Hospital planning in Portugal

Hospital planning in Portugal

Lisbon, 22nd March 2011

Jorge SimõesChair of the Portuguese Health Regulation Authority

2ERS/HospitalPlanning/Mar2011/JorgeSimoes

Outline

1. The Portuguese Health System

2. The hospital sector in Portugal

3. The case of hospital networks

4. The Portuguese National Health Plan


Outline






The Portuguese Health System

Based on a National Health Service (NHS), that is:Universal – for all citizensGeneral – all services for all citizens(almost) Free of charge (at the point of service) – only

minor fees to avoid overconsumption

But with private and public mix in terms of:Funding of servicesDelivery of services

…however this mix had important changes over time



Specialty% private consultations

Dental Care 92,1%Gynecology 67,6%Ophthalmology 66,9%Cardiology 54,2%Orthopedics 45,5%Pediatrics 31,1%Primary care 17,1%

Source: Simões, Barros and Pereira, 2008

Proportion of total consultations in private providers, Portugal 2005

Private and public mix in delivery



Private and public mix in funding (2006)

Public funding 71.2% - National Health Service 57.5% - Public subsystems 7.1% - Other (fiscal deductions) 5.7% Private funding 28.8% - Private subsistems 1.9% - Voluntary health insurance 2.4% - Out-of-pocket payments 23.9%



Effective solutions to rationalize resource utilization in the NHS appeared first in the late 90’s:

1995-2002: NHS reform with emphasis in public and private sector complementarities

2002-2004:• Corporatization of NHS hospitals • Public-Private Partnerships • Annual contracting between the Ministry of Health and

each NHS hospital• Creation of the Portuguese Health Regulatory Authority



2005-2010:• Creation of hospital centers (integration of hospitals)• Creation of the national network of integrated long term

care• Reform of primary care reform


Outline






The hospital sector in Portugal

Definition of “hospital”NHS hospitals: in legislation and contracts - common

characteristics:• Inpatient care• Outpatient care (emergency or consultations)• Diagnostic and therapeutic modalities

For private: no legal definition of hospital• We use inpatient care as main characteristic



Network of hospitals

Geographical distribution Biased in favor of urban areas Concentration is higher for private hospitals Correlation of nº. hospitals and population (unit=district): 0,96

Ownership NumberNHS (public) hospitals 105

Private (for-profit + not-for-profit) 213

Official hospitals (military + paramilitary + prison) 11

Total 329Sources: ACSS, ERS


The hospital sector in PortugalDistrict No. Public Hospitals

Lisboa 22

Porto 16

Coimbra 12

Aveiro 9

Leiria 6

Setúbal 6

Braga 5

Santarém 4

Bragança 3

Castelo Branco 3

Faro 3

Guarda 3

Vila Real 3

Viseu 3

Beja 2

Portalegre 2

Viana do Castelo 2

Évora 1

Portugal mainland 105Sources: ACSS, ERS

District No. Private Hospitals

Lisboa 64

Porto 51

Braga 17

Coimbra 15

Aveiro 11

Leiria 10

Faro 7

Évora 7

Setúbal 6

Viseu 5

Viana do Castelo 5

Castelo Branco 4

Santarém 3

Vila Real 3

Bragança 2

Guarda 2

Portalegre 1

Beja 0

Portugal mainland 213



Sources: ACSS, ERS

Public hospitals in districts Private hospitals in districts



The NHS public hospital sector

Scale of planning National level

Typology of hospitals Reflects the degree of technical differentiation of each hospital

and area of geographical influence:• Central: higher differentiation + larger area• District: medium differentiation + medium area• Level-1: lower differentiation + smaller area

University hospitals: also provide clinical education and training to doctors, nurses and other health professionals




Source: ACSS

Type of hospital NumberCentral hospitals 41 - General 18 - Specialized 23District hospitals 45Level-1 hospitals 19Total 105




Type of management: corporatization of NHS hospitals

SPA hospitals: under the direct administration of the Government

EPE hospitals: corporatized hospitals; remain public property but differ from SPA hospitals in terms of management instruments at its disposal (administrative and financial autonomy)




Public-Private Partnerships (PPP):

Service provided jointly by private and public parties, sharing financial, technical and operational risk;

Three alternatives in Portugal:• Only for management of hospital• Only for construction of hospital• For management and construction of hospital




Type of management NumberSPA hospitals 38EPE (corporatized) hospitals 64PPP hospitals 3Total 105




Integration arrangements Hospital Centers: groups of hospitals in the same geographical

area that have centralized management (in the largest hospital of the group) and share administrative services and have coordinated services• 26 (65 hospitals)

Local Health Units: group of NHS health care providers that integrates hospitals and primary care centers of the same geographical area, that have centralized management (in the largest hospital) and have coordinated services• 6 (11 hospitals and 54 primary care centers)


Outline






The case of hospital networks

Hospital network definition

Integrated and hierarchical system that regulates complementarity relations and technical support among all hospital institutions in a region

Objectives

Granting access to relevant and timely health care for all patients

Optimizing resource utilization



The anatomy of a hospital network

Points of provision• Number• Location• Type of services• Human and physical resources

Geographical area of influence

Patient and information pathways

Rules for patient referencing



Design and implementation of a hospital network

Assess health care needs of populations

Make better use of already installed capacity

Adapt services to regional and local specificities

Integrate inpatient and outpatient care

Integrate in a national wide planning strategy



Options of hospital networks

Option 1: patient referencing rules constitute access norms for legal enforcement

Option 2: hospital networks merely with programmatic/indicative nature



Hospital networks in Portugal 9 enforced by law

Area Ministerial decision

Gastroenterology 16/06/2008

Cardiac intervention 08/10/1999 e 18/07/2001

Immunoallergology 01/03/2002

Rehabilitation medicine 26/03/2002

Neurology 18/07/2001

Nephrology 26/03/2002

Oncology / Paediatric Oncology 17/01/2002

Rheumatology 07/04/2000 e 26/03/2002

Urgency and Emergency 14/11/2001



Hospital networks in Portugal 12 without legal definition

Anatomic PathologyIntensive CareVascular SurgeryEndocrinologyMedical GeneticsInfectology

Mother and child healthOphthalmologyMental healthTransplantationUrology



Some facts (difficulties) about hospital networks in Portugal

Definition of rules and strategies that cannot be put in practice due to resource restrictions

Referencing rules are merely programmatic and indicative, and cannot be legally enforced

Incompatible with other planning instruments of the Portuguese NHS (e.g., contacts between hospitals and the Government)


Outline






The Portuguese National Health Plan

What is a National Health Plan (NHP)

It’s a strategic instrument that allows for coherent health policy alignment, with the scope of maximizing health gains for the general population.


The 2004-2010 Portuguese NHP

Core strategic goals• Achieving health gains• Defining instruments for implementation

Starting point• Potential for illness absence• The Portuguese Health System



WHO evaluation of the Portuguese 2004-2010 NHP

Good:The NHP was well received and promoted a broad

consensus over health prioritiesPortugal achieved many health targetsMost indicators showed improvements, with gaps to

European averages decliningThe NHP provided a comprehensive benchmark for

organizing health system activities



WHO evaluation of the Portuguese 2004-2010 NHP

Not so good:Poor link with governing instruments (contracting,

regulation, performance indicators)Future performance may be compromised by unhealthy

life styles, unsustainable health system and large health inequities

This requires that the next NHP must be strongly oriented to the strengthening of the health system and to the achievement of sustainable health gains



The 2011-2016 Portuguese NHP: Conceptual FrameworkMaximizing health gains for the population through the

alignment and integration of sustainable efforts from all sectors

Focus on access, quality and citizenship.


Mais valor em saúde

Cidadania

Políticas saudáveis

ACCESS

QUALITY

HEATLH POLICIES

More Health Value

CITIZENSHIP


The 2011-2016 Portuguese NHP: critical aspects

To constitute a reference for the health system

To embody a vision of health gains

To develop a model of health planning

To capitalize and improve the performance of all involved

To define mechanisms of monitoring and assessment


Documents

Hospital planning in Portugal