PRIMARY CARE:

PRIMARY CARE: Regional strategies to improve efficacy and equity while

guarateeing economic sustainability

W O R K S H O P

José L. ROCHAGeneral Secretary for Quality and ModernisationRegional Ministry of HealthGovernment of Andalusia, Spain. [email protected]

Strategies and results in Primary Healthcare

in Andalusia

• Andalusia and the APHS: Quick facts

• Primary Care in Andalusia:

• Historical overview

• Main Features

• Outcomes

• Troubles and Challenges

Overview

Andalusia and the Andalusian Public

Healthcare System:

Quick Facts

Andalusia:Geographical situationand population

• 87,597 Km2.• 8.302.923 inhabitants

• 526.942 foreigners • 50% Europeans• 24% Americans• 21% Africans• 3% Asian

• + 1.531.668 andalusian people living in other Spanish regions• + 140.000 andalusian people living outside Spain

RegionalParliament

Regional Court of Justice

Andalusia:Political context

• Political Autonomy since 1981• Regional Institutions

• Parliament• Government (“Junta de Andalucía”)• Court of Justice (TSJA)

Jose A Griñán. President of Government

Fuensanta Coves. Speaker of the Parliament

Lorenzo del Río. Chief JusticeRegional

Government

Andalusia:Social and Economic trends

Gini Index in Andalusia1970-2005

0,310,3150,32

0,3250,33

0,3350,34

0,3450,35

1970 1975 1980 1985 1990 1995 2000 2005

% of GDP (PPP) growth1986-2007

69

110127

EU 15 Spain Andalusia

Source: Eurostat Source: Centro de Estudios Andaluces

Andalusian Public Healthcare System: Main features

1,146 Primary care centers 360 Auxiliary offices for primary care 47 Public Hospitals (16,821 beds)102,000 Healthcare professionals 9,390 M € Health Budget 2011, 6.67% GDP

Primary Care in Andalusia

Historic overview

Legislation Timeline

• 1978: Spanish Constitution• Establishment of the Autonomous Communities• Settlement of the Health protection as a fundamental right

• 1978: Creation of the Family Medicine specialty• 1981: Statute of Autonomy of Andalusia

• 1981: Transfer to the Andalusia Region’s Administration the responsibility on Public Health • 1984: Transfer to the Andalusia Region’s Administration the public network of hospitals, ambulatory clinics and rural offices

• 1984: National Decree on basic structures for primary care (1st step of primary care reform) • 1986: Healthcare National Act

• Change from a social security model to a NHS model• Healthcare as a right for all the population •Consolidation and extension of primary care level

Situation Before the reform:

Individual work of general practitionersNo specific trainingNo health prevention/promotion/educationIsolated rural medicineHospital-centric modelLower salaries than specialistsLow prestige and self-esteem


Main Features

Primary Care in Andalusia:Main features

Organisation and planningAccessibilityTeamworkExtended careIntensive use of ICT

GP as a GatekeeperCapitation: 1 GP/1,400 inhabitantsTeam of professionals working in a PC CentreHomogeneous territorial distribution Aggregation of PC Centres in “Districts” Supportive teams at Districts for Public Health purposes: Epidemiologists, Vets, Pharmacists… Professionals are civil servantsFocus on health promotion and prevention

Accessibility

% of increase of physicians in Andalusia 1984-2008

2353

196

Population Hospital Doctors Primary Care Doctors

1146 Primary Care Centers (and360 auxiliary offices) vs. 33 at 1986Less than 15 min away for anybody

1 Family Physician every 1.400 people on average

Primary care doctors represent 41% of APHS doctors (29% at 1986)

Primary Care in Andalusia:Main features:


Primary Care professionals

Family PhysiciansCommunity NursesPediatriciansMidwivesDentistsPhysiotherapistsSocial WorkersPsychiatrists/psychologistsEpidemiologistsCommunity PharmacistsVeterinariesAdministration workersAuxiliary workers

Primary Care in Andalusia:Main features:


Health Care Information and Management Integrated System

Appointment Prescription

Radiology

Waiting lists

Functional tests

Pathology

Lab tests

Inpatient care

Referrals

Outpatient care

Primary care

Hospital admission

Data warehouse

Emergency care

105 Million of e-prescriptions/year

95 Million of appointments/year

7.9 Million of individual EHR

3 Million of e-referrals/year

3.5 Million of x-Ray images/year


Outcomes

Outcomes: Life expectancy and amenable mortality

Mortality index in Andalusian municipalities vs. Spanish average

Trend to convergence to Spanish average

96% of municipalities have an index equal or lower than

the Spanish average for people 65 years old or less

The south-west area of Andalusia shows a mortality

index higher than the Spanish average for the group of 65-74

years old people

The majority of municipalities have a

mortality index higher than the Spanish’ one for people

with more than 75

2005 - Women 15-44 years old

2005 - Women 45-64

2005 - Women 65-74

2005 - Women 75-84

Higher than Spanish averageNon significative differencesLower than Spanish average

Source: Atlas Interactivo de Mortalidad en Andalucía (AIMA). Revista Española de Salud Pública 2008; 82(4)

Outcomes: Health Expenditure

Figure 3. Health expenditure per capita, US$ PPP, 2008 (or latest year available)

7538

5003

4627

4210

4079

4063

3970

3793

3737

3696

3677

3540

3470

3359

3353

3129

3008

2902

2870

2729

2687

2683

2151

1801

1781

1738

1437

1213

999

852

767

3060

0

2000

4000

6000

8000

Uni

ted

Stat

es

Nor

way

Switz

erla

nd

Luxe

mbo

urg

1

Cana

da

Net

herl

ands

Aus

tria

Irel

and

Ger

man

y

Fran

ce

Belg

ium

2

Den

mar

k

Swed

en

Icel

and

Aus

tral

ia

Uni

ted

King

dom

OEC

D

Finl

and

Spai

n

Italy

Japa

n

Gre

ece

New

Zea

land

2

Port

ugal

Kore

a

Czec

h Re

publ

ic

Slov

ak R

epub

lic

Hun

gary

Pola

nd

Chile

Mex

ico

Turk

ey

USD PPP

Diff. Serie4

1. Refers to insured population rather than resident population. 2. Current expenditure. Source: OECD Health Data 2010 .Data are expressed in US dollars adjusted for purchasing power parities (PPPs), which provide a means of comparing spending between countries on a common base. PPPs are the rates of currency conversion that equalise the cost of a given ‘basket’ of goods and services in different countries.

OECD Health Data 2010.

Social and Economic Council of Spain, 2010.

Outcomes: Health Expenditure

Regional health expenditure (€ per capita). Spain 2007

% of public health budget on Primary Care, Spain 2008

12,4 13

15,3 15,717,6

Ministry of Health and Social Policy. Spain, 2010.

Outcomes: Health Expenditure on Primary Care

AndalusiaSpainCataloniaValenciaMadrid

Outcomes: EfficiencyThe Swedish Healthcare System: How does it compare with other EU countries, the United States and Norway?Swedish Association of Local Authorities and Regions,2008

Desired direction

Health spending in OECD countries: Obtaining value per dollars. GF Anderson, BK Frogner. Health Affairs 2008; 27:1718-1727

Satisfaction survey. Users of primary care services

85,9

87,286,7

87,4

89,789

86,8

88,7 88,389,5

90,6

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Outcomes:Patient satisfaction

General satisfaction on Primary care. Satisfied + Very satisfied (2/5).

Institute for Social Studies of Andalusia. Spanish Scientific Research Council (CSIC)

Primary Care in Andalusia:Key factors:

UniversalityLack of economic barriers for people DecentralisationEquitable planning of public resourcesCoordination and integration of careCommunity focusExtended basket of servicesTeamworkClinical ManagementProfessional commitment & leadershipLong-term policies

Troubles and Challenges

- High Frequentation- Work overload- Chronic Patients- Excess of bureaucracy- Lack of Coordination with Hospitals- Continuous Medical Training- Impact of Feminisation- Desertification of Rural areas- Projected physician Shortage- Professional Migration- …

http://www.opimec.org/

PRIMARY CARE:

Documents

Transcript of PRIMARY CARE: