Spain has a health system that is similar to the NHS, in that it is funded largely out of tax and is mostly free. The country’s autonomous regions have a high level of responsibility for running services, however, and as part of a team from WHO Europe I recently visited Barcelona to look at the Catalan health system.
The system has extensive, devolved powers to organise and provide care for its 7.6 million residents. It’s had severe financial distress, strikes by staff in response to austerity, a large growth in its population, and familiar-sounding challenges on waiting times and staffing. But it has low levels of amenable mortality, is relatively inexpensive (all delivered for 7.2% of GDP in 2016, albeit helped by low staff pay), and as a system enjoys strong public support and high levels of satisfaction.
During my visit, I was struck by how people talked about the policy direction in their areas of interest. They often provided a long-term historical context for what was being planned, and had a good understanding of the strengths and weaknesses of previous initiatives. It also seems that many of those approaches have remained consistent while governments have changed.
There are lessons that the NHS can learn from the Catalan model.
What they do well
Primary care in Catalonia is delivered in purpose-built centres with extended opening hours. They bring together a multidisciplinary team, including family doctors, paediatricians, nurses, physiotherapists and dentists, as well as a number of others such as social workers, phlebotomists, visiting mental health services and some hospital specialists.
Continuity of care is another key component of the system. Patients have a named GP or nurse, but can be seen by other team members if there is an urgent issue.
There is also a proactive approach to managing the population’s health, facilitated by an information system developed by the region and found in almost all primary care practices. This has brought in risk stratification processes (identifying patients at different levels of risk) and pathways that generate alerts, task lists and progress checking – capabilities that even our colleague from Clalit (Israel’s most digitally advanced system) thought were impressive.
During the visit, we also looked at a case management model on providing an extra layer of chronic disease management support for primary care. The model identified the highest-risk 9,000 people from a subpopulation of 450,000, who as they use the system are helped to complete a care plan, including instructions on how they want to be treated in a crisis. The 800 at most risk receive more intensive support (with 24-hour access to advice and active case management), while remaining under the day-to-day care of their GP. This keeps patients in touch with their practice while taking some of the heavier workload away from the GP.
The combination of multidisciplinary primary care and proactive approaches, facilitated by a good information system, seems to have produced major reductions in the number of ambulatory care sensitive admissions and stays in hospital.
Planning and learning
A rigorous planning process has underpinned the system’s development since the early 1990s. This has moved from a focus on diseases, health services and contracts, to a phase of planning service configuration, to an approach now firmly focused on developing policies that support population health management.
There is a parallel process for cross-government planning for public health actions, which has adopted the WHO Health in All Policies approach, and there is also cross-government thinking on mental health. Planning could be more aligned with budgetary processes, and they have more to do in involving wider stakeholders, but they still seem to be effective and enjoy the support of the system.
Importantly, there is also a strong culture of evaluation and learning. Plans are evaluated and the system measured by the Agency for Health Quality and Assessment of Catalonia, which also operates an observatory to provide impartial information about the health system’s performance.
My experience has taught me that health systems that look outwards for learning also tend to be more effective, and Catalonia has a keen interest in other systems, while adapting the learning for their own context.
So what can the UK learn?
There are some interesting parallels between Catalan and British health policy. Not least that CatSalut (an arm’s-length body of the ministry) acts as a single commissioner and the home for the state-owned health services that include most primary care and 20% of the hospitals – which looks quite a lot like NHS England. Both countries also have a similarly low number of hospital beds.
And, despite the two systems having differences, there are certainly wider lessons for the NHS to take from the Catalan model.
First, Catalan experience supports the idea that larger primary care teams offering continuity of care – with a proactive approach to multimorbidity and supported by community services – will bear fruit.
Key to this are a comprehensive patient database and primary care IT systems that support standardised pathways, appropriate prompts and reminders, and other useful tools to support effective patient management. Direct input from mental health and social work staff into primary care units is also integral.
Another lesson is that successful change has been helped by continuity of policy and careful planning over a long period – with a high level of consensus about it too. Focusing on a limited set of priorities has no doubt also helped.
Perhaps the most pertinent thing we can learn is that consistent effort over a long period – using evidence and avoiding wild swings in policy – pays dividends.
Edwards N (2019) "Homage to Catalonia? Reflections from a recent visit", Nuffield Trust comment.