ORIGINAL RESEARCH PAPER
Year : 2007 | Volume
: 20 | Issue : 2 | Page : 42-
Towards Unity for Health in the Barceloneta: An Innovative Experience in Community-Based Primary Health Care
A Segura1, FA Miller1, G Foz2, A Oriol y Bosch1,
1 Institut d´Estudis de la Salut, Barcelona, Spain
2 Institut Catalá de Salut, Barcelona, Spain
Institut d´Estudis de la Salut, Barcelona
Context: This paper describes a unique experience in community-based primary care in the Barceloneta, an economically deprived neighbourhood in Barcelona, Spain. The paper analyzes the reasons for the successes and failures of the project in light of TUFH principles.
Methods: The Primary Care Team (PCT) that staffed and ran the Health Centre in the Barceloneta facilitated the active participation of entities and individuals from the neighbourhood in deciding questions of care provision and resource allocation. They also collaborated with other service providers in the neighbourhood including pharmacists, with whom the PCT developed a program for monitoring diabetic and hypertensive patients in the local pharmacies.
Results: The health centre registered some of the best outcomes in Barcelona, including: time spent with each patient; capacity for the physicians to resolve patient visits without a referral; and patient satisfaction. Outcomes for patients followed by their local pharmacists were equivalent to those seen in the clinic, with lower costs. Despite these impressive results, conflicts among and between various stakeholders led to the project«SQ»s termination.
Conclusions: Innovations in any system can lead to conflicts of interest between stakeholders, derailing even demonstrably effective programs. A stable partnership with other stakeholders, particularly the community and health care administrators, in this case, is key. However, the community is not monolithic, and efforts must be made to ensure that other stakeholders do not widen intercommunity disputes. Effective dissemination of information on the impact of the project on the population is important to maintain relationships with the various stakeholders.
|How to cite this article:|
Segura A, Miller F A, Foz G, Oriol y Bosch A. Towards Unity for Health in the Barceloneta: An Innovative Experience in Community-Based Primary Health Care.Educ Health 2007;20:42-42
|How to cite this URL:|
Segura A, Miller F A, Foz G, Oriol y Bosch A. Towards Unity for Health in the Barceloneta: An Innovative Experience in Community-Based Primary Health Care. Educ Health [serial online] 2007 [cited 2020 Aug 11 ];20:42-42
Available from: http://www.educationforhealth.net/text.asp?2007/20/2/42/101625
The compartmentalization currently seen in health care and social services is an important obstacle to achieve more relevance, responsibility, equity, and better results in the delivery of health care. At the conference “Towards Unity for Health” that took place in Phuket in 1999, it was proposed that there be an effort to foment an organization of health care services that is truly oriented towards the needs of local populations. The strategy to accomplish this would be through the integration of the key stakeholders impacting the health of a community, amongst whom a primary actor is the community itself (Boelen, 2000).
It was in this context that the WHO sent out a request for proposals to select field projects from around the world that would be able to develop the initiative “Towards Unity for Health”. One of the twelve projects selected was the AUPA Project of the Barceloneta, submitted by the primary care team (PCT) that provided health care to the neighbourhood of the Barceloneta, in Barcelona, Spain since 1993 (AUPA are the initials for “Towards Unity for Health” in Spanish and Catalán. In Catalán “Aupa!” also means “Upwards and Onwards!”). This paper describes the innovative aspects of the AUPA Barceloneta project, the evidence of the impact it had on the population, and then analyzes its successes and some reasons for its eventual termination in light of TUFH principles.
In 1993, the PCT, a private group of physicians, was contracted by the Catalán Government to provide health services for the Barceloneta, a poor neighbourhood near the port of Barcelona. As the first private provider contracted to work within the publicly financed Catalán health system, the PCT was characterized by a strong ethic of professional responsibility to care for the entire health needs of the population. This perspective led to uncommon efforts to coordinate activities with other agents working to improve the health of the population in the neighbourhood. Activities included collaborations with medical specialty services, the neighbourhood pharmacists, public health professionals and with teachers in the primary and secondary schools.
The Basic Health Area of the Barceloneta coincides geographically with the neighbourhood itself, which has conserved a very strong identity. [Note: The entire territory in Spain is divided up into Basic Health Areas. Each Basic Health Area has at least one team of health professionals (family physicians, nurses, paediatricians, frequently a social worker, and occasionally podiatrists and dentists) that is responsible for the health care for that population. By law this involves direct patient care as well as health promotion activities for the reference population. However in practice, most primary care teams do little in terms of health promotion activities.]
The Barceloneta’s population is particularly affected by aging and social and economic deprivation, with a notable burden of illness and disability. Life expectancy at birth for males is 8 years less than the city average, and for females it is 4 years less (the city average is 77.5 and 84.3 years, respectively). The health and social needs of this area are markedly higher than the rest of the city, which translates into a higher demand for health services. This is accentuated by the fact that medical care is a benefit with universal access in Spain, which is not the case with social services (Segura, 2004).
Local Services and Civic Entities
The PCT worked with a variety of civic entities including the neighbourhood associations, the commercial associations, the senior centre, the civic centre, and the schools, from day care centres to high schools. Most of the activities were health promotion interventions consisting of health education presentations, and prevention of disease activities such as school health examinations and vaccinations. The PCT also had a regular article and readers’ advise column in each edition of the local newspaper, “La Barceloneta”, which distributed 5000 free copies each month. Moreover, they established regular meetings with these civic organizations to discuss health problems in the community, such as the legionnaire’s disease outbreak during the winter of the year 2000 (Jansa et al., 2002).
Particularly important was the participation of the neighbourhood associations. They shared responsibility with the PCT for making decisions that affected the organization and accessibility of the centre. This, in turn, permitted the adoption of initiatives intended to improve the rational and fair use of health care resources, such as the procedure for making same day appointments.
Medical care was provided by family physicians and paediatricians. When patients were referred to a specialist, instead of going to their office, the specialist consultant came to the clinic and saw the patient together with their family doctor. These joint visits were included within the program of continuing medical education, which served to keep the PCT up-to-date, as well as increase their prestige in the eyes of the patients. Another important consequence was the capacity for the PCT to resolve their patients’ health problems. The proportion of referrals to external specialists in the Barceloneta was two for every one hundred patient visits, while the proportion of referrals in the rest of the city was approximately seven per hundred. It also resulted in more appropriate use of emergency services in the hospital, which decreased by 20% in the first five years of operation. Finally, the patients referred to the hospital from the centre were admitted more quickly given that the hospitalization was part of a process of continuity in care (Segura, 2004).
In assuming the responsibility that comes with the exercise of professional autonomy, peoples’ creativity is stimulated to deal with problems and enact solutions, in internal clinical activities as well as relations external to the clinic. With regard to self-budgeting, the organization of service delivery was based on a functional conception of the team in which every service developed their own competencies in a way that was autonomous, yet coordinated. The primary doctor, as the person responsible for their patient’s care, played a central role in the prescription of medications, the requesting of diagnostic tests, and referrals to specialty services. The nursing personnel developed their own activities to monitor patients with chronic diseases, and carry out complimentary exams (EKGs, spirometry, etc.), extractions for analysis and treatment procedures.
All of the care delivery was registered in a database, which was either exhaustive, or, in the case of same day visits, was registered as a representative sample. The physicians had absolute freedom to prescribe medications, to solicit diagnostic tests and to do referrals. Common criteria were established in a consensual manner, and in some cases, such as with the pharmacy prescriptions, the medications were pre- selected. The physicians were nevertheless able to make the clinical decisions they saw as necessary, with all the providers’ decisions under systematic supervision by the Clinical Director (CD). This information was all registered electronically using software developed by the PCT, which allowed for the budget to be shared with the financial backers and with the community in the external realm. It also was useful internally for sharing data with the PCT, thus guaranteeing the internal transparency necessary to reach the standards and objectives established by the PCT, as well as to correct for deviations from these objectives.
The centre began collaborating with the local pharmacists after an initiative to promote the rational use of medications following an audit done by the University Institute of Public Health of Catalunya in 1995. This audit led to a decrease of 24% in the number of prescriptions originating from the centre and a 26% decrease in the cost within a year of its implementation. It was thus necessary to explain to the local pharmacists the goals and criteria used to make these modifications so that the pharmacists could adequately explain these changes to the patients to whom they were supplying the medications. To do this, joint sessions between the pharmacists and the PCT were arranged. These meetings lead to the pharmacists participating more actively in the care of patients, such as periodic joint sessions analyzing problems that derived from the population’s use of medications and ultimately to new joint initiatives, such as the Community Program for the Control of Patients with Diabetes and Hypertension. The program allowed patients to go to their neighbourhood pharmacist for blood glucose and blood pressure checks, with an electronic linkage to the patients´ records in the clinic. Without diminishing effectiveness, this innovative program improved access, efficiency, and satisfaction for the patients who participated, which was half of the patients who were offered this option (Segura & Miller, 2006).
In similar fashion, a joint program was started to integrate pharmacists with the rest of the health professionals on the PCT in the detection, analysis and eventual correction of medication incidences, the majority of which were problems of non-compliance. Finally, the PCT and the pharmacists jointly carried out a personalized dosing program for patients taking multiple medications who had difficulty adequately self-administering their drugs.
The PCT maintained multiple relationships with academic institutions. Sixth year medical students at the Autonomous University of Barcelona did two month rotations with the PCT. Pharmacy and Podiatry students from the University of Barcelona did practical rotations. Several Master’s students in Public Health at the University of Pompeu Fabra worked on thesis projects with the PCT (Valero et al., 2006), and the University Institute of Public Health did the audit of the drug prescriptions, as mentioned above. Lastly, the Institute for Health Studies supported the participation of a public health professional (the lead author of this paper) in the spirit of social responsibility, as well as to assist the PCT in documenting the trajectory of their project.
In the first two years of operation, the clinic was able to decrease the number of monthly visits by the high frequency patients (those who came to be seen more than 50 times a year) by almost 20%.
The quality ratings for the Barceloneta health centre were the highest in the city for patient visits resolved without a referral, patient satisfaction, and time the patient spent with their doctor.
Patient visits with their physicians averaged 12 minutes for an urgent care visit and 24 minutes for a scheduled visit, compared with the city average of 6 minutes for all types of patient visits.
Emergency Room visits to the nearby hospital were decreased by 20%.
Greater autonomy resulted in a more satisfying work environment for health professionals, as did working with specialists in the clinic.
Pharmacists felt more satisfaction in playing a role as health providers in the care of chronic patients.
Patients were more satisfied with the program that allowed them the convenience of being monitored at their neighbourhood pharmacy, with equally good outcomes (Segura, 2004).
Despite these excellent results, tensions had been mounting between the CD and the municipal government over professional autonomy issues. The CD insisted that to better respond to the needs of the population, as well as to encourage a sense of professional responsibility for the members of the PCT, it was essential to have a large degree of autonomy to decide policies and allocate resources. Over time, however, new people were appointed to assume political roles in the local administration and the health care administration who were not in agreement with this level of autonomy. In the summer of 2004, a conflict arose between different factions within the community on how the centre should handle urgent care visits. The health administration stepped in and imposed a solution, which, in the view of the CD, violated the PCT´s privileged relationship with the community, diminished their credibility as well as further divided the community. The CD left, along with half the PCT, effectively ending the project.
In light of TUFH principles, this experience would suggest several observations:
Implications for Health Care Professionals: By giving the health professionals a new role in deciding how to run their clinic, they were able to organize resources to the greater satisfaction of their patients as well as themselves. Granting them the charge of caring for the entire population, including those who might not present as patients, lead to an extension of their sense of responsibility to provide preventive and health promotion activities for the whole population - a form of professional commitment and responsibility not frequently seen in the Catalán, or any, health system.
Civic Participation: Making efforts to involve community representatives as key stakeholders for running a clinic is an effective way for patients to assume more responsibility in the use of health resources. The CD stressed that they were able to achieve a decrease in high frequency users only by dialoguing with them and coming to agreement on various measures to decrease this behaviour in order to provide better access for more patients (Segura, 2004).
Collaboration with Neighbourhood Pharmacists: Pharmacists have a unique position in the community in that they are very accessible, they often have a good deal of credibility with the population as a resource for medical advice, and many would like to be of more service for patients. They should be considered as potential stakeholders in the local health care arena in the TUFH approach. Having pharmacists participate in monitoring chronic care patients can lead to greater patient satisfaction, lower costs, and equivalent outcomes to patients followed in the health care centre.
The Need for Stable Commitments Between Different Stakeholders: Much of what the PCT was able to accomplish was thanks to their degree of autonomy to do what they felt was most important. The PCT was not constrained by protocols imposed from above in a highly centralized system that dictated how they should arrange their patient schedules or allocate funds for specialty care. In this way they could negotiate appointments protocols directly with patients, or make contracts with specialists to come to the clinic and do joint visits with the PCT. Recent appointees in the local political arena and health administration had a different view of management and did not allow the PCT adequate autonomy to continue its work with the community and other local providers. In light of the TUFH approach, it should be emphasized that once relationships are created with key stakeholders, every effort must be made to maintain these relationships when there is change in personnel.
Evidence of Impact: While the CD kept local politicians and health care administrators informed about the project’s successes, the population could have been better informed about these quantitative results. Perhaps if the community was more aware of the many positive outcomes of the project, they might have found a way to come together and support the PCT when their autonomy was threatened by external political forces.
Communities are not Monolithic: The split within the community on how to handle urgent care appointments demonstrates clearly that communities often do not speak with one voice. To handle such delicate situations it is very important for the other stakeholders to not take sides and further exacerbate the conflict.
Involving Other Service Sectors: Interventions in health promotion and prevention increasingly are involving other service sectors - education and social services in particular. This tendency could receive more emphasis in the TUFH model.
Acknowledgement: Special gratitude is owed to Dr. Juanjo Avendaño, former Clinical Director of the Barceloneta, for his leadership and dedication towards putting TUFH principles into health care practice.
Boelen, C. (2000). Towards Unity for Health: Challenges and opportunities for partnerships in health development. A Working Paper. Geneva: World Health Organization.
Jansa J.M., Cayla J.A., Ferrer D., et. al. (2002). An Outbreak of Legionnaires´ Disease in an Inner City District. International Journal of Tubercular Lung Disease, 6:831-838.
Segura, A. (2004). Monografía 12. El projecte AUPA Barceloneta. (El CAP Barceloneta/Serveis Mèdics: 1993-2003). Barcelona: Institut d´Estudis de la Salut. (Executive summary in English).
Segura A. & Miller F. (2006). Health Services for the Barceloneta. The Network: Towards Unity for Health Newsletter. Vol. 25, No. 01, Pg 21.
Valero Parilla F., Segura Benedicto A., Segú Tolsa J.L. (2006). Utilización de la ecuación de Framingham-REGICOR en un centro de atención primaria. Impacto sobre la prevención primaria de las enfermedades cardiovasculares”. Atención Primaria. 38:490-495.