The Catalan Health System: Le cas de la Catalogne Toni Dedeu, MD MSc Family Medicine Doctor Specialist and Urologist semFYC International Officer in Wonca ( World Organisation of Family Doctors) semFYC: Spanish Society of Family and Community Medicine Advisor to the CEO of the Catalan Institute of Health –ICS European Commission Consultant On behalf of Institut Català de la Salut tdedeu@brihssa.com
The Catalan Health System: Le cas de la Catalogne � Background of the Spanish and Catalan Health System � The Catalan Health System � Primary Care in Catalonia today � The Future of Primary Care in Catalonia � Conclusions
Le cas de la Catalogne Fr Fran ance ce Es Espag pagne ne Catalogne
Spain: a complex reality / Quasi ‐ Federal System La Espagne: ‘Quasi ‐ Fédéral Model’ La CATALOGNE 7 .3 5 4 .4 4 1 habitants Capitale: BARCELONE
La Espagne: une réalité très complexe
Espag Es pagne ne Catalogne Fran Fr ance ce 4 6 .0 6 3 .5 1 1 7 .3 5 4 .4 4 1 6 3 .7 5 3 .0 0 0 � � � citizens on January the c itizens on January the citizens on January the 1 st , 2 0 0 8 1 st , 2 0 0 8 1 st , 2 0 0 8 3 Official � Official languages � 4 Official � languages languages Le français est la langue officielle Catalan, Spanish, Occitan de la République Française (article Spanish, Catalan, Euskera (Bask (Aranès) 2 de la Constitution de 1958) language) and Galizian . Spanish Constitution 1978 Catalan Constitution 2006 � Life expectancy ( 2 0 0 6 ) : 7 9 .7 3 Life expectancy 2 0 0 6 ) : � � Life expectancy ( 2 0 0 6 ) : 7 9 .6 5 8 1 .3 5 Death Rate per 1 0 0 0 inh: � 9 .1 4 � Death Rate per 1 0 0 0 � Death Rate per 1 0 0 0 inh: inh: 8 .4 8 .2 � GDP/ Capita ( 2 0 0 7 ) : 3 3 .1 8 7 US$ � GDP/ Capita ( 2 0 0 7 ) : � GDP/ Capita ( 2 0 0 7 ) : 4 2 .2 9 1 US$ 3 2 .0 8 8 US$ (based on purchasing power parity) (based on purchasing power parity) (based on purchasing power parity)
1 9 3 3 Charity System � _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1 9 3 6 � 1 9 3 9 Spanish Civil W ar (Prelude of the 2 nd World War) ____________________________________________________________________________________________________________________________________________________________________________ 1 9 4 4 � Dictatorship regim e: Social Security based m odel ( initially a poor and basic Bism arkian type of health care coverage. Only for workers, military and civil servants ). Rest of the population: Charity or Private Insurance ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1 9 7 6 Dem ocracy: Research and piloting period of which model to follow. Politicians, � academics, stakeholders, trade unions and medical professional were involved _______________________________________________________________________________________ 1 9 7 9 � Fam ily and Com m unity Medicine Speciality (1 year after Alma Ata Declaration) (Family Medicine vocational training: 3 years/ currently a 4 year programme) ____________________________________________________________________________________________________ N ational H ealth S ervice & P rim ary c are R eform 1 9 8 6 � _ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ __ ___ ___ ___ ___ ___ __ ___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Quasi - Federal System ( Autonom ous Com m unities) 1 9 8 6 � Catalan Health Ministry and Catalan Departm ent of Health
HEALTHCARE SYSTEM STRUCTURAL REFORM: 1 9 8 6 G eneral Healthcare Act: Universal Coverage � B ased on the Beveridge m odel � P rogressive transition towards a tax funded system : NHS � N ational H ealthcare S ystem D ecentralized to Autonomous Communities ( Devolution ) � H ealth services to be free at the point of dem and � A comprehensive range of services � A gatekeeper system through the Family Medicine Doctor/ GP to � the rest of the NHS
HEALTHCARE SYSTEM STRUCTURAL REFORM: 1 9 8 6 � S ervices provided mainly in public facilities � C o-payment in pharmaceutical products for out- patients with exceptions: eg. retired people, special diseases, disabled people. � D ental care: limited public service basket � D escription of Services Basket by OECD categories
Insurance Services CATALAN HEALTH CATALAN INSTITUTE U ICS HEALTH 20% SERVICE S Contracted 100% Providers E Population 70% R Suplem entary Private I nsurers 2 0 % Private Centres 10%
Catalan Catalan Ministry of Health Parliam ent € € Finnancing Department of Health Planning Catalan Public Health Insurance CatSalut Commissioning and Buying Providers PC 2 PC2 IC ICS PC 1 Hospital CATALAN HEALTH INSTITUTE ‐ Consortium 3 Hospital Hospital Primary Mental Consortium 1 Consortium 2 Hospital Other Ambulance Care health s Trust 2 Mental Mental Ambulance Health 1 Health 1 Trust 1
10% 7% 75% 5% 3%
Long-term Care HOSPITALS Mental Health H3 Centres Care H2 H1 C N T Z E S I I
� Gatekeepers � Multidisciplinary Team � GPs (>15 yr old) � Pediatrics ( 0 to 14 yr old) � Nurses � Dentist � Social Worker
Free choice of Practice and GP, Paediatritian and Nurse � Com m unity Care ( All the Team – Com m unity Plans) � Hom ecare ( SW , GP/ P, N,D) � Acute m edicine ( GP/ P, N, Dentist) � Prevention of care ( GP/ P, N, D) � Prom otion of care ( GP/ P, N, D) � Minor surgery ( GP) � Other techniques: anticoagulant control and treatm ent, � spirom etry, ultrasound, etc. ( GP, N) Vocational Training ( GP, N, Adm in, SW ) � Continuous Medical Education ( All the Team ) � Research ( All the Team ) �
� Diversity of Providers � Electronic Clinical Record � I nternet based – All health providers at all levels � Fast Pathw ays: � Cancer fast screening and treatm ent � Heat w ave � Epidem ic � Evidence Based Medicine � Clinical Guidelines � CME ( Continuous Medical Education) � Quality Assurance / Econom ic incentives � Salaried professionals and personnel � Accountability – Quality I ndicators ( I ndividual and Team based) � Pay for Perform ance/ I ncentives � CPD ( Continuous Professional Developm ent)
Disease Managem ent Program m es: � � CHF � COPD � DI ABETES � DEPRESSI ON ▪ EXPERT PATI ENT PROGRAMME ▪ CALL CENTER ▪ GUI DELI NES ▪ ELECTRONI C CLI NI CAL RECORD ▪ Liaison Nurse Health Program m e at School � Com m unity Health Plans � Sport and Health program m e �
Civil Servant Structure. No flexibility in m obility of � professionals Very High Num ber of Consultations x Patient x year at � Prim ary Care level Bureaucratic ‘tics’ � ▪ Seek leave control � Mediatisation of the society Overuse of Em ergency Units at hospitals � � No cost No value! W hat to do w ith dem and? � � Disease Managem ent Program m es - Policy Makers are NOT very enthusiastic � Developm ent of a com patible softw are Prim ary Care - Hospital � “NHS Direct” Sanitat Respon Rethinking of leadership and m ultisectoral approach � � ‘inexistence of a Collective Leadership approach’ to date. To be developed No form al developm ent of Com m unity care. I solated � initiatives by Prim ary Care Team s
1 . Com m unity Centred 2 . Holistic approach to health and social needs / I ntersectoral w ork 3 . Focus on health needs 4 . Em phasis on health prom otion/ capability/ selfcare and com m unity care 5 . Em pow erm ent of the person and the com m unity. Dinam izacion of the social actors in the system 6 . I ntegration betw een healthcare and social services. Partnership and netw orking
Current Model Tow ards the target Model Orientation -Reactive health care -Proactive Care -Equal services for all -Population stratification -Identification of patients with chronic diseases Patient -No choice. Patients went where -Patient Choice were assigned -Patient involvement and selfcare -Passive patient Leadership -County Hospitals -Executive Director and Support team at County level -Full “Commissioning” role: to plan and purchasing of local services Policies and -Catalan Health Plan -Catalan Health Plans + Local strategies Strategic Plans Clinical -Each provider developed their -The same Clinical guidelines for all Guidelines own clinical guidelines Catalonia (HealthTechnology Agency and Department of Health) -Interactive clinical Guidelines within electronic clinical records Care -Not defined -Local level: providers and local Pathw ays clinical leaders design the local care pathways
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