Primary Care Innovation Plan of Catalonia

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

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Abstract

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.

Purpose of health policy or idea

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.

Main points

Main objectives

1. The patient will have more choice and voice and will receive an integrated package of services according to its health needs
2. Higher professional leadership and accountability in service management
3. Integration of public health, community programmes and primary care services

Type of incentives

• For patients: more choice, participation, less bureaucracy and integrated package of services.
• For professionals: more leadership, smaller organisations, enhancement of professional competences, and less bureaucracy.
• For the health system: more efficiency, better matching of political health territories with provider organisations, better quality of the service.

Groups affected

Patients, primary care professionals (family doctors and nurses), provider organizations (Institut Catalá de la Salut, other public and private organizations)

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

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.

Political and economic background

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.

Change of government

In 2003 a coalition of three left wing parties (socialist, nationalist republican and green) assumed power in the regional government.

Complies with

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.

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 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.

Initiators of idea/main actors

• Regierung: Government wants to have a new approach of the provision of primary health care services, but achieving consensus and support from all stakeholders proved very difficult.

• Parlament: No opinion from parliament has been voiced yet.

• Leistungserbringer: Providers oppose the plan because they prefer vertical to horizontal integration. When the plan was drawn up, the main public provider (ICS) launched a reform of its managerial structure based on a vertical integration scheme.

• Kostenträger: Catsalut is in favour of the capitation purchasing system and wants to reduce the growing activity of regional hospitals on a fee for service basis.

• Patienten, Verbraucher: Not aware of the project

• Wissenschaft: The Catalan Scientific Society of Family Doctors, which is very influential, is not having an opinion. The College of Doctors is supporting a group of doctors that runs a self-owned private practice contracting with Catsalut. This group officially supports the plan because it envisages an opportunity of enlarging their business.

• Medien

• Andere: Trade unions oppose the plan because they fear to lose their civil servant status.

• Politische Parteien: Left wing political parties (Green and Republican Nationalist) are strongly against privatisation. These parties do not like public enterprises ruling under the private legislation because they do not want health professionals lose their civil servant status they already have in current public health organisations. The main oppostion party (Nationalist - Christian Democratic) and the Socialist Party are supporting the interest of the community hospital enterprises. However these parties have not yet made public their position.

Approach of idea

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.

Innovation or pilot project

Else - Phased introduction taking place in 2008.

Stakeholder positions

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.

Actors and positions

Regierung
Government	sehr unterstützend		stark dagegen
High level civil servants	sehr unterstützend		stark dagegen
Parlament
Parliament	sehr unterstützend		stark dagegen
Leistungserbringer
Public providers linked to municipalities	sehr unterstützend		stark dagegen
Private providers	sehr unterstützend		stark dagegen
Catalan Government (main public provider)	sehr unterstützend		stark dagegen
Kostenträger
Catsalut	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Citizens	sehr unterstützend		stark dagegen
Wissenschaft
Catalan Society of Family and Community Medicine	sehr unterstützend		stark dagegen
College of Doctors	sehr unterstützend		stark dagegen
Nursing societies	sehr unterstützend		stark dagegen
Medien
Media	sehr unterstützend		stark dagegen
Andere
Trade unions	sehr unterstützend		stark dagegen
Politische Parteien
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

Influences in policy making and legislation

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.

Legislative outcome

pending

Actors and influence

Regierung
Government	sehr groß		kein
High level civil servants	sehr groß		kein
Parlament
Parliament	sehr groß		kein
Leistungserbringer
Public providers linked to municipalities	sehr groß		kein
Private providers	sehr groß		kein
Catalan Government (main public provider)	sehr groß		kein
Kostenträger
Catsalut	sehr groß		kein
Patienten, Verbraucher
Citizens	sehr groß		kein
Wissenschaft
Catalan Society of Family and Community Medicine	sehr groß		kein
College of Doctors	sehr groß		kein
Nursing societies	sehr groß		kein
Medien
Media	sehr groß		kein
Andere
Trade unions	sehr groß		kein
Politische Parteien
Green	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

Positions and Influences at a glance

Adoption and implementation

The directors of the plan desire to implement several pilot projects during 2009, although the territories have not yet been selected.

Monitoring and evaluation

If the pilot projects are launched an evaluation programme will be developed, although indicators are not already defined.

Review mechanisms

Halbzeitevaluation

Dimensions of evaluation

Struktur, Prozess, Ergebnis

Expected outcome

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. 

Impact of this policy

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.

References

Sources of Information

www.gencat.net/salut/depsalut/html/ca/dir2252/index.html

Author/s and/or contributors to this survey

Joan Gené Badia

Empfohlene Zitierweise für diesen Online-Artikel:

Gené Badia, Joan. "Primary Care Innovation Plan of Catalonia". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/es/a12/3