1 ”Better Health- A Shared Challenge for Hospitals and Primary Health Care” Dra Mª Teresa García Ortiz Instituto Nacional de Gestión Sanitaria Ministerio de Sanidad, Política Social e Igualdad. España 2011 MINISTERIO DE SANIDAD, POLÍTICA SOCIAL E IGUALDAD

Primary Health Care  Background  Model of primary care in Spain  Strategic framework for the improvement of primary care in the 21st century

Background  Alma Ata 1978  Creation of the Speciality Family and Communitary medical practitioner  RD Basic Structures of Health 137/1984  1986 General Health Act  Cohesion & Quality Act (2003)

PRIMARY HEALTH CARE MODEL IN SPAIN

Main Hospital : primary care Specialized ambulatory care Health Care Area Basic Health Zones Structure of the Health Care Area

PRIMARY CARE AS GATEKEEPER  Primary Care is the axis of the health system and it is the nearest health resource for most people.  80% health’s problems are solved in PH Care, and the general practitioner is the one who decides when another health professional or specialized service has to give further assistance to the patient.  This is the level where most activities of health promotion, health education and preventive medicine are assumed. Physical rehabilitation and social support are also offered.  Specific activities, focusing on specific groups are also carried out (women, children, elderly people, oral and dental health, terminal patients and mental health)

RD 137/1984, January 11 Basic Structures of Health  - Health Zone delimitation  - Health Care Centre  - Primary Care Team: Composition functions  - Working time

Health Care Zone  Health Zone, is a Geographical demarcation  The demarcation is done with demographic, geographic and social criteria  The population covered in each area is between 5,000 and 25,000 inhabitants.

Primary Health Care Team of one Centre  Composition :  General practitioners  Paediatric specialists  Nurses, nurse assistants and midwifes.  Pharmaceuticals  Social worker  Administrative staff

Primary Health Care Functions :  Medical assistance in the centre and at home and urgent assistance  Promotion of health, Prevention of diseases, and social rehabilitation  Health Education to the population  Evaluation of the activities and results  Participation in health programmes

Primary Health Care: other units  Prevention of diseases (e.g. education, vaccinations )  Physiotherapy  social health care  Special attention to women, children and risk groups  Palliative care of terminal ill patients  Mental health  limited dental health care

Improvements of the New Model of Health Care: 1. The incorporation of family physicians, pediatricians and nurses to primary care teams, resulting in professional renewal and upgrading of training 2. Full-time work a day. It moves away from 2 hours to 7 hours working time (more dedication per patient )

Improvements of the New Model of Health Care: 3. Teamwork: from an individual job to a coordinated actions doctor-nurse and the incorporation of clinical sessions, discussion of cases, etc 4. Promotion and prevention programs 5. Use of the clinical record and new technologies

Strategic framework for the Improvement of the Primary Health Care in Spain:

Strategy PHC 21  Political Objectives (Summit of Presidents, September 2005): increase resources and capacity of primary health care  The Ministry of Health, Social Policy and Equality Project has led the Strategic Framework for improving primary care in the twenty-first century  Collaboration of more than 90 experts nominated by scientific societies, autonomous regions and associations of patients

Objectives

Define a strategic framework to consolidate the public health system, with the central axis primary health care, continuity of care in hospital and social services. revisar

Methodology  Assess the current situation of primary care, analyzing the achievements of the reform, but also the difficulties  Propose improvements and changes necessary to improve the quality scientific and technical, to provide an efficient service to citizens.

Analysis based on 5 thematic areas  Activity in primary health care  Organization and management  Resolution  Evaluation and improvement of primary care processes  Health outcomes

Outline document for each group: 1. Justification 2. Evolution and current situation

Main Characteristics I: 1.The consolidation of the working model for primary care teams within the public health system with universal coverage and a high degree of acceptance by the population 2.The existence of a portfolio of explicit, specific primary care- based health programs 3.The high level of technical training for professionals working in this field 4.Implementation of an organizational culture that includes work by objectives and processes

(I): THREATS AND OPPORTUNITIES (I):  Epidemiological changes produced by : Aging of the population Increase of chronical diseases and disabilities Emerging infectious diseases and those related to lifestyles Influence of migration Increased incidence of mental pathology New challenges in reproductive health etc.

New Challenges for Primary Health Care C. XXI (I) 1. Growth and progressive aging of the population 2. Increased prevalence of chronical and degenerative diseases 3. Immigration 4. Trend towards medicalization of health problems 5. Increased workload in consultations 6. Better-informed users, generating new needs and more expectations in health.

New Challenges for Primary Health Care C. XXI (II) 7. Lost of importance of health promotion and disease prevention in the daily chores of professionals 8. Emergence of different organizational models 9. Technological development 10. Problems in coordination between primary and specialized health care, etc..

Strategic framework improving Primary Health Care:

The axes of the Strategic Framework  1. Citizen  2. Professionals Key objectives  1. Quality  2. Solving skills  3.Continuity of care

Axes (I): 1. Citizen:  It is necessary that the citizens feel part of the public health system  Participation in decision-making about their health problems

Axes (II): 2. Professionals :  Professionals have to be involved in the management of the health services and to participate in decision-making processes  AP-21 Project is committed to motivating factors and incentives for professionals, both from the economic point of view and with the autonomy of management, the promotion of training and research, etc..

Key Objetives (I) Quality:  The commitment to quality must be comprehensive, including not only scientific and technical components, but accessibility, resources, organization and participation.

Key Objetives (II) 2. Solving skills  85% health’s problems must be solved in PH Care (effectiveness)  increasing diagnostic and therapeutical capacity, thereby improving the training of professionals  Development and implementation of clinical guidelines

Key Objetives (III) 3. Continuity of care  Coordination between primary and specialized health care is an essential objective.  Coordination between primary health care and public health  Coordination between primary health care and social care

Elements that reinforce Coordination (I)  Shared Health Clinical e-Record  Computerization of all health centres  Electronic prescriptions  Electronic connection between all Primary Care Centres and Hospital  e-access to Lab data and Digital Imaging  Common and Shared Training Activities  Unification of the Organization (Same Manager Team)

Elements that reinforce Coordination (II)  Common Objectives in the “Management Contract”  Electronic administrative procedures from the Health Centre  Definition of common guides and protocols  Introduction of Incentive Professionals (Career / Objectives)  Same Patient Identification Code (CIP)  Discharge Report sent to Family/Nurse Primary Centre from hospital

Some figures. Spain 2009 Source: Ministerio Sanidad, Política Social e Igualdad

Structure:Centres and Teams

Professionals Ratios Medicina de familia Pediatría Enfermería Auxiliar administrativo

Activity

Conclusion The changes and improvements made by the new model of primary health care have been an unprecedented leap in health care for the Spanish population, with beneficial results in the development of numerous health indicators. This is a stimulus for further work on the weaknesses identified in this project.