshments will be available at a modest charge You will get a warm welcome and an opportunity to make new friends Alvor Bowls Club welcomes new members and visitors Full details can be found on our website www.alvorbowlsclub.com If you need any further information about the Open Day please contact Denise Redding (+351) 917 773 113 They say you always remember your first love and I’ll always remember popping my Portugal cherry with this trip It was my first time visiting this sun-splashed country of unspoiled beaches Douro wine and custard tarts; and I admit I’d ignorantly always thought of Portugal as an extension of Spain so it had never made my bucket list Receive today's headlines directly to your inbox every morning and evening Please check your inbox to verify your details three outdoor swimming pools with a large pool deck lounge and bar and restaurant – The Sunset The young and dynamic team have also created a tailored programme of activities to include signature outdoor fitness classes for guests to make the most of the al fresco lifestyle In addition to its prime location on Alvor Beach the hotel is just a 10-minute walk from the popular Três Irmãos beach and the picturesque village of Alvor known for its ideal location for sailing on the Atlantic Ocean due to the calmer seas and weather conditions New to the Azores, Pestana Bahia Praia is located in Vila Franca do Campo With direct access to one of the island's most beautiful beaches the hotel offers clear views spanning the Atlantic ocean as well as the surrounding mountains The hotel features 85 junior suites and 5 senior suites which work in unison with the surrounding environment The newly refurbished facilities include restaurants The hotel also boasts a beautiful and intimate 17th century chapel perfect for a romantic wedding by the ocean The hotel's refurbishment has brought with it new concepts such as a personal check in and the innovative grab & go service which allows guests to order and take their food from the Ocean Bar straight to the beach along with the terraces and each of the 202 accommodations offer wonderful views of the surrounding coast The hotel's iconic marble spiral staircase leading to the lake has maintained its place during the refurbishment whilst new additions include the innovative a la carte restaurant as well as a more contemporary style using decorative elements inspired by works of Portuguese plastic artists For more information on the Pestana Hotel Group, please visit www.pestana.com The Pestana Group is Portugal's largest international tourism and leisure group and one of the largest in Alexandra StraesslePRCOPestana Hotel Group makes the most of local techniques and the region’s climate in a design by its owners A pattern of cement blocks poetically punctuate Casa M's exterior a home which stands sentinel on a hill in Alvor The Portuguese region has over 300 days of sun per year which makes it challenging to design homes without the AC unit – a bête noire of green-minded architects One natural cooling tactic – common in Palm Springs and São Paulo the hollow bricks that allow cool air to permeate a space without exposing it to the sun.  husband and wife Luis Fonseca and Inês Almeida placed LED lights between the cobogós and the windows encasing them The effect surprised them: when turned on at night the reflected light inside the blocks illuminated the interiors like wall lamps minimalist home glows like a magical lantern partners and architects at local studio A-lab Architecture maximised several other opportunities when designing their single-family townhouse that was completed in August 2023 One such opportunity arose from their longitudinal L-shaped lot wedged between two other residential structures on an incline.  The couple created a design that spreads across three stories but uses half-floors and mirrors creating visibility between rooms when you’re using the stairs Fonseca described this as allowing for beautiful moments throughout the day interactions that always make family members feel like they are in each other’s company (the couple live there with their two children) The stairs’ stacking effect also generates natural ventilation where the sea breeze enters and travels up through the open skylight in the interior courtyard sun via the skylight is tempered with exterior shading while passive solar energy heats the home in winter Such considerations showcase the couple’s passion for sustainable living.  'We designed this house to be a case study for what we think luxury living is,' Fonseca says as he prepared lunch with vegetables his son had fetched at the market that morning 'People associate luxury with a jacuzzi on the roof and cold air-conditioning blasting [set using] their phone before they even get home We’re believers in passive architecture.'   the drawing of acoustic curtains across selected spaces allows for partitioning and climate control the children can create a play area on the veranda by separating it from the kitchen or the adults can create a more cinematic movie-watching experience (and trap in the heat of the fireplace in winter) without waking the children by closing off the living room escapism and design stories from around the world direct to your inbox After spending time in the home – the butterfly chair on the veranda overlooking the fishing boats is a particular highlight – it starts to feel a bit like being in one of those drawings of a dollhouse cut in half Beautiful moments unfold as easily as the house does But perhaps nothing compares to the fishing boats’ view at night: the white home on the hill a-lab.no Stacy Suaya is a Los Angeles-based writer focusing on design Her stories have appeared in New York Times Styles Alvor Bowls Club held its ever-popular annual Australian Pairs Bowls Tournament from 27th March to 1st April with a total prize fund of 3,250€.  An international line-up of 27 pairs of players from the Algarve Holland and Canada competed in the competition and the standard of bowling seems to improve year on year Following an initial round-robin stage the bowlers were streamed into two groups for the knock-out stages One group continued in the main Tournament won by Irish bowlers David Doyle and Paul Gartland while the other bowlers entered the subsidiary Plate won by Algarve bowlers Linus Muirhead and Carla Kenney The weather throughout was great and the bowlers enjoyed the bowling and also the social side of the Tournament The 2024 Tournament will run from 22nd to 27th March and entry details will be available on the Club website (alvorbowlsclub.com) On Tuesday 5th and Wednesday 6th March Alvor Bowls Club held our club competition finals which were the culmination of competitions over a 12 week period The weather was just perfect and club members family and friends showed up to support the finalists The matches were exciting and closely contested and trophies and medals were presented to the winners and runner ups Catherine Webb won the Ladies Singles and the 2 Wood singles and Colin Cummins won the Men’s Singles who also won the Championship Aussie Pairs with Martin Sillwood Glen and Julie Moulds won the Conjugal Pairs together with the 2 Wood Pairs Russell Morris and Graham Hey won the Drawn Pairs and Steffen Dahlmann won the Handicap Singles Our final presentation was for the Alvor Monday League and the winner was Janette O’Neill with Catherine Webb runner up They were presented with medals and a voucher for Drakes Pride accessories from the Club shop Alvor Bowls Club welcomes visitors and new members playing both flat green and crown green bowls and full details can be found on the website (www.alvorbowlsclub.com) Pestana Hotel Group has expanded its portfolio with the additions of Pestana Alvor South Beach Pestana Bahia Praia and Pestana Alvor Praia Inspired by the South Beach spirit in Miami where the hotel group has an Art Deco hotel is just 97 steps from the ocean with direct access to the beach The hotel features 90 guestrooms including 57 suites three outdoor swimming pools with a large pool deck lounge and bar There is also a tailored programme of activities including signature outdoor fitness classes to create a sense of an al fresco lifestyle Pestana Bahia Praia is located in Vila Franca do Campo on the island of Sao Miguel which can be viewed from the 85 junior and five senior suites The hotel also boasts an intimate 17th century chapel Exquisite gardens and one of the best beaches in Algarve border Pestana Alvor Praia along with the terraces and each of the 202 accomodations offer views of the surrounding coast The hotel’s refurbishment has brought with it new concepts such as a personal check-in and a grab and go service Pestana Alvor Praia’s iconic marble spiral staircase leading to the lake has maintained its place during the refurbishment whilst new additions include the à la carte restaurant www.pestana.com Registered in England and Wales with Company Number 06637145 We are using cookies to give you the best experience on our website You can find out more about which cookies we are using or switch them off in settings This website uses cookies so that we can provide you with the best user experience possible Cookie information is stored in your browser and performs functions such as recognising you when you return to our website and helping our team to understand which sections of the website you find most interesting and useful Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings we will not be able to save your preferences This means that every time you visit this website you will need to enable or disable cookies again More information about our Cookie Policy After the success of the international triples tournament at Alvor Bowls Club October 1st saw the start of the domestic season with the annual Ladies v Gents triples competition.  There was a really good turn-out again and this year the ladies dominated The most successful ladies team were Jeanette O’Neill everyone enjoyed a barbecue cooked by Linus Muirhead It was good to see everyone coming together and enjoying not only the game but the social occasion Alvor Bowls Club welcomes new members and visitors. Full details can be found on our website, www.alvorbowlsclub.com - Free tuition and equipment can be arranged for new bowlers there are other bowls clubs along the length of the Algarve who will welcome you to their green to enjoy this competitive but friendly and sociable game The Municipality of Portimão will inaugurate on Saturday the works of the old auction market in Alvor representing an investment of 234 thousand euros that transformed the building into a space of “cultural dynamism” The refurbishment of the building aims to “honour the community of Alvor and the richness of its maritime heritage” now having an interactive kiosk with detailed information about the identity of the historic fishing village indicated the Chamber of Portimão in a statement visitors will have access to data “about the human occupation of the area with some of the main activities and spaces over time the material and immaterial heritage composed of the main local fishing arts and exploration of the Alvor estuary” The intervention "represents an out-of-doors project of the Museum of Portimão which has collected valuable assets from the population of Alvor which has greatly contributed to the interactive module" “it is part of the municipal plans to integrate the auction and the surrounding area in tourist circuits related to cultural and natural heritage fishing and environmental sustainability or ecotourism” The inauguration of the new cultural space is part of the celebrations of the 35th anniversary of the elevation of Alvor to the category of village The redevelopment project for the property was started in 2020 by the municipality of Portimão Best in Travel is here! Discover 2025’s destinations The 30 best countries, cities and regions to visit in 2025 Plan your trip with Elsewhere, by Lonely Planet See where a Lonely Planet Membership takes you Subscribe to our weekly newsletters to get the latest travel news, expert advice, and insider recommendations Explore the world with our detailed, insightful guidebooks Stay ahead of the curve with our guidebooks Uncover exciting new ways to explore iconic destinations Every month, we release new books into the wild Search Search Close search menu Explore Best in Travel 2024 Africa Close menu Countries Antarctica Antarctica Close menu Regions Asia Asia Close menu Countries Australia & the Pacific Australia & the Pacific Close menu Countries The Caribbean The Caribbean Close menu Countries Central America Central America Close menu Countries Europe Europe Close menu Countries Middle East Middle East Close menu Countries North America North America Close menu Countries South America South America Close menu Countries The trip my girlfriend, Frances, and I took to southern Portugal at the tail end of September was a compromise. The previous few years we’d either been to Italy (where my folks have a place) or France (where hers do) Both of us thought it was time to go somewhere where neither was the local expert but that would mean budgeting more carefully than usual The plan was to stay somewhere fairly remote and quiet close to the coast, enjoy the sunshine and food, and do some gentle exploring, mainly based around wildlife-watching The following spending diary covers the first four days of a longer holiday Flights: €162 return from London Gatwick to Faro with easyJet Accommodation: €150 (my half of five nights). We wanted to get an AirBnB so we could mostly self-cater with the odd meal out. After weeks of diligent research (in which I played almost no part), Frances settled on the ‘Tiny House’, an aptly named mini wooden cabin deep in the countryside outside the town of Silves There wasn’t a lot to it: basically a room with a double bed The weather was so good that we spent most of our time outdoors anyway This was slightly more expensive than anticipated I had arranged a car before we left using an online deal but then ended up taking out more insurance at the desk as I was worried about driving on unmade roads (and I have weak sales resistance) noting with pleasure how warm and sunny it was (it would stay in the high 20s for the whole trip) sleepy little place – hilly and whitewashed with stork nests on chimney pots €0.35 each) and a pasta meal for that evening We also picked up a couple of big bottles of water These were particularly important as the Tiny House’s water is provided by a well which was not only in short supply after a long we followed the clear but lengthy driving instructions to Tiny House 1st gear all the way" said the instructions and I wasn’t about to disagree) and is quite wonderfully isolated: no phone signal we celebrated with a pastel de nata and a beer we were joined by some additional visitors Around half a dozen geckos emerged from the shadows to position themselves next to the two outdoor lamps waiting for moths to pick off They would be our constant evening companions throughout the week 10am: Our first breakfast was bread and jam – the latter happily found in the fridge we headed out to find a nature reserve we’d read about The Quinta da Rocha is an area of wetlands next to the estuary of the Alvor River and home to various species of wading bird although locating it proved tricky as it’s completely unsignposted We eventually stumbled our way there to be rewarded with views of flamingos We also saw an osprey – usually the sort of bird that you see only after months of diligent preparation and staking out 1pm: For lunch we headed to the slightly touristy resort of Alvor where parking was again free Besieged by hungry seagulls at a seafront restaurant I had a grilled golden bream with salad and potatoes (€13.50) and a large beer for (€3.50) This was slightly more expensive than it should have been as we weren’t yet comfortable with the idea of sending back the couvert a mini starter – usually a basket of bread and a bowl of olives – that comes before the main meal and which you have to pay for unless you actively decline it being British it took me about four meals before I could bring up the courage to say "Nao obrigado" rather than "Thank you so much" we had an ice cream from a local shop (two scoops for €3.50) and went for a wander we ended up again at the Lidl in Silves where we replenished our supplies 11am: After a pre-bought breakfast of pastries and fruit, we headed to the beach at Praia da Marinha Described online as one of the "10 most beautiful beaches in Europe" (although aren’t they all?) But as we were close to the end of the season I’m not really a beach person but even I could see it's very picturesque: a curve of sand set within rugged cove I did my best to squintingly read my book in the blazing sun while Frances swam 1pm: On the beach, we ate sandwiches we had brought. We then went for a long walk along the clifftops, admiring the views and the many people ignoring the signs not to get too close to the edge. This stretch is famed for is wave-cut rock formations, particularly Benagil a great cathedral-like cavern where a succession of boat trips journey to throughout the day We had considered taking one ourselves (it would have cost €30) but decided in the end that the free views from the cliff tops were impressive enough 2.30pm: After about an hour or so of walking a small watersports centre where we had a cola (€2.50) and a large beer (€4.50) at a bar by the beach We then did the same walk we’d just done but in reverse getting back to the car in just under an hour 6pm: Another supermarket run to get more fruit bread and wine as well as some eggs for that evening’s meal of omelettes 6pm: After a day spent lying in the hammock reading exploring the walks around Tiny House and generally not doing much we headed into town for a drink at the Café Ingles Frances had a mojito while I had a beer (€3.50) 8pm: It was then on to Silves’ best-regarded restaurant The guidebook’s threat that we’d have to "fight for a table" turned out to be an exaggeration but it was certainly packing them in compared to the nearly empty sushi place next door We couldn’t decide if we wanted the couvert or were still too cowardly to turn it down followed by fish: baked cod for me (€11.50) and sole for Frances with a bottle of red wine (€8.50) we shared a dessert of ice cream in a frozen lemon (€5) 7.30am: For the most part we were happy to improvise our days and take things as they came but there was one activity we both definitely wanted to do before leaving: dolphin watching It wasn’t going to be cheap but we figured that it would be worth it – provided we saw some dolphins 10am: We had a late breakfast at a street-side cafe: a ham and cheese toasted sandwich (€2.60) and a coffee (€1.70) for me. Then, armed with a free map picked up at the Algarve Water World kiosk, we wandered round the historic centre taking in the sights until it was time to board our boat. 2pm: Dolphin watching had given us an appetite, so back on land we headed to the second restaurant we saw, the M. Rest. & Grill, located in a narrow street alongside various similar establishments. There, I had piri piri chicken (€8.50) and a beer (€4) which, in my post-dolphin excitement, I forgot to photograph. However, we did finally work up the courage to politely ask the waiters not to bring the couvert. €162.67 + flights (€162) + accommodation (€150) + car rental and tolls (€98) = €572.67 Alvor Bowls Club ran its annual Crown Green Bowls Tournament from 26th February to 1st March with a prize fund of 1850€.  Bjarne Robberstad (born 1965) professor of health economics former chair of the Norwegian advisory board for drug reimbursement (Blåreseptnemnda) and departing member of the National Council for Quality and Priorities in the Health Services The author has completed the ICMJE form and declares the following conflict of interest: He is a colleague of Ole Frithjof Norheim with whom he has co-authored a number of publications Email: bjarne.robberstad@uib.no In Norwegian health services there is a broad consensus that serious health conditions must be given higher priority than less severe conditions giving emphasis to age when setting priorities is highly controversial it is impossible in practice to emphasise «severity» without imposing «age discrimination» and we must choose between giving relative priority to the young and giving relative priority to the old The Norheim Commission has proposed replacing the current «severity criterion» with a new «health loss» (1) The proposal has generated debate and has been criticised for representing an age criterion that discriminates against the elderly stated that the health loss criterion is overly «theoretical and difficult» The article was provocatively entitled Age will not be the deciding factor for treatment (2) I  feel that this debate underlines the need for a clarification of the terminology concerning what makes a condition «severe» This should include a review of how alternative severity definitions are affected by age Severity was proposed as a priority setting criterion by the Lønning II Commission along with the criteria benefit and cost efficiency The commission claimed that the severity of a condition should be based on the loss of prognosis in the absence of treatment or other interventions and be assessed in relation to a) the risk of death or loss of function b) the degree of physical and mental loss of function and c) pain Despite the rapid implementation of the principle in laws and regulations the definition has proven difficult to apply consistently in practice it is vague regarding how past and future health should be assessed While item (a) above obviously applies to future health items (b) and (c) can apply backwards as well as forwards in time the degree of loss of prognosis has never been specified in terms of how great the risk of loss of function needs to be before a condition is deemed severe Severity can be operationalised in seven different ways with the aid of a simple graph with lifespan on the horizontal axis and health-related quality of life on the vertical axis (Figure 1) but restricted his discussion to four different definitions (4) the vertical axis represents health-related quality of life and the horizontal axis shows years of life The red curve is a fictional example illustrating the health profile of a person who falls ill approximately in mid-life The area under the curve (the integral) can be referred to as «good years of life» The answer depends on whether the degree of poor health is assessed at the time of diagnosis in the future (prognosis) or across the lifespan (5 (i) Severity = 1 – Hd (Reduction in the level of health at the time of diagnosis) This definition is based on the patient’s acute need for help by emphasising the degree of present poor health (1 – Hd) It can be justified in terms of the need for emergency help or the «rule-of-rescue» principle This definition only addresses health-related quality of life and is perhaps the most common way to refer to «severity» in the literature (4 By assessing «severity» at the time of diagnosis This principle is thus the only way to assess severity completely independently of age since duration will obviously be relevant to the severity of a disease Painful drilling into a tooth with no anaesthetic will hardly be considered «severe» enduring the same pain as a chronic condition would literally be insufferable (ii) Severity = Tu – Td (Life expectancy at the time of diagnosis) The second definition assesses the degree of severity on the basis of remaining life expectancy in the absence of treatment (Tu – Td) and can also be justified in terms of the patient’s acute need for help (rule-of-rescue) a short remaining life expectancy is deemed more serious than when the prognosis is longer British health authorities emphasise such «end-of-life» assessments (10) Both of these first definitions have only one dimension of health and are therefore overly simplistic 1 – Hd ignores prognosis in relation to survival while Tu – Td ignores acute need for pain relief (iii) Severity = A3 (Quality adjusted life expectancy at time of diagnosis) A third possibility is to assess the prognosis as a combination of health-related quality of life and remaining life expectancy with no treatment (the area A3) This alternative is perhaps closest to the definition of severity proposed by the Lønning II Commission (3) and it is also recommended in the Directorate of Health’s manual for economic evaluation (11) «severity» is used to refer to definitions (i) one could argue that Tu – Td is independent of age (4) the prognosis will be affected by the patient’s age for example with regard to most forms of cancer (12) when the life expectancy of a healthy person (T*) is shorter than the expected prognosis of an average patient (T* – Td) < (Tu – Td) the correlation between age and severity is very high Two alternative definitions assess the severity of the disease on the basis of future health in a more sophisticated manner: (iv) Severity = (T* – Tu) / (T* – Td) x 100  % (Relative future loss of years of life) (v) Severity = B2/(A3+B2) x 100  % (Relative future loss of quality adjusted life years) These two definitions are concerned with the realisation of the patient’s health potential This is calculated as the fraction of the health loss with disease over the remaining health in the absence of disease at the time of diagnosis based either on years of life (iv) or quality adjusted life years (v) severity is an expression of how much of his or her future health the patient loses as a result of the disease Dutch researchers have proposed proportional shortfall as a priority setting criterion (14) and proportional shortfall thus ignores the past disease burden of chronic sufferers which has been criticised for concealing the magnitude of this health loss (15) A health loss of five days when life expectancy is ten days is deemed just as serious as a health loss of five years when life expectancy is ten years it has been argued that proportional shortfall is an age-neutral definition for severity (16) with this principle «severity» will increase with age because the area B2 shrinks with age and because B2 is below the fraction bar in (v) While this is a relatively trivial mathematical observation it has ethical implications that are problematic to many proportional shortfall implies that the loss of a quality adjusted life year for a 78-year-old (e.g prostate cancer) will be deemed 40 times more «severe» than the loss of a quality adjusted life year for a one-year-old (e.g To the extent that the health loss criterion represents «age discrimination» we can therefore say that proportional shortfall is «reverse age discrimination» The relationship between age and severity when the future health loss is one good year of life for all and when proportional shortfall is used as the definition The example shows that relative future health loss amounts to «reverse age discrimination» and that the relative priority given to elderly people increases exponentially Future good years of life without illness (A3+B2) we can use remaining life expectancy at different age levels This reduces the effects for relative priority at an advanced age but does not change the fact that the method represents «reverse age discrimination» and that the relative priority increases exponentially with age (Table 2) The relationship between age and severity when future good years of life are based on a life table (17) instead of a fixed reference age (vi) Severity = T* – Tu (absolute loss of years of life) (vii) Severity = B1 + B2 (absolute loss of quality adjusted life years) These two definitions focus on the patient’s absolute health loss or absolute shortfall over their lifespan either in the form of lost years of life (T* – Tu) or in the form of good years of life (B1 + B2) The latter corresponds to the health loss criterion proposed by the Norheim Commission (1) and is based on Williams’ «fair innings» argument (18) According to this definition «severity» is considered as the health loss endured over the entire lifespan including the time both before and after diagnosis is regarded as more severe than short-term illness it is health loss (or disease burden) over the lifespan that is relevant for assessing severity (B1 + B2) This principle has been criticised for being essentially an age criterion leading to priority decreasing with increasing age (17) This is correct in the sense that a chronic illness which strikes at a young age resulting in a greater health loss and consequently higher priority than a similar illness developing later in life and illness that significantly reduces the quality of life of elderly people may be assessed as more severe than illness that to a lesser extent reduces the quality of life of younger patients It is also a fact that long-term illness in elderly people may amount to a greater absolute shortfall than shorter-term illness in younger patients The argument about a direct correlation between severity and age (16) is thus erroneous The absolute shortfall criterion as a measure of severity is not entirely unproblematic the principle takes into account the prognosis without treatment assessed as the product of life expectancy without treatment and the degree of poor health (area A3 in the figure the principle may be insensitive to highly acute conditions (1 – Hd) in which the duration (Tu – Td) is so short that A3 becomes very small (e.g Such counterintuitive priority setting consequences merit further investigation Hearings are being held on the Norheim Commission’s recommendations and the Norwegian Storting will later decide how severity should be operationalised and weighted in health priority setting Olsen has proposed to split the concept of severity into four parts (4) also include proportional shortfall in the form of years of life (iv) quality adjusted life years (v) and absolute loss of years of life over the lifespan (vi) These seven alternatives emphasise different aspects of this question and they vary in how they are sensitive to the patient’s age Alternatives (i) and (ii) are overly simplistic and both overlook factors that are clearly essential with regard to what makes a condition severe the same can be said of alternatives (iv) and (vi) since they both disregard health-related quality of life we are left with three alternatives that can be assessed more closely Severity defined as expected quality adjusted life years at the time of diagnosis (iii) is perhaps closest to the current definition formulated by the Lønning II Commission and described in the regulation on priority setting it is possible to specify more clearly how this definition should be applied in practice (9) The principle will nevertheless place great emphasis on the risk of imminent death higher priority is placed on illness that strikes elderly compared to younger patients will also result in high priority being given to elderly it is easy to show that this weighting in favour of the elderly may be exponential Since both alternatives (iii) and (v) favour the elderly both will serve to reinforce existing parities in lifetime health between groups of patients This happens because giving priority to the strongest (in terms of achieved health over the lifespan) implies less priority to the weakest groups of patients gives relatively higher priority to patient groups with major health loss and long-term illness Therefore this criterion appeals to those who think that the health services should contribute to reducing inequalities in life time health The principle also has some empirical support the principle may be insensitive to certain issues in emergency medicine The Norheim Commission believes that this concern can be countered by the proposed «health benefit» criterion (1) although applied research should be undertaken to better elucidate whether the sum of such a pluralist perspective agrees with people’s preferences and the value basis of the health services The relationship between severity and age is a sensitive question and arouses strong opinion the debate on age discrimination has been imprecise oversimplified and overall more confusing than constructive as illustrated by the feature in Aftenposten on 16 June 2015 (2) Since it is ethically problematic to disregard the duration of illness when assessing severity age-neutral alternatives for operationalising the concept we have a choice between two alternatives that indirectly favour older people and one alternative that indirectly favours younger patients The English expression «age before beauty» is generally used in a humorous way to give precedence to elderly people for example when there are too few vacant seats on a bus Is this what we want in the Norwegian health services NOU 2014: 12. Åpent og rettferdig – prioriteringer i helsetjenesten. www.regjeringen.no/no/dokumenter/NOU-2014-12/id2076730/ (17.5.2015) Dommerud T. Alder blir ikke avgjørende for behandling. Aftenposten 16.6. 2015. www.aftenposten.no/nyheter/iriks/Alder-blir-ikke-avgjorende-for-behandling-8060667.html (17.6 NOU 1997: 18. Prioritering på ny. Gjennomgang av retningslinjer for prioriteringer innen norsk helsetjeneste. www.regjeringen.no/no/dokumenter/nou-1997-18/id140956/ (17.5.2015) Olsen JA. Hva menes med «sykdommens alvorlighetsgrad»? Tidsskr Nor Legeforen 2013; 133: 64 – 7. [PubMed] Nord E. Concerns for the worse off: fair innings versus severity. Soc Sci Med 2005; 60: 257 – 63. [PubMed] [CrossRef] Priority to the worst off in health care resource prioritisation Shah KK. Severity of illness and priority setting in healthcare: a review of the literature. Health Policy 2009; 93: 77 – 84. [PubMed] [CrossRef] Olsen JA. Priority preferences: «end of life» does not matter, but total life does. Value Health 2013; 16: 1063 – 6. [PubMed] [CrossRef] Økonomisk evaluering av helsetiltak – en veileder Long-term cancer survival: Patterns and trends in Norway 1965 – 2007 Johannesson M. Should we aggregate relative or absolute changes in QALYs? Health Econ 2001; 10: 573 – 7. [PubMed] [CrossRef] Lindemark F, Norheim OF, Johansson KA. Making use of equity sensitive QALYs: a case study on identifying the worse off across diseases. Cost Eff Resour Alloc 2014; 12: 16. [PubMed] [CrossRef] Statistisk sentralbyrå. Statistikkbanken. www.ssb.no/statistikkbanken/ (8.6.2015) Williams A. Intergenerational equity: an exploration of the «fair innings» argument. Health Econ 1997; 6: 117 – 32. [PubMed] Ottersen T. Lifetime QALY prioritarianism in priority setting. J Med Ethics 2013; 39: 175 – 80. [PubMed] [CrossRef] Dolan P, Tsuchiya A. Health priorities and public preferences: the relative importance of past health experience and future health prospects. J Health Econ 2005; 24: 703 – 14. [PubMed] [CrossRef] Stolk EA, Pickee SJ, Ament AH et al. Equity in health care prioritisation: an empirical inquiry into social value. Health Policy 2005; 74: 343 – 55. [PubMed] [CrossRef] Bjarne Robberstads drøfting av alder og alvor (1) er teknisk interessant men jeg mener han skaper forvirring ved ikke å skille mellom hva et godt etablert uttrykk som «en tilstands alvorlighet» betyr i medisin og hvilken vekt man kan ønske å legge på ulike hensyn ved prioritering Helse- og omsorgsdepartementet har fra en arbeidsgruppe under ledelse av professor Jon Magnussen bestilt en vurdering av gjeldende prioriteringskriteriers alvorlighetsbegrep og mulig operasjonalisering av dette at langvarig lidelse er mer alvorlig enn kortvarig lidelse (for eksempel kyssesyke vs influensa) Men det er også klart at gjenstående levetid ikke inngår i Lønning 2's alvorlighetsbegrep Det følger av Lønning 2's klare standpunkt om at alder/gjenstående levetid ikke skal være et selvstendig prioriteringskriterium Man kan diskutere i det vide og det brede nøyaktig hvilke aspekter alvorlighetsbegrepet i dag rommer men et enkelt sett av faktiske observasjoner er kanskje vel så hensiktsmessig for å få skilt lort fra kanel Jeg nøyer meg med følgende fire: A Når 40-åringer og 70-åringer får livstruende sykdom: Dagens språk: De regnes som like alvorlig syke Prioritet: De får samme prioritet for livreddende kirurgi – også om den er svært kostbar B Når 50-åringer og 80-åringer får like sterk kronisk smerte: Prioritet: De møter samme betalingsvillighet for smertedempende legemiddel på blåresept C Når en 60-åring og en 80-åring får sykdommer som forventes å redusere førstnevntes gjenstående levetid fra 20 til 10 og sistnevntes fra 6 til 3 år: Dagens språk: De regnes som like alvorlig syke.... men betalingsvilligheten for behandling er trolig likevel større for 60-åringen ut fra en tanke om at 80-åringen «har fått sitt beger rimelig oppfylt» D Når en 20-åring og en 90-åring er i livstruende tilstand: men 20-åringen får prioritet / møter større betalingsvillighet som Robberstad nevner som målebegrep nummer 5 er en operasjonalisering av alvorlighet som ivaretar denne språklige forståelsen i det den gir samme skåre for de to gruppene i hvert av eksemplene ovenfor Som mål på alvorlighet bryter absolutt prognosetap med denne språkforståelsen i alle de fire eksemplene dette: Man undersøker hvilken modell – her hvilken definisjon - som gir best tilpasning til data vil prioritering etter relativt prognosetap være konsistent med prioriteringene i dag i eksemplene A og B Prioritering etter absolutt prognosetap tilsier endret praksis Å vektlegge relativt prognosetap alene vil ikke fange opp prioriteringene i eksemplene C og D Men alder/gjenstående levetid som tilleggskriterium til alvorlighet målt som relativt prognosetap vil kunne ivareta prioriteringsverdien «oppfylt beger» i de situasjoner og i den grad dette er ønskelig (eksemplene C og D) Det er i prinsippet selvsagt mulig å vurdere nye måter å bruke ordet alvorlighet på heretter For eksempel kan man gå inn for at i eksemplene A og B skal heretter 40-åringene sies å være mer alvorlig syke enn 70-åringene Da blir absolutt prognosetap en egnet operasjonalisering av alvorlighet Men da er det ikke bare salige Inge Lønnings språk man vil forandre men også språket til klinikere og folk flest Det er en tung og uhensiktsmessig vei å gå og etter min mening respektløst overfor etablert språk Vil man ha større vekt på alder og gjenstående levetid ved prioritering er det bedre å ta dem inn som separate tilleggskriterier enn å gi seg til å tukle med språket Ved å holde begrepene og kriteriene adskilt får man også den nødvendige frihetsgraden til å bestemme presist i hvilke konkrete sammenhenger og hvor sterkt alder og gjenstående levetid skal vektlegges jfr for eksempel forskjellen på A og B vs C og D Erik Nord gir uttrykk for at «en tilstands alvorlighet» i dag er eit godt etablert uttrykk Dette har eg til gode å høyre frå personar som har forsøkt å operasjonalisere det i praksis Uttrykket ser ikkje ein gong ut til å vere spesielt godt etablert hos Erik Nord Her tek han til orde for å definere alvor som relativt framtidig tap av helse (definisjon iv eller v i min kronikk) Tidlegare har han argumentert for både definisjon (i) og (iii) (1) Desse alternativa kan implisere høgare prioritet for sjukdom som rammar eldre enn tilsvarande sjukdom for yngre (iii eller bety at vi ved vurdering av alvor skal sjå heilt vekk frå varigheten av sjukdom (i) Ein konsekvens av desse alternativa er høgare prioritet til marginal livsforlenging på slutten av livet på bekostning av tiltak for kronikarane Nord foreslår å vurdere alvorlighetsmodell med hjelp av ei regresjonsanalytisk tilnærming for å sjå kva modell som passer best til data Han konstruerer deretter fire «observasjonar» som han meiner viser at alvorlighet vurdert som absolutt tap av gode leveår bryt med «språkforståelse» medan relativt framtidig helsetap ikkje gjer det Regresjonsanalyse kan gi underlege resultat når observasjonane er få og selekterte Eg meinar Nord sine eksempel A og B har liten relevans for denne debatten Desse pasientgruppene har alle høg prioritet tidlegare og føreslåtte nye prioriteringskriterier Her er det ingen dilemma og ingen diskurs Det vil vere nyttig for debatten om ein sluttar å antyde at 70-åringar med livstruande sjukdom eller 80-åringar med sterke smerter ikkje lenger skulle få behandling Diskusjon av prioritet er best å gjere på «marginen» altså i situasjonar der det faktisk kan vere aktuelt å seie nei til behandling fordi den ikkje er tilstrekkeleg nyttig eller fordi den ikkje gjeld alvorleg nok sjukdom til å prioriterast framfor andre tiltak Eksempel C og D er langt meir interessante i så måte Det finst sjølvsagt ingen «korrekte» preferansar om desse spørsmåla men eg er grunnleggande usamd med Nord i at det er like alvorleg for ein 80-åring å miste tre leveår som for ein 60-åring å miste 10 leveår Eg er også usamd i at det skulle vere like alvorleg med livstruande sjukdom for ein 90-åring som for ein 20-åring Erik Nord nyttar Inge Lønning som sannhetsvitne for eigne preferanser og språkforståing Som teolog er det mogleg at Lønning hadde over gjennomsnittleg sans for profetiske nådegaver Men det er vanskeleg å skjøne logikken når Erik Nord profetisk tolkar Lønning 2’s runde definisjon av alvor som brøken av helsetapet med sjukdom over gjenverande helse i mangel av sjukdom på diagnosetidspunktet Ordet «relativt prognosetap» er nemleg ikkje nemnt i Lønning 2’s rapport (2) og rapporten er fri for tekniske presiseringar i denne retningen 189) at «Utvalget finner det riktig å påpeke at den offentlige helsetjenesten har et særlig ansvar for de kronisk syke» Nords alvorlighetspreferanser representerer lågare prioritet til desse pasientane Nord bør også slutte å kritisere «alder/gjenstående levetid som selvstendig prioriteringskriterium» Det er nemleg ingen som foreslår dette sjølv om pressedekning kan gi inntrykk av det motsette (3) Helsetapskriteriet seier rett og slett at stor sjukdomsbyrde er meir alvorleg enn mindre sjukdomsbyrde I staden for å repetere slike unøyaktigheter bør vi fokusere på å greie ut etiske implikasjonar av alternativa og å undersøke betre korleis dei samsvarer med allmenn intuisjon Gode «aldersnøytrale» definisjonar for alvor eksisterer ikkje Eitt sentralt spørsmål vert då om eldre si helse indirekte skal prioriterast opp eller om vi heller indirekte skal prioritere langvarig sjukdom som rammer unge som er ein av konsekvensane av Norheimutvalet sitt forslag Prioriteringsutvalgets innstilling (NOU 2014:12) Forklaring av utvalgets forslag med kritiske kommentarer til prosess Gjennomgang av retningslinjer for prioriteringer innen norsk helsetjeneste Alder blir ikke avgjørende for behandling Nyeste ledige stillinger fra legejobber.no Hold deg oppdatert om ny forskning og medisinske nyheter Sjefredaktør Are Brean • Tidsskriftet er et medisinskvitenskapelig tidsskrift med åpen tilgang Tidsskriftet redigeres etter redaktørplakaten ISSN 0029-2001 (papir) ISSN 0807-7096 (nett).