1. WHO Public Health approach in the planning and implementation of Palliative care: Experience and evidence from Catalonia Xavier Gomez-Batiste Pal Care, Institut Catala d’Oncologia Socio-Health, Catalan Department of Health Spanish Society for Pall care (SECPAL)

2. CATALONIA 6.7 milion habitants > 16% > 65 1 million > 65 ys 100.000 elderly with pluripathology and dependency Dementia: 90.000 Cancer mortality: 13.000 Aids: 300

3. Catalonia: Public Health Care system (universal coverage, free access) Hospitals: 14.000 beds Sociohealth Centers: 5.000 Residential: 45.000 Regional Cancer Institute Primary care network

4. Background British experience on Hospices: model of care and internal organisation, but outside the NHS The Public Health approach: E. Wilkes (1985) + Jan Stjernsward (WHO) + V Ventafridda

5. PCPC: global results 2004 Nº total resources: 162 Interventions/year: > 20.000 Coverage cancer: 75% Cancer vs noncancer: 60/40% Coverage, geographical: 100% Total beds: 550 Beds /milion hab: 85 Full time doctors: 140

6. Units 2001: placement Hosp Univ: 6 Hosp Gen: 4 CSS: 38 MEP: 11 ICO: 1 Nº total: 60 Beds: 550 (9.5/UCP) Length stay: 22.8 days Mortality: 69.7% Discharges home: 23.0%

7. Home Care Support Teams Nº total: 62 Nº new patients/year: 250 Cancer (46%), geriatrics (46%), chronic Prevalents: 30-40 Time intervention: 6 weeks Place of death: 61% home, 19% CSS, 12% HA Nº total professionals (2003): 318 Cost: savings of 1.000 euros/patient

8. CP: levels of complexity General Measures in Conventional Services Basic Support Teams Reference: complexity+ training+ research Complete teams Units

9. Complex metropolitan systems (300-500.000 hab): levels, coordination

10. ICO: Palliative Care Service Unit 16 beds Outpat’s/DC Support team CSUB ICO PADES + UCPSS

11. PCS at ICO: basic outputs New patients/year: 1.000 (Cancer 100%) Median survival 1st visit: 3.5 months Mean age: 60 years Length of stay (Unit) : 9 days Mortality (Unit): 50% Cost: 30% of Medical Oncology

12. PCS at ICO: other aspects Reference for training (Master, Intermediate, Basic): more than 5.000 profesionals trained Research: CATPAL cooperative group (more than 17 studies) Quality improvement: EFQM model

13. ICO 1998: the “ping-pong” model ONC RDT URG HMT PAL CARE PAIN CIR ORL

14. ICO 2005: interphase Oncology-Pal care “From competition to cooperation” UFP UFM UFORL UFGINE USAC Palliative Care Service: clinic, unit, support team PACMAC Case management Continuing care EmergenciesCoordination

15. Definitions and trams Diagnosys Death Specific Treatment Suportive care Palliative care Terminal care Bereavem ent Complexity vs prognosis

16. PVAA 166,8 million € 3% of total CHS budget PVAA 166,8 million € 3% of total CHS budget PCPC: 23,7 million € 0,43 % total CHS budget PCPC: 23,7 million € 0,43 % total CHS budget

17. Legislation and standards Decret Catalunya 1990 Recomendaciones de la SECPAL, Ministerio de Sanidad (1993) Estàndards de cures pal.liatives, SCS, SCBCP (1993) Decreto/orden 1993 (Opioides) Ministerio Plan Nacional de Cuidados Paliativos (2001) Guía de criterios de calidad en cuidados paliativos: SECPAL, Ministerio Sanidad (2002) Indicadores de calidad en cuidados paliativos: SECPAL, Ministerio de Sanidad

18. Fuente: Directorio SECPAL Spain 2002 by Regions

19. Spain 1984-2002 Fuente: Directorio SECPAL

20. Results on the use and cost of reources

21. COMPARISON 1992-2002: USE/COST OF RESOURCES INGR: % malalts / ESTMITJ: dies / URGENC: %malalts COST: euros x 100 (XGB et al, 2002)

22. Hospital Costs: 1992 vs 2001 (Cost / process-patient / 6 weeks at 2001 prices) 1992: 4.987 euros 2001: 1.701 euros Difference: 3.286 euros / patient TESISTAULESTEXTCAPVI1

23. National Policy: Elements Evaluation of needs Defined targets, aims and principles Leadership Implementation of specific services General measures in conventional services Opioid availability Education and training Standards, legislation, definition of services Financing model Evaluation Implementation plan with specific budget

24. Principles Measures in all places Sectorized Insertion in preexisting services, including sociohealth Gradual implementation Public Planning Public Financement

25. Aims Coverage: for all in everywhere Equity and accesibility Quality: effectiveness, efficiency, satisfaction Reference WHO

26. Initial key procesess Clear ideas Clear definition of clients and services Leadership Training References/experiences Institutional support pva20

27. Leadership Joint venture between Ministry of health and financing agency Professionals: well trained and highly committed Organisations (Providers): public, profit, nonprofit Academic (Universities)

28. General measures Targets: Hospitals (oncology, internal medicine, geriatrics, emergencies), mid- term and long-term resources (nursing homes), primary care teams Training: policies, sessions, formal training, local references Change of organisation: teamwork, presence and support of the family Liaison of resources

29. Specific Resources Specific nurses Support teams: in hospitals, community, both, systems Units: type, dimension, placement Nº beds: 80-100/milion Placement: 10-20% acute, 40-60% sociohealth (mid-term), 10-20% residential, 10-20% hospices

30. Types of processes (always combined) Implementation of new specific resources Adaptation of conventional resources (general measures) Reallocation of resources (reconversion) “Catalythic” implementation or investment

31. Palliative care and geriatrics and cancer Links with geriatrics in Sociohealth centers, nursing homes, and community Links with cancer in hospitals, cancer centers, and the community Both necessary

32. Common Resistances “We are already doing so...” “There is no need of specific services, we will do a lot of training....” “Palliative care services will be seen as places to die....” “This is good for England, USA, or Catalonia, but it will not work in our country....”

33. Expected results Enormous improvement of the quality of care Effectiveness Efficiency: saving more than the structrural cost Satisfaction: patients, families, professionals, and politicians

34. Palliative Care: added values Care and organisation models useful in all the system Model of care appliable to other conditions earlier Emphasis in quality of life Impact on the global efficiency High patient’s and familie’s satisfaction Ethical approach