Toni Dedeu: accelerating reform of primary care delivery

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Toni Dedeu: accelerating reform of primary care delivery

  1. 1. Primary care inEurope: can wemake it fit forthe future?European Health Summit 2013: Primary care case studiesJanuary 2013Dr. Toni DedeuSenior International Officer. Ministry of Health of CataloniaPresident Elect. EUREGHA (European Regional & Local Health Authorities)
  2. 2. KEY TOPIC 3ACCELERATING REFORM OF PRIMARY CAREDELIVERY AND ORGANISATION• Policy levers that can succesfully drive change • Including the role of payment and incentives • How to enable new professional roles and skill mix
  3. 3. HEALTH POLICY TRIANGLE (WALT & GILSON, 1994) (BUSE ET AL, 2005) Context Actors / Players Individuals Groups OrganitsationsContent Process
  4. 4. FRAMEWORK FOR THE StructureEUROPEAN PRIMARY ProcessCARE MONITOR Outcome Governance of PC PC Workforce Economic Conditions system development Access to PC Comprehensiveness Continuity of PC Services of PC services Coordination of PC Quality of Care Efficiency of PC
  5. 5. PROCESS HEALTH POLICY Process› Identification of the problem: › which topics are in the political agenda? PC Reform needed?
  6. 6. Departament de Salut Devolution process to Autonomous Communities Catalan healthcare system 2001 1987 1990 2001 2001 1990 1981 2001 2001 2001 1987 2001 2001 2001 1984 1994 2001
  7. 7. PROCESS HEALTH POLICY Process› Formulation of a health policy: A policy for PC? › Who is involved in the formulation of the health policy › Is there any consensous about the policies›Implementation of a health policy: Pilots? / Development and implementation?› Evaluation of the policy implemented › Once an specific policy has been implemented, is there any evaluation? Has PC been evaluated sufficiently?
  8. 8. Context CONTEXT ›Situational factors: › wars, › epidemies, › heat waves, › new governement with new policies / new Minister
  9. 9. Context CONTEXT  Structural Factors: › Political system, › Type of economy › Demographic factors
  10. 10. Departament de Salut Health care models in Europe Health care financing in the EU (andCatalan healthcare system beyond) Health financing policy encompasses a range of functions:  Collection of funds  Pooling funds  Purchasing health services  Coverage, benefits and cost sharing Source: Kutzin J (2001). A descriptive framework for country-led analysis of health care 10 financing arrangements. Health Policy, 56(3):171-203
  11. 11. Context CONTEXT ›Cultural factors: › Status quo, Good for providers For the people, far from optimal › lobbies, › ethnic minorities, › jerarquies, religion, etc.
  12. 12. Context CONTEXT ›External or international factors: › EU: Any evidence PC is a prority in the EU? › % of FP7 projects in PC › HORIZON 2020 › Directives › Joint Actions › WHO › Cooperation and agreements between countries.
  13. 13. CONTENTContent What have we got in the basket? What are the limits of PC?
  14. 14. RELATIONSHIP BETWEEN HEALTHCARE EXPENDITURE AND LEVELS OF CARE Decreasing patient episodes Self-care or care by families, Primary care Secondary Terciary friends or care care other carers Lower costsSource: Peckham and Exworthy 2003 Proportion of expenditure on healthcare
  15. 15. ACTORSactors Stakeholders with interests involved in the decision making process in health policy  Ideologies, Political parties  Mass media: press, TV, radio blogs, tweets, comentators,  Health care providers, Insurance companies, professional organisations and bodies, pharmaceutical companies  Professionals: doctors, nurses, dentists, pharmacists, phisiotherapists, social workers, healthcare managers, etc  Payers of services: Governments, workers, interest groups in the health sector who contribute somehow financing the system, ...  Citizens: groups of patients, communities, local governments, associations, carers, ...
  16. 16. Departament de Salut ACTORS (Some of them) Catalan healthcare system CatalanParliament Catalan Government € Ministry of Health Financing Planning Catalan Public Health Insurance CatSalut Commissioning and Buying Contract Providers Social-Health Care ICS PC 1 PC2 Hospital CATALAN HEALTH INSTITUTE - Consortium Hospital Hospital 3 Hospitals Primary Mental Other Consortium 1 Consortium 2 Ambulanc Health Care e Trust 2 Mental 16 Mental Ambulanc Health 1 Health 1 e Trust 1 Other
  17. 17. Departament de Salut Catalan Healthcare System Catalan healthcare system • NHS based system - Beveridge • Universal coverage and free • Public financing of the services • Purchaser - Provider split • Providers with various ownership formula • Access equity (365 Primary Health Centers and 69 hospitals – towards a cluster formula)  Investments in Primary Care produce more equity than investments in the health system in general Source: PHAMEU Project
  18. 18. Departament de Salut CATALONIA Catalan healthcare system Population over 60 years (2009): 21,7% Immigrant population (2010) 19% High urban concentration (5M citizens around BCN) Middle size cities spread in the territory Geographically diverse and well communicated Distance between towns – less than 10 km 98% of the population has a Primary Health Centre closer than 10km
  19. 19. Catalan Healthcare SystemDepartament de Salut Catalan healthcare systemCitizen’s Pathways. Gatekeeping based Emergencies HOSPITALS C H1 H2 H3 I T I PRIMARY Social & Z HEALTH Healthcare CENTRE Services E N Emergency/ Triage Mental Health S Call Centre 061 /112 Care
  20. 20. PrimaryDepartament de Salut care (Health and Social?) Multidisciplinary TeamCatalan healthcare system The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Pharmacists Maternal Community approach Care The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Midwife and Gynaecologist Community GP Activities Paediatritian Nurse The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Patient Physiotherapy Consultants Social Dentist Worker The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Nurse Patient Liason Mental Health Groups
  21. 21. GOVERNANCE Vision and direction of a primary care system  Policiy on equity in access to primary care systems  (De)centralisation of primary care management and service development  Quality management infraestructure  Appropriate technology in primary care  Patient advocacy  Ownership status of primary care practices  Integration of primary care in the health care systemSource: PHAMEU Project
  22. 22. HEALTH PLAN - Priorities and Projects 9 priority areas and 31 projects1  Objectives and Health Programmes    Chronic Performance Improvement2 Care improvement of quality at Orientation at primary care high level specialization level  Focus to patients and their families and carers  New purchasing and commissioning of health services3  Clinical and professional knowledge at the front line  Governance improvement and professional and citizen’s participation  Strengthening the information system, transparency and evaluation
  23. 23. 3Departament de Salut Primary Care: Scope of Services  Performance Catalan healthcare system improvement at primary care level Free choice of Primary Health Centre, GP, Paediatrician and Nurse  Acute medicine (GP/P, N, Dentist)  Acute homecare (GP/P/N/SW/D)  Chronic Care (All the Team + Call Center + Nurse Liaison + Coordination + …  Promotion and Prevention of care (GP/P, N, D)  Homecare (SW, GP/P, N,D)  Minor surgery (GP)  Other techniques: anticoagulant control and treatment, spirometry, ultrasound, etc. (GP, N)  Vocational Training (GP, N)  Continuous Medical Education (All the Team)  Research (All the Team)  Community Care (All the Team + Community agents /Community Plans)
  24. 24. GOVERNANCE  Vision and direction of a primary care system  Policiy on equity in access to primary care systems  (De)centralisation of primary care management and service development  Quality management infraestructure Appropriate technology in primary care  Patient advocacy  Ownership status of primary care practices  Integration of primary care in the health care systemSource: PHAMEU Project
  25. 25. 3Departament de Salut Primary Care: Scope of Services  Performance Catalan healthcare system improvement at primary care level +  Free choice of Primary Health Centre, GP, Paediatrician and Nurse  Acute medicine (GP/P, N, Dentist)  Acute homecare (GP/P/N/SW/D)  Chronic Care (All the Team + Call Center + Nurse Liaison + Coordination + …  Promotion and Prevention of care (GP/P, N, D)  Homecare (SW, GP/P, N,D)  Minor surgery (GP)  Other techniques: anticoagulant control and treatment, spirometry, ultrasound, etc. (GP, N)  Vocational Training (GP, N)  Continuous Medical Education (All the Team)  Research (All the Team)  Community Care (All the Team + Community agents/Community Plans) High performance in Dematology Ophtalmology ENT (Ear Nose & Throat diseases) Mental Health Mucolosketetal disesases
  26. 26. AppropriateDepartament de Salut technology in primary care Catalan healthcare system Key ICT Projects – Governing characteristics Medical Image Telemedicine Digitization Plan NETWORKING MODEL RESOURCES SHARING Catalan Shared Medical Record INTEROPERABILITY Personal Health Electronic Folder Prescribing CO-RESPONSIBILITY COLLABORATION MODEL 26
  27. 27. GOVERNANCE  Quality management infrastructure  Patients receive higher quality care in geographical areas where performance measures and monitoring has been established  Pay for performance schemes provide financial incentives that can change professional behaviour and improve the quality of careSource: PHAMEU Project
  28. 28. ECONOMIC CONDITIONSOF THE PRIMARY CARESYSTEM Health care funding system Health care expenditures Primary care expenditure Employment status of primary care workforce Remuneration system of primary care workforce Income of primary care workforce
  29. 29. PRIMARY CAREWORKFORCEDEVELOPMENT Profile of primary care workforce Recognition and responsibilities Education and retention Professional associations Academic status of the primary care discipline Future development of the primary care workforce

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