Primary care in Europe: can we make it fit for the future? European Health Summit 2013: Primary care case studies January 2013

Dr. Toni Dedeu Senior International Officer. Ministry of Health of Catalonia President Elect. EUREGHA (European Regional & Local Health Authorities)

KEY TOPIC 3 ACCELERATING REFORM OF PRIMARY CARE DELIVERY AND ORGANISATION

• Policy levers that can succesfully drive change

• Including the role of payment and incentives

• How to enable new professional roles and skill mix

Actors / Players

Individuals

Groups Organitsations

Context

Content Process

HEALTH POLICY TRIANGLE (WALT & GILSON, 1994) (BUSE ET AL, 2005)

FRAMEWORK FOR THE EUROPEAN PRIMARY CARE MONITOR

Governance of PC system Economic Conditions PC Workforce

development

Access to PC Services

Comprehensiveness of PC services Continuity of PC

Coordination of PC Quality of Care Efficiency of PC

Structure

Process

Outcome

PROCESS HEALTH POLICY

› Identification of the problem: › which topics are in the political agenda?

PC Reform needed?

Process

Departament de Salut Catalan healthcare system

Devolution process to Autonomous Communities

1981

1984

1987

1987

1990 1990

1994

2001

2001

2001

2001 2001

2001

2001

2001

2001

2001

PROCESS HEALTH POLICY

›Formulation of a health policy: A policy for PC?

› Who is involved in the formulation of the health policy › Is there any consensous about the policies

› Implementation of a health policy: Pilots? / Development and

implementation? ›Evaluation of the policy implemented

› Once an specific policy has been implemented, is there any evaluation?

Has PC been evaluated sufficiently?

Process

CONTEXT

›Situational factors: ›wars, ›epidemies, ›heat waves, ›new governement with new

policies / new Minister

Context

CONTEXT

Structural Factors: ›Political system, ›Type of economy › Demographic factors

Context

Departament de Salut Catalan healthcare system

Health care models in Europe Health care financing in the EU (and beyond)

10

Health financing policy encompasses a range of functions: Collection of funds Pooling funds Purchasing health services Coverage, benefits and cost sharing

Source: Kutzin J (2001). A descriptive framework for country-led analysis of health care financing arrangements. Health Policy, 56(3):171-203

CONTEXT

›Cultural factors: › Status quo,

› lobbies, › ethnic minorities, › jerarquies, religion, etc.

Context

Good for providers For the people, far from optimal

CONTEXT

›External or international factors:

› EU: Any evidence PC is a prority in the EU? › % of FP7 projects in PC › HORIZON 2020 › Directives › Joint Actions

› WHO › Cooperation and agreements between countries.

Context

CONTENT

What have we got in the basket?

What are the limits of PC?

Content

RELATIONSHIP BETWEEN HEALTHCARE EXPENDITURE AND LEVELS OF CARE

Self-care or care by families, friends or other carers

Primary care Secondary care

Terciary care

Decreasing patient episodes

Proportion of expenditure on healthcare

Lower costs

Source: Peckham and Exworthy 2003

ACTORS

Stakeholders with interests involved in the decision making process in health policy Ideologies, Political parties Mass media: press, TV, radio blogs, tweets, comentators, Health care providers, Insurance companies, professional organisations

and bodies, pharmaceutical companies Professionals: doctors, nurses, dentists, pharmacists, phisiotherapists,

social workers, healthcare managers, etc Payers of services: Governments, workers, interest groups in the health

sector who contribute somehow financing the system, ... Citizens: groups of patients, communities, local governments, associations,

carers, ...

actors

Departament de Salut Catalan healthcare system

Providers

(Some of them)

Catalan Public Health Insurance CatSalut

Catalan Government

Ministry of Health

Financing

Catalan Parliament

Planning

Commissioning and Buying

CATALAN HEALTH INSTITUTE - ICS

Hospitals Primary Care

Mental Health Other

PC 1 PC2

Social-Health Care

Hospital Consortium 1

Hospital Consortium 2

Hospital Consortium

3

Mental Health 1

Mental Health 1

Ambulance Trust 1

Ambulance Trust 2

€

16 Other

Contract

ACTORS

Departament de Salut Catalan healthcare system

Catalan Healthcare System • NHS based system - Beveridge • Universal coverage and free • Public financing of the services • Purchaser - Provider split • Providers with various ownership formula • Access equity (365 Primary Health Centers

and 69 hospitals – towards a cluster formula)

Investments in Primary Care produce more equity than investments in the health system in general Source: PHAMEU Project

Departament de Salut Catalan healthcare system

Population over 60 years (2009): 21,7%

Immigrant population (2010) 19%

High urban concentration (5M citizens around BCN)

Middle size cities spread in the territory

Geographically diverse and well communicated

Distance between towns – less than 10 km

98% of the population has a Primary Health Centre closer

than 10km

C A T A L O N I A

Departament de Salut Catalan healthcare system

Catalan Healthcare System Citizen’s Pathways. Gatekeeping based

C I T I Z E N S

Emergencies

PRIMARY HEALTH CENTRE

HOSPITALS

H1 H2 H3

Social & Healthcare Services

Mental Health Care

Emergency/ Triage Call Centre 061 /112

Departament de Salut Catalan healthcare system

Primary care (Health and Social?) Multidisciplinary Team

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Patient

Community approach

Nurse

Dentist

Nurse Liason

Social Worker

GP Paediatritian

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Physiotherapy

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Mental Health

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Consultants

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Patient Groups

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Community Activities

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Maternal Care

Midwife and Gynaecologist

Pharmacists

GOVERNANCE Vision and direction of a primary care system Policiy on equity in access to primary care systems (De)centralisation of primary care management and

service development Quality management infraestructure Appropriate technology in primary care Patient advocacy Ownership status of primary care practices Integration of primary care in the health care system

Source: PHAMEU Project

HEALTH PLAN - Priorities and Projects 9 priority areas and 31 projects

Objectives and Health Programmes

Chronic

Care Orientation

Performance improvement

at primary care level

Improvement of quality at

high specialization

level

Focus to patients and their families and carers New purchasing and commissioning of health services Clinical and professional knowledge at the front line Governance improvement and professional and citizen’s participation Strengthening the information system, transparency and evaluation

3

2

1

Departament de Salut Catalan healthcare system

Primary Care: Scope of Services

Free choice of Primary Health Centre, GP, Paediatrician and Nurse

Acute medicine (GP/P, N, Dentist)

Acute homecare (GP/P/N/SW/D)

Chronic Care (All the Team + Call Center + Nurse Liaison +

Coordination + … Promotion and Prevention of care (GP/P, N, D) Homecare (SW, GP/P, N,D) Minor surgery (GP) Other techniques: anticoagulant control and treatment, spirometry,

ultrasound, etc. (GP, N) Vocational Training (GP, N) Continuous Medical Education (All the Team) Research (All the Team) Community Care (All the Team + Community agents /Community Plans)

Performance improvement

at primary care level

3

GOVERNANCE

Vision and direction of a primary care system Policiy on equity in access to primary care systems (De)centralisation of primary care management and

service development Quality management infraestructure

Appropriate technology in primary care Patient advocacy Ownership status of primary care practices Integration of primary care in the health care system

Source: PHAMEU Project

Departament de Salut Catalan healthcare system

Primary Care: Scope of Services

Free choice of Primary Health Centre, GP, Paediatrician and Nurse Acute medicine (GP/P, N, Dentist)

Acute homecare (GP/P/N/SW/D)

Chronic Care (All the Team + Call Center + Nurse Liaison + Coordination + … Promotion and Prevention of care (GP/P, N, D) Homecare (SW, GP/P, N,D) Minor surgery (GP) Other techniques: anticoagulant control and treatment, spirometry, ultrasound, etc. (GP,

N) Vocational Training (GP, N) Continuous Medical Education (All the Team) Research (All the Team) Community Care (All the Team + Community agents/Community Plans)

Performance improvement

at primary care level

+

Dematology Ophtalmology ENT (Ear Nose & Throat diseases)

Mental Health Mucolosketetal disesases

High performance in

3

Departament de Salut Catalan healthcare system

26

INTEROPERABILITY

Catalan Shared Medical Record

Telemedicine Medical Image Digitization Plan

Personal Health Folder

Electronic Prescribing

RESOURCES SHARING NETWORKING MODEL

COLLABORATION MODEL CO-RESPONSIBILITY

Key ICT Projects – Governing characteristics

Appropriate technology in primary care

GOVERNANCE

Quality management infrastructure

Patients receive higher quality care in geographical areas where performance measures and monitoring has been established

Pay for performance schemes provide financial incentives that can change professional behaviour and improve the quality of care

Source: PHAMEU Project

ECONOMIC CONDITIONS OF THE PRIMARY CARE SYSTEM

Health care funding system Health care expenditures Primary care expenditure Employment status of primary care workforce Remuneration system of primary care workforce Income of primary care workforce

PRIMARY CARE WORKFORCE DEVELOPMENT

Profile of primary care workforce Recognition and responsibilities Education and retention Professional associations Academic status of the primary care discipline Future development of the primary care

workforce