WHO Public Health approach in the planning and

implementation of Palliative care:

Experience and evidence from Catalonia

Xavier Gomez-BatistePal Care , Institut Catala d’Oncologia

Socio-Health, Catalan Department of HealthSpanish Society for Pall care (SECPAL)

CATALONIA

• 6.7 milion habitants• > 16% > 65• 1 million > 65 ys• 100.000 elderly with pluripathology

and dependency• Dementia: 90.000• Cancer mortality: 13.000• Aids: 300

Catalonia: Public Health Care system (universal coverage, free access)

Hospitals: 14.000 beds

Sociohealth Centers: 5.000 Residential:

45.000

Regional Cancer Institute

Primary care network

Background

• British experience on Hospices: model of care and internal organisation, but outside the NHS

• The Public Health approach: E. Wilkes (1985) + Jan Stjernsward (WHO) + V Ventafridda

PCPC: global results 2004

• Nº total resources: 162• Interventions/year: > 20.000• Coverage cancer: 75%• Cancer vs noncancer: 60/40%• Coverage, geographical: 100%• Total beds: 550• Beds /milion hab: 85• Full time doctors: 140

Units 2001: placement

Hosp Univ: 6Hosp Gen: 4

CSS: 38

MEP: 11

ICO: 1

Nº total: 60Beds: 550 (9.5/UCP)Length stay: 22.8 daysMortality: 69.7%Discharges home: 23.0%

Home Care Support Teams

• Nº total: 62• Nº new patients/year: 250• Cancer (46%), geriatrics (46%), chronic• Prevalents: 30-40• Time intervention: 6 weeks• Place of death: 61% home, 19% CSS, 12% HA• Nº total professionals (2003): 318• Cost: savings of 1.000 euros/patient

CP: levels of complexity

General Measures in Conventional Services

Basic Support Teams

Reference:

complexity+ training+ research

Complete teams

Units

Complex metropolitan systems

(300-500.000 hab): levels, coordination

ICO: Palliative Care Service

• Unit 16 beds

• Outpat’s/DC

• Support team

CSUB

ICO

PADES + UCPSS

PCS at ICO: basic outputs

• New patients/year: 1.000 (Cancer 100%)

• Median survival 1st visit: 3.5 months

• Mean age: 60 years

• Length of stay (Unit) : 9 days

• Mortality (Unit): 50%

• Cost: 30% of Medical Oncology

PCS at ICO: other aspects

• Reference for training (Master, Intermediate, Basic): more than 5.000 profesionals trained

• Research: CATPAL cooperative group (more than 17 studies)

• Quality improvement: EFQM model

Cuidados PaliativosCuidados Paliativos

ICO 1998: the “ping-pong” modelICO 1998: the “ping-pong” model

ONCONC

RDTRDTURGURG

HMTHMT

PAL CAREPAL CARE

PAINPAIN

CIRCIR

ORLORL

ICO 2005: interphase Oncology-Pal careICO 2005: interphase Oncology-Pal care

“From competition to cooperation”

UFP

UFM

UFORL

UFGINE

USAC

Palliative Care Service: clinic, unit,support team

PACMAC PACMAC Case Case managementmanagement

Continuing careContinuing care

EmergenciesEmergencies

CoordinationCoordination

Definitions and trams

Diagnosys Death

Specific Treatment

Suportive care

Palliative care

Terminal care

Bereavement

Complexity vs prognosis

SOCIOHEALTH ACTIVITY IN CATALONIAProgress 1990-2002

28.000

39464

53884

7772082000

14.99118.390

23.143

6.70012.285

650025824

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

1990 1993 1995 1997 2001 2003

SOURCE: Information system "Programa Vida als Anys"

Nº Users

PVAA Budget (million Ptas)

PVAA 166,8 million €3% of total CHS budgetPVAA 166,8 million €

3% of total CHS budget

PCPC: 23,7 million € 0,43 % total CHS

budget

PCPC: 23,7 million € 0,43 % total CHS

budget

Legislation and standards

•Decret Catalunya 1990•Recomendaciones de la SECPAL, Ministerio de Sanidad (1993)•Estàndards de cures pal.liatives, SCS, SCBCP (1993)•Decreto/orden 1993 (Opioides) Ministerio•Plan Nacional de Cuidados Paliativos (2001)•Guía de criterios de calidad en cuidados paliativos: SECPAL, Ministerio Sanidad (2002)•Indicadores de calidad en cuidados paliativos: SECPAL, Ministerio de Sanidad

Fuente: Directorio SECPAL

Spain 2002 by Regions

0

50

100

150

200

250

300

350

85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01

Recursos HospitalariosRecursos DomiciliariosOtros RecursosTotal Recursos

Spain 1984-2002

Fuente: Directorio SECPAL

Results on the use and cost of

reources

0

10

20

30

40

50

60

70

80

INGRÉS ESTMITJ URGENC DOMI COST

1992

2002

COMPARISON 1992-2002: USE/COST OF RESOURCESINGR: % malalts / ESTMITJ: dies / URGENC: %malalts COST: euros x 100 (XGB et al, 2002)

Hospital Costs: 1992 vs 2001(Cost / process-patient / 6 weeks at 2001 prices)

•1992: 4.987 euros

•2001: 1.701 euros

Difference: 3.286 euros / patient

National Policy: Elements• Evaluation of needs• Defined targets, aims and principles• Leadership• Implementation of specific services• General measures in conventional services• Opioid availability• Education and training• Standards, legislation, definition of services• Financing model• Evaluation• Implementation plan with specific budget

Principles

• Measures in all places• Sectorized • Insertion in preexisting services,

including sociohealth• Gradual implementation• Public Planning• Public Financement

Aims

• Coverage: for all in everywhere

• Equity and accesibility• Quality: effectiveness,

efficiency, satisfaction

• Reference WHO

Initial key procesess• Clear ideas• Clear definition of clients

and services• Leadership• Training• References/experiences• Institutional support

pva20

LeadershipJoint venture between

• Ministry of health and financing agency

• Professionals: well trained and highly committed

• Organisations (Providers): public, profit, nonprofit

• Academic (Universities)

General measures

• Targets: Hospitals (oncology, internal medicine, geriatrics, emergencies), mid-term and long-term resources (nursing homes), primary care teams

• Training: policies, sessions, formal training, local references

• Change of organisation: teamwork, presence and support of the family

• Liaison of resources

Specific Resources

• Specific nurses

• Support teams: in hospitals, community, both, systems

• Units: type, dimension, placement

• Nº beds: 80-100/milion

• Placement: 10-20% acute, 40-60% sociohealth (mid-term), 10-20% residential, 10-20% hospices

Types of processes (always combined)

• Implementation of new specific resources

• Adaptation of conventional resources (general measures)

• Reallocation of resources (reconversion)

• “Catalythic” implementation or investment

Palliative care and geriatrics and cancer

• Links with geriatrics in Sociohealth centers, nursing homes, and community

• Links with cancer in hospitals, cancer centers, and the community

• Both necessary

Common Resistances• “We are already doing so...”

• “There is no need of specific services, we will do a lot of training....”

• “Palliative care services will be seen as places to die....”

• “This is good for England, USA, or Catalonia, but it will not work in our country....”

Expected results• Enormous improvement of the quality

of care

• Effectiveness

• Efficiency: saving more than the structrural cost

• Satisfaction: patients, families, professionals, and politicians

Palliative Care: added values

• Care and organisation models useful in all the system

• Model of care appliable to other conditions earlier

• Emphasis in quality of life• Impact on the global efficiency• High patient’s and familie’s satisfaction • Ethical approach