|Implemented in this survey?|
The law is in part the result of a process of health management and responsibilities decentralization, from the central government to regional tiers, which started in Spain more or less around the beginning of the 1980s.
The main aim of the programme is to improve levels of efficiency in the provision of social and health care for those groups that have, simultaneously, both social and health problems (frail
elderly people, the disabled, the mentally ill, those with drug dependencies, etc.). Likewise, another aim of the programme, which is closely related to the previous one, is to avoid patients with
fundamentally social problems being treated unnecessarily in health care settings, ie "bed-blockers".
The programme, in order to attempt to meet the objectives set, foresees the development of the following activities during its period in force (2003-2007): 1) the creation of operational health and social care coordination structures, where the principal exponent of these are the so-called base coordination teams (BCT); these teams, of which there will be one in each basic health area/basic social action area, are made up of members coming from both primary health care teams and social services centres; 2) the development of a work methodology by the BCTs based on case management: ie valuing both the social and health care needs of the subjects and establishing and monitoring integrated packages of care for each; 3) the design, development and implementation of a shared information system, that allows social and heath care professionals partial access to the other's system database; and 4) the specific training of professionals from both areas in the coordination of social and health care, producing training support materials and distributing them.
However, despite the ambitious nature of the aforementioned measures, the Plan does not indicate the additional costs that their development implies. In this respect, it merely mentions that the annual contributions for the development of these measures will be decided by the regional government on setting the budgets for each year.
The only incentive system set out in the Plan for the planned activities to go ahead is a non-financial one. Specifically, given that the central management bodies for both the health care system and social services have to take charge of the Plan, these bodies have to assume responsibilities through the formalising of "commitment documents". These documents, which have to be subscribed to annually, set explicit commitments in terms of the development of the measures foreseen in the Plan. No mention is made, however, of what happens if these commitments are not complied with.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
|Implemented in this survey?|
Castilla y León is the region of Spain with the highest level of demographic ageing (22.3% of the population is over 65, compared to 18% for Spain as a whole). This autonomous region also
has a much greater social services provision than the national average, with management being the responsibility of the town councils (home help) and regional government (day centres and residential
care homes). In early 2002, the regional government took over full control of health care from central government, creating a new Health and Social Welfare Ministry. These three factors - an aged
population, important social services provision and a single Ministry - constitute, without doubt, the reasons behind this region's leading the way in terms of integrating social and health care.
Indeed, this 2nd Plan for integrating health and social care continues on from another Plan, under the same name, that was approved in 1998. The fact that the region has recently taken control of
health care has, doubtless, allowed for the elaboration of this second more ambitious Plan.
In any case, beyond the specific aspects of the new Plan, the underlying ideas are identical to those that have led to the integration of social and health care in other developed countries. These experiences, which are both infrequent and rarely evaluated, start from the same premise that the current fragmentation of social and health care services generates inefficiency for two reasons: on the one hand, the synergies that could be produced if there were greater coordination between social and health care services are not taken advantage of and, on the other, the low levels of interconnection between both leads to an inadequate balance of care (typically, the lack of social services leads to overuse of the health services). Castilla y León's 2nd Plan, produced by the Health and Social Welfare Ministry, is also based on these two aforementioned premises.
 In this respect, we would recommend visiting the International Journal of Integrated Care website (http://www.ijic.org).
The Plan has to be understood in its own terms. It is a general regulatory framework that foresees the development of a series of actions aimed at promoting greater integration of the social and health services. It is obvious then that, without the law, it is very unlikely that these measures will be developed in the future. The most relevant aspect, however, is whether the law is enough to promote the changes it is designed for. In this respect, the most important obstacles faced as are follows:
The Plan is still only a few months old and, thus, there has yet to be any evaluation of the results. However, two evaluations are set to be made in the next few years: one at the halfway point of the Plan (2005) and the other when it ends (2007). Likewise, despite being less exhaustive than these evaluations, there are also to be annual follow-up reports for the Plan. All these evaluation tasks are to be carried out by a Health and Social Welfare Ministry body, from qualitative indicators relating, basically, to the level of compliance with the "commitment documents" mentioned above.
The Plan is an ambitious and, technically, well developed document. It is explicit in terms of the actions that have to be developed to increase the integration of the social and health services. The main weakness in the programme, however, is that it does not explicitly state the additional amounts of money that it can count on for carrying out the planned activities. Likewise, given that any attempt to improve coordination between the health social services brings with it high transaction costs for both, the programme's current lack of incentives - financial or otherwise - may seriously compromise the possibility for substantial change. In any case, as the programme is going to be in force for four years, we hope that time will bear out whether the aforementioned uncertainties are resolved in the right direction.