Each of the care system levels has become strong in a particular feature in Spain: in primary care, it has been the role of the gatekeeper; in hospitals, the hierarchization of medical services and in the socio-sanitary area, the offer of post-acute beds. And if we look at what these strengths have been translated into, we will rapidly agree that the primary care has achieved a performance of proximity and effectiveness in prevention, the hospitals have obtained very satisfactory levels of resolution in acute diseases and the socio-sanitary has contributed the essential decompression to the system.
These same strengths, which are certainly well recognized, become rigidities when new requirements that somehow question the status quo, emerge. However, I will demonstrate in 4 examples how the health system has been able to offer imaginative responses, without any hassle:
- The tumour committees of hospitals have been created over three decades ago to coordinate clinical actions as these were beginning to be complex and, although after the committee meeting each faculty resumes work in each of their corresponding medical service, this instrument has brought some order to the clinical process, and thus is perceived by those involved, including the patients.
- The programs of transferring complex patients between hospital and home are initiatives of coordination between hospital nurses and primary care nurses. Each of them continues to work at their care level, but this time they have memorized phone numbers and emails, and this "little" communicative improvement has been very effective in reducing unnecessary readmissions.
- The performance of primary care towards patients with type 2 diabetes is an example of "unilateral" integration. When this country reformed primary care, it decided that diabetes was specific to the first level and, for this reason, for this pathology, the primary care exceptionally does not act as gatekeeper, but instead it displays a team based on nurses performing under the slogan: "We take care of everything“. The distanced specialist only intervenes in complex cases. The results are excellent.
- The programs focusing on sexual and reproductive health constitute an example of organizational integration that has grouped under one umbrella the so called family planning centres, the "quota" specialists and the hospital Obstetrics and Gynaecology services. Many of these programs knew how to take advantage of this integration "from above" in order to improve processes "from below", but this is not a success in all cases.
Coordination is always good and efficient, as improved results are obtained with the same resources. The integration, however, is more complex: it requires leadership and unification of resources but unfortunately this is not always synonymous with success, at least when there aren’t any well-defined objectives of integration.