1. Primary care in
Europe: can we
make it fit for
the future?
European Health Summit 2013: Primary care case studies
January 2013
Dr. Toni Dedeu
Senior International Officer. Ministry of Health of Catalonia
President Elect. EUREGHA (European Regional & Local Health Authorities)

2. KEY TOPIC 3
ACCELERATING REFORM OF PRIMARY CARE
DELIVERY 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. HEALTH POLICY TRIANGLE (WALT & GILSON, 1994) (BUSE ET AL, 2005)
Context
Actors / Players
Individuals
Groups
Organitsations
Content Process

4. FRAMEWORK FOR THE Structure
EUROPEAN PRIMARY Process
CARE 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. PROCESS
HEALTH POLICY
Process
› Identification of the problem:
› which topics are in the political agenda?
PC Reform needed?

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. 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. Context
CONTEXT
›Situational factors:
› wars,
› epidemies,
› heat waves,
› new governement with new
policies / new Minister

9. Context
CONTEXT
 Structural Factors:
› Political system,
› Type of economy
› Demographic factors

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. Context
CONTEXT
›Cultural factors:
› Status quo,
Good for providers
For the people, far from optimal
› lobbies,
› ethnic minorities,
› jerarquies, religion, etc.

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. CONTENT
Content
What have we got in the basket?
What are the limits of PC?

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 costs
Source: Peckham and Exworthy 2003 Proportion of expenditure on healthcare

15. ACTORS
actors
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. Departament de Salut ACTORS
(Some of them) Catalan healthcare system
Catalan
Parliament 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. 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. 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. Catalan Healthcare System
Departament de Salut
Catalan healthcare system
Citizen’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. Primary
Departament de Salut care (Health and Social?)
Multidisciplinary TeamCatalan healthcare system
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Pharmacists
Maternal
Community
approach Care
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Midwife and
Gynaecologist
Community GP
Activities Paediatritian
Nurse
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Patient Physiotherapy
Consultants
Social
Dentist
Worker
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Nurse
Patient
Liason Mental Health
Groups

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 system
Source: PHAMEU Project

22. HEALTH PLAN - Priorities and Projects
9 priority areas and 31 projects
1
 Objectives and Health Programmes
  
Chronic Performance Improvement
2 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 services
3  Clinical and professional knowledge at the front line
 Governance improvement and professional and citizen’s participation
 Strengthening the information system, transparency and evaluation

23. 3
Departament 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. 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 system
Source: PHAMEU Project

25. 3
Departament 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. Appropriate
Departament 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. 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 care
Source: PHAMEU Project

28. ECONOMIC CONDITIONS
OF THE PRIMARY CARE
SYSTEM
 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. PRIMARY CARE
WORKFORCE
DEVELOPMENT
 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