Integrating health and social care

• 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

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.

Purpose of health policy or idea

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
Transferability	strongly system-dependent		system-neutral

Political and economic background

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

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[1], 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.


[1] In this respect, we would recommend visiting the International Journal of Integrated Care website (http://www.ijic.org).

Stakeholder positions

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:

• Firstly, as has been seen in the development of the 1st Plan, the unequal level of health and social services cover is one of the main obstacles to the existence of genuine coordination between the two. For this reason, if advances are to be made in this sense, it is necessary for Castilla y León to first define what type of public coverage for long-term care services it is going to offer: having to choose whether to follow a means-tested model such as that used currently or opting instead for a universal coverage scheme such as that used in health care.
• Likewise, despite the recent transfer of health care powers, it is still true that social and health care services continue to rest in the hands of various levels of government: thus, despite the regional government managing all health services, social services are managed at both this level and by local authorities. The existence of two decision-making Administrations thus leads to difficulties in any attempt to achieve a greater level of integration of social and health care.
• Finally, the different professional cultures in the social and health sectors, centred on care and cure respectively, also act as an obstacle in increasing the integration of social and health services. Furthermore, training and staffing systems do not promote the specialised professional profiles required in the field of integrated care. The recent proposal of the nursing associations to create the specialties of geriatric, community and public health nursing has not yet been addressed by the Ministry. The medical specialty of geriatrics, introduced in the late 80s, is also still underdeveloped in Spain: geriatricians represent less than 2% of hospital physicians, and only 43 of the more than 5,000 postgraduate training positions for resident doctors available in 2001/2 were allocated to geriatric medicine.

Influences in policy making and legislation

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.

Expected outcome

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.

References

Author/s and/or contributors to this survey

David Casado

Suggested citation for this online article

David Casado. "Integrating health and social care". Health Policy Monitor, October 2003. Available at http://www.hpm.org/survey/es/b2/4