The Catalan Health System: Le cas de la Catalogne Toni Dedeu, MD MSc - - PowerPoint PPT Presentation

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

tdedeu@brihssa.com

On behalf of

Institut Català de la Salut

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

Es Espag pagne ne

Fr Fran ance ce

Le cas de la Catalogne 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

• 4 6 .0 6 3 .5 1 1

citizens on January the

1 st, 2 0 0 8

• 4 Official

languages

Spanish, Catalan, Euskera (Bask language) and Galizian . Spanish Constitution 1978

• Life expectancy 2 0 0 6 ) :

7 9 .6 5

• Death Rate per 1 0 0 0

inh: 8 .4

• GDP/ Capita ( 2 0 0 7 ) :

3 2 .0 8 8 US$

(based on purchasing power parity)

Catalogne

• 7 .3 5 4 .4 4 1

citizens on January the 1 st, 2 0 0 8

• 3 Official

languages

Catalan, Spanish, Occitan (Aranès) Catalan Constitution 2006

• Life expectancy ( 2 0 0 6 ) :

8 1 .3 5

• Death Rate per 1 0 0 0 inh:

8 .2

• GDP/ Capita ( 2 0 0 7 ) :

4 2 .2 9 1 US$

(based on purchasing power parity)

• 6 3 .7 5 3 .0 0 0

citizens on January the 1 st , 2 0 0 8

• Official languages

Le français est la langue officielle de la République Française (article 2 de la Constitution de 1958)

• Life expectancy ( 2 0 0 6 ) :

7 9 .7 3

• Death Rate per 1 0 0 0 inh:

9 .1 4

• GDP/ Capita ( 2 0 0 7 ) :

3 3 .1 8 7 US$

(based on purchasing power parity)

Fr Fran ance ce Es Espag pagne ne

• 1 9 3 3

Charity System

• 1 9 3 6

1 9 3 9

Spanish Civil W ar (Prelude of the 2nd 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)

____________________________________________________________________________________________________

• 1 9 8 6

N ational H ealth Service & Prim ary care Reform

• 1 9 8 6

Quasi - Federal System ( Autonom ous Com m unities)

Catalan Health Ministry and Catalan Departm ent of Health

HEALTHCARE SYSTEM STRUCTURAL REFORM: 1 9 8 6

• General Healthcare Act: Universal Coverage
• Based on the Beveridge m odel
• Progressive transition towards a tax funded system : NHS

National Healthcare System

• Decentralized to Autonomous Communities (Devolution)
• Health 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

Services provided mainly in public facilities Co-payment in pharmaceutical products for out-

patients with exceptions: eg. retired people, special diseases, disabled people.

Dental care: limited public service basket Description of Services Basket by OECD categories

HEALTHCARE SYSTEM STRUCTURAL REFORM: 1 9 8 6

U S E R

CATALAN HEALTH INSTITUTE

ICS

20%

Contracted Providers 70%

Private Centres 10%

CATALAN HEALTH SERVICE 100%

Population

Suplem entary Private I nsurers 2 0 %

Insurance Services

Providers

Catalan Public Health Insurance

CatSalut

Catalan Ministry of Health Department of Health

Finnancing Catalan Parliam ent Planning Commissioning and Buying CATALAN HEALTH INSTITUTE ‐

IC ICS

Hospital s Primary Care Mental health Other PC 1 PC2 PC 2

Hospital Consortium 1 Hospital Consortium 2 Hospital Consortium 3

Mental Health 1 Mental Health 1 Ambulance Trust 1 Ambulance Trust 2

€ €

3% 75% 10% 7% 5%

C I T I Z E N S

HOSPITALS

H1 H2 H3

Long-term Care Centres Mental Health Care

Gatekeepers Multidisciplinary Team

GPs (>15 yr old) Pediatrics (0 to 14 yr

• ld)

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
• Equal services for all
• Proactive Care
• Population stratification
• Identification of patients with

chronic diseases Patient

• No choice. Patients went where

were assigned

• Passive patient
• Patient Choice
• Patient involvement and selfcare

Leadership

• County Hospitals
• Executive Director and Support

team at County level

• Full “Commissioning” role: to plan

and purchasing of local services Policies and strategies

• Catalan Health Plan
• Catalan Health Plans + Local

Strategic Plans Clinical Guidelines

• Each provider developed their
• wn clinical guidelines
• The same Clinical guidelines for all

Catalonia (HealthTechnology Agency and Department of Health)

• Interactive clinical Guidelines

within electronic clinical records Care Pathw ays

• Not defined
• Local level: providers and local

clinical leaders design the local care pathways

Form er Model Tow ards the Current Futur

I T system

• Various Electronic Clinical records
• IT systems not interconnected
• No warnings nor calls for risk

situations

• Unified Electronic Clinical Record
• Warning systems interconnected withing

the different care levels and professionals

Professionals -Doctors + Nurses

• Professionals with a range of backgrounds

Care

Hospital Bed + + + Office/ Practice + + + + Homecare + Telephone/ email - Telemedicine - Hospital Bed + + Office/ Practice + + + + Homecare + + Telephone/ email + + + + Telemedicine + + + Development of new indicators which favour integrated care

Relation W ith Social Services

• Dependecy Act of Catalonia.

Difficulties to be implemented.

• Non existence of a cooperation model

between health and social services

• Design of a cooperation model between

social and health services

Reorganization of the Catalan Health System

1986

Federal System

Catalan Health Minister and Catalan Department of Health

2009 Territorial Governments

Aim: Health System and Local authorities working together 7 Health Regions

Empowerment of the Local: 37 Territorial Governments (county level)

• Department of Health
• County Authorities
• Local Authorities
• Citizen and local stakeholders’

participation

Clinical Governance

1 . Marroco 2 3 5 .1 3 3 2 . ( EU-2 7 ) Rom ania 9 6 .6 9 5 3 . Ecuador 8 6 .9 2 2 4 . Bolivia 6 3 .3 0 1 5 . Colom bia 5 1 .6 8 4 6 . ( EU-1 5 ) I talia 4 8 .3 6 0 7 . China 4 6 .7 6 5 8 . Peru 3 7 .3 4 5 9 . Argentina 3 6 .6 4 4 1 0 . ( UE-1 5 ) France 3 6 .1 7 3

TOTAL POPULATI ON: 7 .5 1 8 .2 7 2 ( 1 st January 2 0 0 9 ) SPANI SH NATI ONALI TY: 6 .2 8 1 .8 2 9 Non Spanish Nationality: 1 .2 3 6 .4 4 3

1 1 . Pakistan 3 5 .8 9 4 1 2 . Brazil 3 0 .2 8 9 1 3 . ( EU-1 5 ) Germ any 2 4 .1 9 3 1 4 . Dom inican Republic 2 2 .2 6 1 1 5 . ( UE-1 5 ) United Kingdom 2 1 .8 5 4 1 6 . Senegal 1 9 .4 5 5 1 7 . Chile 1 7 .6 9 3 1 8 . ( UE-1 5 ) Portugal 1 7 .6 7 0 1 9 . Gam bia 1 7 .1 8 0 2 0 . Ukraine 1 7 .0 7 8

Africa European Union Latin America Asia

European Non EU

Catalonia 2050: 45% total population aged 60 yr or more

www.idescat.cat/cat/poblacio/projeccions/

Osteoporosis Heart Disease Diabetes Dysmetabolic Syndrome Depression Immunological Disorders Dementia

tdedeu@brihssa.com

Thank you