Coordination, integration (in Spanish Health Care System)

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:

Adding value to doctor's remuneration

Perspective article: “Adding Value to Relative-Value Units.” See it on our #HealthPolicy page: http://t.co/2JG09NVWKW
— NEJM (@NEJM) noviembre 28, 2013

NEJM devotes an editorial and a couple of articles (they can be downloaded for free) to the new model for doctor’s remuneration by Medicare. This is a matter specific to the Americans, you’ll say. Therefore, it wasn’t necessary to choose it as this tweet to discuss. Although I have to admit that in these aspects of innovations in cataloguing and financing models, sometimes the Americans are right, as was in the case of DRG, then we all rush to import them into our systems.

Adjusting contracts to the value provided by services

'Commissioning for value'bona iniciativa del NHS per identificar els millors programes d millora de la salut http://t.co/7whaXuF2d4
— Dr J Vidal-Alaball (@jvalaball) noviembre 22, 2013

Dr. Josep Vidal-Alaball is a family doctor trained in England and passionate about public and community health. He’s a keen Twitterer, very active in innovation.

The link in Dr. Vidal Alaball’s tweet, directs us to the English National Health Service’ website, named "Right Care", where it is stated that the purpose of the health system is to deliver more value to people’s health and, according to this statement, proposes that service contracts should be adjusted in-line with this value (Commissioning for value) and clarifies that the NHS adopts Michael Porter’s definition of value: clinical outcomes in relation to costs.

"The values of clinical practice" Campaign for doctors in training

The Clinical Management Section of the Catalan Society of Health Care Management (SCGS) has just released a video to promote the values of the clinical practice among physicians in training.

To activate English subtitles go to "settings" in the lower right banner

I would like to highlight 10 keys that, according to the video, should allow a generational change in the practice of medicine:

1. Learn to listen patients and appreciate what their circumstances are.
2. Forget about persuasion and learn the technique of motivational interviewing.
3. Help patients to make clinical decisions for themselves.
4. Rate the burden of treatment and learn to deprescribe whenever necessary.
5. Take the time for clinical reasoning and adopt the Bayesian probabilistic thinking.
6. Request tests that make sense clinically, thinking about the value they will bring.
7. Learn to teamwork, specially when facing complex patients.
8. Watch out for overdiagnosis when practicing prevention and share it with target people.
9. Incorporate palliative methodology in your clinical practice and know how to have the proper conversation about the end of life with patients and their families.
10. Know how to get the "Right Care" sources.

Main "Right Care" sources

• The Cochrane Collaboration, active since 1993.
• Collection of articles Less is more in JAMA Network, since 1998.
• Campaign Too much medicine of the British Medical Journal, since 2002.
• Do not do. Recommendations arising from clinical practice guidelines from NICE, since late 2006.
• Choosing Wisely. ABIM Foundation Program. Collect recommendations from American scientific societies, since 2011.
• The "Essencial" Project from AQuAS. It has the support of Catalan scientific societies, since 2013.
• Diana Salud, a website of the epidemiology research network CIBERESP. Excellent searcher of 18 sources "Right Care" worldwide.

From this blog I wish the campaign "The values of clinical practice", promoted by the Clinical Management Section of the SCGS, to echo, both in medical schools and medical residents programmes.


Jordi Varela
Editor