Catalan Health System Toni Dedeu, MD, Ph D, MSc Director of International Affairs and Cooperation

1. Catalan Health System Toni Dedeu, MD, PhD,MSc Director of International Affairs and Cooperation Barcelona, 10th March 2011 Government of Catalonia Ministry of Health

2. The Globe Europe Catalonia Government of Catalonia Ministry of Health

3. Socio-demographic characteristics of Spain 17 Autonomous Communities Area:504,750 km² Population (2008)1:46,745,807 Life expectancy (2007)2:81.05 years Birth rate (2007)3: 10.98 Gross Mortality rate (2007)4:8.59 Infant mortality (2007)5:3.7 GDP/Capita(2008)6:94.4 • Municipal Registre 01/01/2009 INE /INS National Instite of Statistis • (2-5) INE / INS National Instite of Statistis • (6) Eurostat UE-15=100 Government of Catalonia Ministry of Health

4. Historical and political context 1. DECENTRALISATION OF THE STATE: 1981 • Transfer of responsibility for regional healthcare to the Catalan Autonomous Government • GENERAL HEALTHCARE ACT:1986 • National Healthcare System • Universal coverage • A Taxation based financing system Government of Catalonia Ministry of Health

5. Devolution process to Autonomous Communities 1987 2001 2001 1990 1990 2001 1981 2001 2001 2001 2001 2001 1987 2001 2001 1984 1994 Government of Catalonia Ministry of Health

6. The Spanish National Healthcare System • Funded by taxes • Decentralized to autonomous communities • Universal coverage • Free access • Very wide range of publicly covered services • Co-payment in pharmaceutical products for outpatient care • Interterritorial Board Government of Catalonia Ministry of Health

7. Health System Decentralization Central Government - Basic legislation and coordination - Financing - Minimum package funded through NHS - Pharmaceutical policy - International health policy - Educational requirements Autonomous Government - Subsidiary legislation - Public health - Organizational structure - Accreditation and planning - Purchasing and service provision Government of Catalonia Ministry of Health

8. C A T A L O N I A Government of Catalonia Ministry of Health

9. C A T A L O N I A Autonomous Community Area:32,106 km2 Population:7,611,711 inhabitants* Life expectancy:81.4 years Birth rate (2007):11.68/1,000 inhabitants Gross Mortality rate (2007):8.28/1,000 inh. Infant mortality:2.7 /1,000 live births GDP/Capita(2008)1:110.4 High urban concentration Own language and culture Tourism(2008):17,335,800 visitors • Employment by sectors : • Services 65.42% • Industry 21.43% • Construction 11.40% • Agriculture 1.74% • Source: IDESCAT • RCA 2009 • (1) UE-15=100 Government of Catalonia Ministry of Health

10. Catalan population 2008 Government of Catalonia Ministry of Health

11. Health & Social Trends in Catalonia: Chronic Diseases/Ageing / Caring and Dependency Catalonia 2050: 45% total population aged 60 yr or more www.idescat.cat/cat/poblacio/projeccions/

12. Trends • Demographic transition: ageing population, decreasing total fertility rates, immigration • Epidemiological transition – changing diseaseprofiles to chronic diseases • Increasing patient expectations and medicallitigation – need for evidence-based practice • Decreased information asymmetry andincreased consumer choices • Technology changes • Demand for cost-effective healthcare services Government of Catalonia Ministry of Health

13. Getting ready • Health Map 1984 .Resources • Health Map 2008 Public Health and Social Services • Health Plan • Master Plans • Purchasing System. Contracts • Central Results Warehouse • Quality Assurance Agency • Innovation Plan for Primary Health and Community Care • Public Health Act Government of Catalonia Ministry of Health

14. Catalan Healthcare System Primary Healthcare Providers Catalan Parliament Catalan Government € Financing Ministry of Health Planning Catalan Public Health Insurance CatSalut Commissioning and Buying Providers Social-HealthCare PC2 PC 1 Hospital Consortium 3 CATALAN HEALTH INSTITUTE - ICS Hospital Consortium 1 Hospital Consortium 2 Primary Care Hospitals Mental Health Other Ambulance Trust 2 Mental Health 1 Mental Health 1 Ambulance Trust 1 Other

15. Catalan Government Budget 2010(39,699 B €) Government of Catalonia Ministry of Health

16. Healthcare Budget by service range CatSalut/ICS 2010 9,779.81 € billion euros Government of Catalonia Ministry of Health

17. General diagram of the Catalan Healthcare System Insurance Services U S E R CATALAN HEALTH SERVICE CatSalut (CATALAN PUBLIC HEALTH INSURANCE) 100% CATALAN HEALTH INSTITUTE (ICS) 20% Public Service Network CONTRACTED PROVIDERS 70% SUPLEMENTARY PRIVATE INSURERS 20% PRIVATE CENTRES 10% Government of Catalonia Ministry of Health

18. Emergency Call Centre 061 /112 Catalan Healthcare SystemCitizen’s Pathways. Gatekeeping based GATEKEEPER ROLE HOSPITALS C I T I Z E N S H1 H2 H3 Social & Healthcare Services Mental Health Care

19. Chronic Care Expanded Model • Integration of health promotion into the prevention and management of chronic disease • Demonstrates clear associations between the health system and the community Victoria Barr, Sylvia Robinson, Brenda Martin-Link, Lisa Underhill, Anita Drotts & Darlene Ravensdale (2002) Adapted from Glasgow, R., Orleans, C., Wagner E., Curry S., Solberg, L (2002) and the WHO -Ottawa Charter of Health Promotion (1986) Government of Catalonia Ministry of Health

20. Chronic Care Expanded Model Government of Catalonia Ministry of Health

21. Chronic Care Expanded Model Government of Catalonia Ministry of Health

22. Chronic Care Expanded Model Government of Catalonia Ministry of Health

23. Reform process evolution • Building healthy public policy • Creating supportive environments • Strengthening community action Government of Catalonia Ministry of Health

24. Pharmacists Catalan Healthcare System Primary Healthcare Team & Primary Healthcare Government of Catalonia Ministry of Health

25. Primary HealthcareResources / Population • Resources of PHC per population: • 1 family doctor per 1600-2000 inhab. >14 years • 1 pediatrician per 1500 children < 14 years • 1 dentist per 11000 inhab. • 1 nurse per MD • 1 social worker • 1 support officer / 5000 inhab. Government of Catalonia Ministry of Health

26. Catalan Health SystemPrimaryCare: Scope of Services • Free choice of Practice and 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 + … • Promotionand 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)

27. Primary Health Care Centres PHC PHC Government of Catalonia Ministry of Health

28. Primary Health Care Centres PHC Sort PHC in Barcelona city Government of Catalonia Ministry of Health

29. The Catalan HealthcareNew perspectives Government of Catalonia Ministry of Health

30. Facts &Trends • Practice performance variation gap is shrinking Primary Healthcare Teams in Barcelona area - 2008 Homecare programme Government of Catalonia Ministry of Health

31. Tools • Quality Indicators / Performance Indicators introduced in the payment system /Accountability • 100% Electronic Record at Primary Healthcare • Shared Clinical Record HC3 • Clinical guidelines • Multidisciplinary Teams • Nurses roles • Public Health Act • Innovation Plan for Primary healthcare and community care Government of Catalonia Ministry of Health

32. The Health Care in Catalonia PC H Physician Patient Encounter Nurse Patient Encounter Nurse Patient Telephonic communication Physician (Nurse) Patient Encounter Diagnostic Therapeutic Procedures Care plan Diagnostic Therapeutic Procedures Monitoring Therapeutic Care plan Diagnostic Therapeutic Procedures Computerized Clinical guideline Computerized Clinical pathway Computerized Monitoring Computerized Clinical guideline PCIS CCG PCIS Homecare: PDA PCIS Telephone CC HIS CCG Government of Catalonia Ministry of Health

34. Key ICT Projects – Governing characteristics Telemedicine Medical Image Digitization Plan • NETWORKING MODEL • RESOURCES SHARING Catalan Shared Medical Record • INTEROPERABILITY Personal Health Folder Electronic Prescribing • CO-RESPONSIBILITY • COLLABORATION MODEL 35

35. Provision of Services: Challenges Government of Catalonia Ministry of Health

36. Sustainability • Universal coverage • Public financing of the services • Purchaser-Provider split • Citizen’s participation • Patient choice • Continuity of care • Integration and coordination Government of Catalonia Ministry of Health

37. Equity • Access • 68 hospital centers • Primary Healthcare centers • Socio-healthcare centers • Mental Health centers • Telemedicine • Call Center • Health Direct • Patient’s Folder • Internet Government of Catalonia Ministry of Health

38. Health & Social Trends in Catalonia: High Tech / Genomics / Telemedicine • Holistic Approach • Collective Leadership • Networking • Integrated Care Government of Catalonia Ministry of Health

39. Gràcies Thank you Spacibo bolchoi tdedeu@gencat.cat www.gencat.cat/salut/ Government of Catalonia Ministry of Health