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1 March 2011; Column 2011 - 2
By Toni Dedeu, MD, MSc, PhD
Director of International Affairs and Cooperation, Ministry of Health of Catalonia, Spain.
Former International Officer of the Spanish Family and Community Medicine Society
Primary care in Spain has been playing a significant role since the early 80's when a major transformation of the health care system took place, along with the political reorganisation of the state in the Autonomous Communities (ACs). The principals of the Spanish health system are those of a National Health System (NHS) model, focusing on universal coverage, with free access to health care for the entire population . This also includes the integration of different health service networks and political devolution to the ACs. Primary care plays a central role as a gatekeeper, whose core functions are integration of promotion, prevention, rehabilitation and curative activities.
The devolution process in the health sector occurred in different stages within the 17 ACs, and this has resulted in different models of care under an umbrella of an NHS, common for all Spain.
The primary health care workforce in Spain is organized around a multidisciplinary team, who work in primary health centres. They provide a wide range of services with the main emphasis on prevention and promotion of health, acute and chronic care, homecare and community care activities. The core of the team is made up of physicians who are family and community medicine specialists, paediatricians, nurses, auxiliary nurses, social workers, dentists and administrative staff. The team works closely with midwives, gynaecologists, public health professionals, pharmacists, radiologists, physiotherapists and laboratories.
Coordination with other health professionals and health care levels is fluent and currently strengthened with the support of Information Technologies (IT) and also thanks to the widespread implementation of the electronic clinical records in more than 97% of the practices . The shared clinical record among different levels of care with digital imaging and laboratory results is in the process of being implemented throughout the country, with very advanced models in specific ACs. This IT support has facilitated the development of new formulas of integrated care and chronic care management. It is currently working on the patient folder, which will give the patient access to clinical records online or via mobile phone and will enable the patient to decide which medical information should be shared.
The implementation of IT in the health system, has also allowed the development of quality tools of evaluation, which include a huge range of indicators, some of which are related to performance and others to coordination and efficient use of financial resources. This evaluation is generalised to all the multidisciplinary primary health teams .
A characteristic of the Spanish health care model, with different approaches in various ACs has resulted in a rich variety of models. Moreover, the Spanish primary health system in itself is an excellent testing ground and this could be of great value when implementing formulas at a European level.
However, there are several barriers for the development of primary care. Its budget has not increased over the last few years; hospital lobbies still find it difficult to shift into territory based capitation; and an integrated care perspective is not a priority. The current economic downturn should be taken as an opportunity to accelerate the innovative formulae in order to coordinate and integrate care.
Unlike many European countries, University departments in family medicine do not exist in Spain. The specialisation period is carried out in Family and Community Medicine Teaching Units, which are responsible for coordinating the postgraduate and specialization four-year programme of the speciality in family and community Medicine. On the other hand, the multidisciplinary team work has resulted in an excellent platform for research and continuous medical education. It has the support of scientific societies and primary care research institutes. This compensates for the inexistence of University Departments .
Policy makers in Spain should promote experimentation and allow pioneers to develop new models. It should also provide more autonomy at a local level.
There are still obstacles which impede change, such as the top-down approach and the civil servant workforce in most of the territories.
They are governed by rigid rules and regulations and a highly politicized system of promotion with no new public management being incorporated in the system.
The current crisis, along with the development of IT, provide an opportunity to develop a more flexible and innovative model of organisation. Empowering patients in their self-care; new roles of the healthcare professionals; electronic prescriptions; the use of telemedicine and tele-healthcare, along with the implementation of new approaches to the management of chronic care, are in the agenda in the Spanish health system. These should all contribute to the sustainability of the system and guarantee health equity.
2. Borkan, J., Eaton, C., Novillo-Ortiz, D., Rivero, P. & Jadad, A. 2010, Renewing Primary Care: Lessons learned form the Spanish Health Care System, Health Affairs, vol. 29, no.8 pp. 1432-1441. 2010
4. Espasa, M. 2009. Gasto y financiacion en Atencion Primaria. Expenditure and financing in Primary Care.In Proyecto de Investigacion: La Atencion Primaria de Salud en Espana y sus comunidades autonomas. IDIAP and University Pompeu Fabra. Barcelona, Spain. 2009
5. Navarro, V and Martin-Zurro, A. 2009. Primary healthcare in Spain and its Autonomous Communities. La Atencion Primaria de Salud en Espana y sus comunidades autonomas. IDIAP and University Pompeu Fabra. Barcelona. 2009