CASAP: A new form of primary care delivery

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The importance of accessing primary care as an entry door to the health public system and the current context defined by lack of professionals and limited resources has generated the need to incorporate organisational innovations that provide this service in a decisive and efficient form. The consortium CASAP, though under public ownership, has its own judiciary and managerial autonomy and is the new organisational formula developed in the Catalan health system to attend to these demands.

Purpose of health policy or idea

The purpose of this policy is to promote new organisational forms in primary care  which would improve the efficiency and the quality of services, by creating entities that enjoy autonomy and greater managerial capacity. In addition, it seeks to involve local authorities in the organisation and responsibility of health services within their domain.

Main points

Main objectives

Provide greater managerial capacity and autonomy to the primary care centres (PCC).

Involve local authorities in the organisation of health resources.

Increase the efficiency and quality of services provided by the PCC.

Improve staff management, in particular to increase motivation and performance.

Strengthen the gate-keeping role of the PCC in the health system and extend the decisive capacity of the primary care.

Type of incentives

Particular legal framework

Financial management autonomy

Staff management and contracting in the labour regime

Capacity to offer a portfolio of complementary activities and private services

Autonomy in the establishment of agreements with different providers

Groups affected

Patients, Professionals, Health autorities

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

This initiative can potentially benefit the primary care system in three ways.

• First, it permits the development of a gate-keeping function by the centres in the health care system.
• Second, it reduces the congestion of other health care levels due to its capacity to offer complementary services.
• Finally, it stimulates the search for mechanisms of both vertical and horizontal integration to improve the development of activity and to reduce costs.

Political and economic background

The current conjuncture arising from the lack of professionals and the resource limitation in the public health system, has made necessary to search for new organisational forms that improve the management of the primary care centres and reinforce their gate-keeping function in the health care system. Since the promulgation of the LOSC (Health Care Organisation in Catalonia Act) in 1990, the primary care public services in Catalonia have been based on a model that separates provision and purchase.

The public purchaser, CatSalut, has three models of service provision for primary care.

1. First, the Catalan Institute of Health(CIH), which is the main public provider of health services in Catalonia and to whom the resources of the National Health Service were transferred as a result of the decentralisation process.
2. Second, Sanitary Integrated Organisations (SIO), which are public-private consortia with participation by the Autonomous Administration or local authority, and are organised around the management of a hospital.
3. Third, the Associative Base Entities (ABE), which are private associations constituted principally by family doctors, and are analogous to British fundholdings.

Unlike the previous policy of the Autonomous Government of Catalonia, which promoted the diffusion of the ABE, the new government, headed by the socialist party, chose to design another organisational form that had autonomy, but kept public ownership and counted on the participation of Local Authorities.

CASAP provides services to approximately 24,000 inhabitants of Castelldefels' city.

Change of government

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The Consorci Castelldefels Agents de Salut D'Atenció Primària (CASAP) is a new organisational form developed in the Catalan health system in 2005. The consortium is constituted of the regional health authority CIH (70 %) and the local authority (30 %). It has been defined as a legal public entity, and has the freedom to operate under both public and private law.

The idea was generated beforehand both by local authorities and the Catalan Institute of Health (CIH), the autonomous health services' main public provider. There's no such organisation in their setting.

It differs from other organisational models in the Catalan Primary Care System by not being linked to a hospital entity (unlike the SIO model) and by keeping its public ownership (unlike the ABE).

This organisational form grants autonomy on financial management and on the hiring of staff under the same labour rules as for private organisations. The consequences of these specific issues allows them develop a more agile and flexible management to provide services adapted to the needs of their respective populations.

Initiators of idea/main actors

• Regierung: Catalan Minister of Health has always been enthusiastic and promoted new actions. Authonomical government agrees on the project and makes a bill, thus creating the consortia.

• Leistungserbringer: Catalan Health Institute (CIH) is the main provider in the public health system. It promotes the idea to cooperate with local authorities and it is one of the partners in CASAP.

• Kostenträger: CatSalut is the public purchaser organisation

• Patienten, Verbraucher: Patients are supportive because it increases the supply of services

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

The Catalan Health Service, the autonomous organisation for the purchase of public services, agreed to the idea. There was no reaction from other organisations, though health professionals in surrounding Catalan Health Institute primary care teams were suspicious of it. Professionals were selected for building the team in order that they have a vested interest. The manager was hired some months in advance of its opening, both for selection of human resources and connecting with other levels of care.

Actors and positions

Regierung
Catalan Ministry of Health	sehr unterstützend		stark dagegen
Local Authorities	sehr unterstützend		stark dagegen
Leistungserbringer
Catalan Health Institute (CIH)	sehr unterstützend		stark dagegen
Kostenträger
CatSalut	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen

Influences in policy making and legislation

There were not significant influences during the legislation process.

Legislative outcome

success

Actors and influence

Regierung
Catalan Ministry of Health	sehr groß		kein
Local Authorities	sehr groß		kein
Leistungserbringer
Catalan Health Institute (CIH)	sehr groß		kein
Kostenträger
CatSalut	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

In 2005, CASAP was formally constituted, comprised of the CIH and the Local Authority of Castelldefels. Its function was to manage the new primary care centre of the locality. They selected a management team, composed of a director-manager, an assistant director and a financial manager, and established the selection criteria of skills and attitudes used to evaluate candidates for other staff positions, with evaluation delegated to the management team.

Subsequently, diagnostic resources were acquired and the additional pathologies the centre would solve (programmes of dietetic advice, day surgery, nicotine addiction, etc.) were determined which there was extended the public provision of services, and since the consortium constitution, and they elaborated a portfolio of private services (dentistry, speech therapy, psychology and acupuncture).

Monitoring and evaluation

No special mechanism of periodic monitoring has been established to evaluate implementation, but the public purchaser has defined yearly objectives, some of them clinical and others organisational. The managers of the centre also have internal management indicators to monitor performance (assistance results, questionnaires on the motivation and training of professionals, and the degree of satisfaction of their patients).

Review mechanisms

Halbzeitevaluation

Dimensions of evaluation

Prozess, Struktur

Results of evaluation

The centre has got good clinical results with no waiting lists. Quality survey and professional qualitty survey give good results, too. The motivation of the staff is increased up to the level of the ABE's centers.

Expected outcome

The introduction of this new organisational form facilitates an improvement in the efficiency and quality of services provided by primary care centres, by means of an organisational structure that stimulates improved stakeholder performance.

Explanations for this improvement are:

• greater autonomy and managerial capacity, placing emphasis on results and managerial performance, which encourages the adaptation of care services to receivers´ needs;
• developing mechanisms of control and supervision that value  performance;
• greater inclusion of professionals and a flexible selection system that facilitates a major adjustment of the needs and rewards dynamism.

Another benefit is the maintenance of public ownership since it reduces the adverse incentives to the unjustified derivation of cases to other health care levels.

The most prominent obstacles of its generalisation are political interference and controversies that block these organisations' operation, or the generalisation of territorial consortia that are turned into one more funding level exercising the functions of public purchaser, instead of those of planning.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

The impact of this initiative can be considered positive due to the potential gains in efficiency and service quality, which lead to an increase in user satisfaction and are an advantage in the context of a global cost reduction.

Since the experience has thus far been restricted to a single centre, impact of the initiative is limited; nevertheless future generalisation may be predicted in light of this centre's favourable results.

References

Sources of Information

• Rico A, Saltman,R: ¿Un mayor protagonismo para la atención primaria?Reformas organizativas de la atención primaria de salud en Europa. Spain: Revista de Administración Sanitaria, 6(21); 39-67, 2006.
• Catalan Institute of Health (Institutat Català de la Salut. More information available at : www.gencat.net/ics
• Catalan Health Service (CatSalut). More information available at: www.gencat.net/catsalut

Author/s and/or contributors to this survey

Gabriel Ferragut Ensenyat

Empfohlene Zitierweise für diesen Online-Artikel:

Gabriel Ferragut Ensenyat. "CASAP: A new form of primary care delivery". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/es/b10/2