|Implemented in this survey?|
There is debate concerning the experiences with integrated care projects that are taking place in different autonomous regions. The experiences are not homogeneous, they do not have the same characteristics and there is debate on how integration should be done, and even if it should be done at all due to a lack of evidence available. See J. Pou et al, 2005, for a summary of experiences.
Integration of primary and hospital/specialised care, in the hope that this will improve efficiency, reduce costs and improve the quality of health services to patients. The autonomous regions are trying different ways of integrating care and of achieving better coordination among primary and specialized care.
The objectives are to:
Doctors and other professionals in the NHS, patients, health managers and providers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The ever pursued objectives of efficiency and quality, together with budget constraints, have forced health authorities to try different formulas of organizing provision, purchase and financing of public health services.
Integration and/or better coordination of primary and specialized care is now a method tried by different regional health authorities, as well as transferring risks to providers by means of paying providers on a per capita basis. The evidence in other countries as well as the theoretical advantages of integrated care has impelled the on-going pilot projects. See for example the case of Catalonia in HPM report (1) 2003.
Also demographic and lifestyle factors (like higher prevalence of chronic diseases) have contributed to the implementation of integrated care experiences.
|Implemented in this survey?|
There is no white paper on integrated care that clearly defines the objectives, the process and the characteristics of integrating care. Experiences from other countries (mainly USA) have contributed to the implementation of integrated care pilot projects in different regions and those experiences have contributed to expanding them to broader areas within each region (e.g. Catalonia), even though still not much evidence is available on the achievement of the desired goals. The idea of implementing integrated care has come from health authorities and in some cases from other influential agents (e.g. the "Consorci Hospitalari de Catalunya", an association of publicly-owned health care providers).
Integrated care can also be seen as one step closer to the reforms being implemented within the on-going process of decentralization; the following steps are, e.g. in the case of Catalonia, allowing some public providers to have greater management flexibility and autonomy (e.g. transforming them to public enterprises, as it is the case with the "Institut Català de la Salut"), and further decentralization towards local governments.
The approach of the idea is described as:
Local level - Catalan Health System, Navarra Health System, etc.
Public administration in general is very supportive; it is the leading actor.
Health professionals and managers of primary care are somehow unenthusiastic about the reform because they fear that it will give hospitals and hospital managers even greater power within the public health system, so that the role of primary care will be reduced. They also argue that there is not much mobility of professionals across primary and specialized care. Furthermore, they claim that if hospitals will gain even more power this may reduce the quality of the NHS through a less population-oriented care, a reduction of patient satisfaction, a reduction in the budget assigned to research in primary care, public health and prevention.
Health professionals in general are "waiting and seeing".
Patients and society in general are not usually asked about their opinions on the reform.
|Regional governments||very supportive||strongly opposed|
|Doctors and other health professionals||very supportive||strongly opposed|
There is no specific legislation on this.
|Regional governments||very strong||none|
|Doctors and other health professionals||very strong||none|
The hospital and primary care sector and hence the professionals working in those health areas are involved in the implementation process of pilot projects. Financial and other incentives are needed for their success: payment on a per capita basis (well adjusted to population needs that take into account e.g. needs on prevention and old age patients needs), incentives to change the actual structures and change the way of thinking of both primary care and hospital doctors, towards a culture of cooperation rather than competition.
Other needed measures are:
Little evidence is available on the results obtained by the existing experiences, even though it seems that the transfer of risks to health providers created by the payment on a per capita basis has not created risk selection problems.
However, most experiences are quite new, so that not much evidence is available yet. Moreover, the experiences are not homogeneous, it seems that regional health authorities that want to improve the system try to copy (with ad-hoc constraints and differences) the formulas tried by other regional health authorities. A nation-wide comparison of results is needed, but there are not yet any signs of that being done.
Event though little evaluation has been done, we know that:
Effects will partially depend on the way integration can be/is done and the participation of the affected groups, especially doctors and other health professionals, who are the ones that have to provide services to patients and who can make things work better or worse.
It is also important that hospital care does not become even more important than it is now, and that the role of primary care in the system is not reduced; for that, the election of managers of integrated services is an important issue.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The integrated care pilot projects are expected to increase efficiency and quality, but there is still the need to continue reforming the process and learning from existing experiences.
Jonay Ojeda, José Manuel Freire and Juan Gervás (2006): La coordinación entre atención primaria y especializada: ¿reforma del sistema sanitario o reforma del ejercicio profesional?, Revista de Administración Sanitaria, 4 (2): 357-83.
Pou, Joan, Joan Gené, Cristina Cámara, Ikaki Berraondo, Joan Puig (2006): Gerencia única: una ilusión sin evidencia. Atencíon Primaria, 37 (4), pp. 231-234.
Consorci Hospitalari de Catalunya: Recomenacions i precaucions sobre l'ús de l'assignació per càpita a Catalunya (2001).
Various articles in Revista de Administración Sanitaria, (2006).
Vázquez, Mª Luisa, Ingrid Vargas, Joan Farré and Rebeca Terraza (2005): Organizaciones sanitarias integradas: una guía para el análisis", Revista Española de Salud Pública, 79 (6), nov./des.