Noticia del primer Taller del grupo de interés PolicyAES: “Alternativas de organización y gestión de la Atención Primaria. La experiencia con las EBAs (externalización de la atención primaria) como limitación del radicalismo selectivo”
Within the framework of the XLIII Conference on Health Economics held in La Laguna, the following took place: Thursday, June 27, 2024, the launch of the interest group PolicyAES, which held its first Workshop. Considering the relevance of Primary Care (PC) in the formation of health policies and the view of the etymologically agonising situation that our model is suffering, it was proposed to provide a multifaceted vision of the PC that really exists, for which three reference presentations were commissioned: on the NHS PC model from its foundation to the present day; the possibilities of development and improvement that can be exploited in our PC from the perspective of the professionals committed to it, and the existing experience in the country of operating centres that are reasonably in line with the designs of the reference model, that is, the Base Entities. Associative (EBAs), a unique experience limited to a dozen centres in Catalonia.
To map the model of the UK NHS, from its inception in 1947 and its subsequent reforms, was attended – by videoconference – by Katherine Checkland, Professor of Health Policies and Primary Care In the Division of Population Health, Health Services Research and Primary Care, from the University of Manchester.
In his presentation he showed the minuscule presence of paid work in the provision of medical services in primary care, with the relationship between these and the NHS being the signing of contracts linked to the achievement of objectives. Thus, all Family Medicine services are provided in accordance with a contract signed with the centre, not with the professionals, and which can be of three types: General medical services (MSG), Personal medical services (PMS) and Alternative medical service provider (APMS)While the first, the most prevalent (70%), is negotiated at a national level, the other two are governed by local agreements. PMS account for 29% and APMS for barely 2%, compared to more than 4% a decade ago.
Any organisation that hires a GMS must include its GPs and their contracts are permanent. A PMS contract can be signed by any NHS employee, organisation or GP and although they are permanent they can be revoked. APMS contracts are the only ones that can be signed by commercial entities that do not have to include GPs and their duration is pre-established, generally 5 years.
GMS and PMS are very similar: a fixed population sum, a variable payment for compliance with quality incentives and different amounts for portfolio expansions called “enhanced services” which is what distinguishes the latter.
Since 2004, the forms of ownership have multiplied, including, among others, ownership by a group of doctors, alone or in partnership with a commercial organisation, or through a company – for profit or not – belonging to a group of doctors. There are also contracts with large-scale partnerships that own several centres, vertical integration as extensions of hospitals that host inmates, companies, generally not-for-profit, that provide specific services, such as continuing care, and even with commercial companies – such as Centene, Babylon or Virgin – that have been abandoning the sector in recent years.
The comparisons between results of the different models are few and from the last decade. The reference publication shows that practices with alternative contractors, APMS type, tended to be smaller and serve younger, more diverse and more disadvantaged populations than traditional ones and obtained worse results than these in 15 of the 17 quality indicators after adjustment for practice and population characteristics. On the other hand, they obtained a higher percentage of patient satisfaction with the hours of care and the greater prescription of generic drugs.
The analysis of the SNS Model (Royal Decree 137/1984) The presentation was given by Amparo Gómez Rodríguez de Acuña, Vice President of SOCAMFYC and Coordinator of the EAP Consultation and Organization Management working group. After a summary of the normative and organizational axes of the AP designed since the Royal Decree in question, she directly addressed its current problems and shortcomings.
He focused the horror of his presentation on discovering the necessary and feasible lines of improvement in an essential. update of the AP that makes it effectively resolute and fulfill the population needs within the framework of the principles that configure it. But this was not done by litanies, but by accurately scrutinizing «screenshots» of the indicators currently in use, noting the problems and deriving from them lines of improvement as sensible as they are necessary. As Amparo Gómez rightly pointed out, she preferred to focus her presentation by placing herself at a micro-management level, hoping to bring to the table a vision from below of what is needed and what improvements should be made, but understanding that it is also necessary to act with true leadership at the meso-management and macro-management levels.
She paid special attention to unraveling the current inefficient way of dealing with chronicity, requiring truly proactive nursing action, helping chronic patients to have comprehensive assessments that allow appropriate decisions to be made tailored to each case. That is, taking into account the clinical, but also the functional, cognitive, affective, social and their preferences in decision-making. And this proactive role, in addition to being essential with High Complexity Patients, is also essential for efficient follow-up with Chronic Patients and/or in Health Programs. In this sense, she pointed out that collaborative and teamwork must be based on the distribution of tasks based on the skills of each person, and that assuming this spontaneously would be the main lever of change for an improvement of the current care model, which AP needs.
In conclusion, in his reasonable opinion, improving the current model of care would urgently require:
- A change in mentality, motivation and active participation of AP professionals for better organization of work and distribution of tasks based on skills.
- To be able to have a timely analysis of the situation and results in order to optimize and distribute resources appropriately.
- Of the professionalization and leadership of the Management Teams of the Primary Care Teams, as drivers of the work and good performance of all the professionals of the Team.
- And clarity of ideas, leadership and courage from senior management to undertake the changes that we request from our position and that are needed.
To talk about the EBA Model (Associative Base Entities) under DECREE 309/1997 On his birthday, Toni Iruela, associate professor at the Faculty of Medicine of the University of Vic – Central University of Catalonia (UVic-UCC) and technical director of ACEBA (Catalan Association of Associative-Based Entities), which represents self-managed health centres in Catalonia integrated into the CatSalut public health network, came.
Dr Iruela described the essential features of the model and its scope, as well as sharing his reflections on the limitations of its scope. The original design of the project sought to enable healthcare professionals to become providers of publicly funded primary care services, with the aim of diversifying the provision of healthcare services and promoting professionalism and management autonomy. The necessary regulatory reform was carried out, especially of Law 15/1990, on Health Regulation in Catalonia (LOSC), and Decree 309/1997, which establishes the accreditation requirements for Association-Based Entities for the management of centres. With these resources, a group of enterprising professionals formed the entity Equipo de Asistencia Primaria Vic SLP, which opted to be awarded, through a public tender, the concession for the management of primary care services at ABS Vic 2, which was the first self-managed primary care centre since 1 October 1996. Between 2000 and 2004, 9 new entities were created, and there are currently a total of 13 Basic Health Areas managed under this model.
EBAs represent the only experience of approximating the relationship between funders and healthcare professionals to that of most similar countries, which are governed by contracting rather than by employment.
It is striking that EBAs are among the few experiences subject to competent and rigorous evaluation, and they have not been evaluated just once, but up to three times.[i]
Available studies evaluating this experience are shown positive results both from the perspective of cost savings and in terms of quality and satisfaction indicators.
Finally, Iruela recognized the glove of the Workshop subtitle – “The experience with EBAs as a limitation of selective radicalism” – after acknowledging that he had gone looking for the literature on selective radicalism, defined as the set of chosen, far-reaching transformations on a key and reduced front that are generalized by a process of innovation/diffusion.
In their view, the lack of generalisation of a reasonably successful experience in the territory where it has been tested is due to an explicit and manifest lack of interest in it on the part of the health management institutions. The moderators pointed out that in the rest of the territories, even in those most fervently in favour of any “corporatisation”, in a quarter of a century there has been no show of any intention to advance along these paths. The main limitation therefore seems to be a political lack of interest, curiously coinciding among all the governing formations.
In short, a highly illustrative workshop to recalibrate the pros and cons of different courses of action, thanks to the preparation and effort of the panelists who were a luxury that we will not fail to thank and – as there is no good action that does not entail a punishment – recommend its circulation in other forums and debates.
Finally, to put a but, it would be the one referring to the limitation of time for debate after the presentations, which turned out to be manifestly insufficient. We would have gladly given up all those present to the refrigerator, but it was already time for the ceremony to appoint Bea as Honorary Member of AES and nobody, sensibly, wanted to miss such an emotional, deserved and heartfelt moment.
- Extraordinary report from the Ombudsman of Greuges to the Parliament of Catalonia on the approach to the situation of primary health care in Catalonia. Official Bulletin of the Parliament of Catalonia, October 24, 2002. 2002.
https://www.sindic.cat/site/unitFiles/2182/atencio_primaria.pdf
- Institute for Health Studies. Evaluation of primary care service delivery models in Catalonia, Generalitat de Catalunya, Department of Health. 2006.
https://www.uch.cat/comunicacio/noticies-101/edicio-de-linforme-avaluacio-dels-models-de-provisio-de-serveis-datencio-primaria-a-catalunya.-resum-executiu-100 .html
- Avedis Donabedian Foundation. Evaluation of the reform of primary care and the diversification of services. Barcelona, FAD. 2002
https://webs.academia.cat/revistes_elect/view_document.php?tpd=2&i=9054
