|Implemented in this survey?|
In 2007 the Catalan Department of Health initiated a consensus process with professional leaders and primary care providers to renew primary care in Catalonia. Aimed to improve patient choice and voice, the Innovation Plan was to reinforce primary care services encouraging integration and close cooperation with other community services but lacking support from key players has come to a hold. Other key aspects are health information system, professional leadership and capitation-based purchasing.
The Innovation Plan (IP) is a plan of the Catalonian Government's Health Department aimed to reinforce person-centered integrated care within the public health services. Special emphasis is laid on improving primary care, community interventions and on care to the dependent and patients with chronic conditions. The plan is based on an ambitious reform of the payment system, the organisation and the provision of the primary care services in the community.
It is expected that current demand based care, provided by multiple disintegrated organisations will shift to a more personalised care orientated to needs. It is expected that patients will become more autonomous and will receive an integrated package of services according their needs. Changes will promote self-care, participation and the integration of public health, primary care and social services at the local level. Currently, each primary care team covers a population from 5 to 25 thousand inhabitants and additional special programmes cover services such as palliative home care. 40 different enterprises manage primary care teams. The reform wants to incentivize the merging in a single public enterprise of the different health care organisations providing services to communities of 100.000 inhabitants, in order to decentralise decisions and reduce transaction costs. The centralised main public provider of primary care services (Institut Catala de la Salut) will be motivated to create local consortiums with other primary health care providers in the local communities. The reform will substitute the existing bureaucratic structures empowering professionals in the leadership of care processes and in services management. Key issues are the development of regional clinical guidelines and local agreements on the clinical pathways as well as the connection of every provider into the network of clinical data already available for the major public provider of primary care services (Institut Català de la Salut). The public insurance company Catsalut that covers the whole population will contract the package of services to local providers based on a local health plan and will pay on a capitation basis.
Patients, primary care professionals (family doctors and nurses), provider organizations (Institut Catalá de la Salut, other public and private organizations)
|Medienpräsenz||sehr gering||sehr hoch|
The Innovation Plan proposed a radical change of the whole Catalan health care system, not simply a reform of primary care services. Proposals will benefit patients but threaten the current status of community hospitals, and face the oposition of trade unions.
We see the plan as an opportunity for rationalising health services and for shifting health care organisations from response to demand of care of the population needs.
In the eighties, during the transition from dictatorship to democracy, Spain developed a system of primary health care services based on health centres. Teams covering delimited geographical areas were launched.
This process in Catalonia was carried out since 1986 until 2003 by several mandates of the same nationalist party. In this autonomous region, in contrast to other parts of Spain, the reform was not only carried out within the public health service. The reorganization also opened the possibility of managing primary health care teams and other community health care services to other public and private providers. As a result, Catalonia opened an internal market and launched a few experiences of buying services on a capitative basis from the providers of the territory.
In 2003 a coalition of three left wing parties (socialist, nationalist republican and green) took office. The new government however followed the health policy path of its predecessor. In 2006 the coalition passed a law that decentralised health governance to territorial (local) authorities and introduced participation councils with municipalities, citizens and health care providers.
In 2007, the government faced a very important strike of unhappy and disappointed primary care doctors. The Innovation Plan intends to adjust the reform of the eighties to new policies and population needs.
In 2003 a coalition of three left wing parties (socialist, nationalist republican and green) assumed power in the regional government.
A major strike of disappointed doctors because of political continuity, relative shortage of primary care professionals compared to the rise in demand forced Gvt to respond.
|Implemented in this survey?|
The new policy is inspired by the experience of Kaiser Permanente in California, and of the Primary Care Trusts in the UK. The objective is to expand to the whole region the experiences of the expert patient, as well as of patient-centered care. At the core of the new policy are specific tools such as the universal application of the Catalan Health Information System Network (eCAP) and the publication of national evidence-based guidelines. The plan foresees that purchaser and providers align their objectives and performance to the local policies fixed by new territorial governance councils.
The approach of the idea is described as:
new: The process began two years ago with the appointment of a directorate by the regional government. The reform is based on an evaluation of current primary health care and on a participative process that involves primary care providers.
Else - Phased introduction taking place in 2008.
Government is forced to have a new plan on primary health care in order to differentiate its policy from that of its predecessors and for improving professional morale. On the other side, the coalition fears that it has to face a conflict with providers or professionals in the current political context. Most primary care providers also manage community hospitals. Such organisations are in favour of vertical integration. They see primary care as the entrance to their hospitals, and nursing homes and community long term as the exit. In previous decades they enlarged their organisation adding primary care services, nursing homes and long term care services. Currently they fear a new plan that favours horizontal integration of primary care services and supports free choice of hospital. At present 70 % of primary health care professionals in Catalonia have a civil servant status. Trade unions believe that new consortiums of primary care services at the local level might challenge this privilege.
|Government||sehr unterstützend||stark dagegen|
|High level civil servants||sehr unterstützend||stark dagegen|
|Parliament||sehr unterstützend||stark dagegen|
|Public providers linked to municipalities||sehr unterstützend||stark dagegen|
|Private providers||sehr unterstützend||stark dagegen|
|Catalan Government (main public provider)||sehr unterstützend||stark dagegen|
|Catsalut||sehr unterstützend||stark dagegen|
|Citizens||sehr unterstützend||stark dagegen|
|Catalan Society of Family and Community Medicine||sehr unterstützend||stark dagegen|
|College of Doctors||sehr unterstützend||stark dagegen|
|Nursing societies||sehr unterstützend||stark dagegen|
|Media||sehr unterstützend||stark dagegen|
|Trade unions||sehr unterstützend||stark dagegen|
|Green||sehr unterstützend||stark dagegen|
|Left Wing Republican Nationalist||sehr unterstützend||stark dagegen|
|Socialist Party||sehr unterstützend||stark dagegen|
|Nationalist - Christian Democratic Party||sehr unterstützend||stark dagegen|
|Conservative Party||sehr unterstützend||stark dagegen|
Although implementation of the Innovation Plan will require a change in legislation, the reform is not yet on the agenda. In fact given strong opposition from proponents of vertical integration and traditionally strong stakeholders (Catsalut and the hospitals) at present it seems unlikely that the plan will ever pass legislation in its current shape.
|High level civil servants||sehr groß||kein|
|Public providers linked to municipalities||sehr groß||kein|
|Private providers||sehr groß||kein|
|Catalan Government (main public provider)||sehr groß||kein|
|Catalan Society of Family and Community Medicine||sehr groß||kein|
|College of Doctors||sehr groß||kein|
|Nursing societies||sehr groß||kein|
|Trade unions||sehr groß||kein|
|Left Wing Republican Nationalist||sehr groß||kein|
|Socialist Party||sehr groß||kein|
|Nationalist - Christian Democratic Party||sehr groß||kein|
|Conservative Party||sehr groß||kein|
The directors of the plan desire to implement several pilot projects during 2009, although the territories have not yet been selected.
If the pilot projects are launched an evaluation programme will be developed, although indicators are not already defined.
Struktur, Prozess, Ergebnis
The government created the plan for introducing minor changes in the health centres that will please professionals and patients. It was not expected that the consensus process came out with an ambitious reform of the whole health care system. At this point it seems quite likely that the innovation plan will never be implemented. It might finish as yet another well-intended document on the shelves. The few people who support the proposal are not influential enough and current political and social context do not favour change. Community hospitals are the cornerstone of the Catalan Health System since the early eighties. Without important cultural, legislative and finance changes it is impossible to tip the balance from them toward primary health care.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
If the policy were implemented it would indeed improve substantially the effectiveness and efficiency of health care services.
Joan Gené Badia