Country and population

Spain is an EU country in the south-west of Europe. Politically it is a democracy organized in the form of a parliamentary government under a constitutional monarchy. It is divided into 17 autonomous communities (ACs), each of which has wide legislative and executive autonomy, their own Parliament and government. Spain has 45.99 million inhabitants (Eurostat, 2010) in a territory of 504 750 km², and the density of the population varies among the 17 autonomous communities, ranging from 26.19 inhabitants/km² in Castile–La Mancha AC to 803.49 inhabitants/km² in Madrid AC (INE, 2010b). The 2009 population growth was 0.07% and the total fertility rate is 1.4 children per woman. Currently, 23.3% of Spanish people are aged under 16 years and 24.61% are over 65 years (INE, 2010b). As in other countries in western Europe and because of the “baby-boom” after the Second World War, it is estimated that more than one-third of the Spanish population will be over 60 in the year 2050.

Development and economy

Spain has undergone a profound transformation of the state over the last three decades, and the main characteristic of this change has been the wide political decentralization of the state structures. At a central level, legislative power is placed in a two-chamber Parliament (Congress and Senate). At a territorial level, each AC has a Statute of Autonomy with its elected Parliament and government. Most AC laws have the same legal status of those of the state.

Spain joined the EU in 1986 and experienced rapid economic growth during the following 20 years, with annual increments of more than 3% of its GDP (Eurostat, 2009). However, this has slowed down and in the last two years there has been a negative growth. This has resulted in a dramatic unemployment rate, which moved from 9.3% in 2008 to 19.9% in mid 2010 (UNDP, 2009; INE, 2010a). The GDP per capita was US$ 32 030 PPP in 2009, and estimates for 2010 fix the GDP per capita at US$ 29 900 PPP. Spain ranked 20th on the Human Development Index with 0.863 (UNDP, 2010). Immigration has become a new phenomenon in Spain, and from 2000 to mid 2010, 4.9 million people have moved to Spain. Currently, the immigrant population makes up 12.2% of the total population. Regarding education, 68.1% of the population completed secondary level education, and 2.1% of the population are considered illiterate (eLiceo, 2010).

Health of the population

Life expectancy at birth in Spain is 84.27 years for women and 78.06 years for men. The healthy life expectancy is 63.2 in females and 63.7 in males, among the highest in the world (Eurostat, 2009). Infant mortality was 4.21 deaths for 1000 live births in 2009 (WHO Regional Office for Europe, 2010). Fertility rate is 1.47 children born per woman. Regarding the top causes of death, ischaemic heart disease is the main one (13%), followed by cerebrovascular diseases (10%); other main causes of death are trachea, bronchus and lung cancer (5%) and chronic obstructive pulmonary disease (5%) (WHO, 2009).

Characteristics of the health care system

The Spanish health care system underwent a major transformation along with the political reorganization of the state with the formation of ACs. It moved from a charity-based system with some aspects of the Bismarck model to a National Health System (NHS). The 1986 General Health Act defines the Spanish NHS, and its principles:

• universal coverage with free access to health care for the entire population;
• public financing, mainly through general taxation;
• integration of different health service networks under the NHS structure;
• political devolution to the ACs;
• a new model of primary health care, emphasizing integration of promotion, prevention and rehabilitation activities; and
• a gatekeeping system at the primary health care level (BOE, 1986: Article 15.1).

The devolution process in the health sector occurred in different stages. The responsibility for managing its own health system was transferred to Catalonia in 1981, Andalusia in 1984, followed by the Basque Country in 1987. In addition to the ACs mentioned, until 2001 the central government had only devolved responsibility for the health care network to the Canary Islands, Galicia, Navarra and Valencia, which together cover approximately two-thirds of the Spanish population. A central institution, INSALUD, effectively managed most health care services in the other 10 ACs. The transfer of the main social security health care network took a considerable time and was only completed in 2002. Each AC has created a health service department to manage health services, under a regional government department or health authority. The main responsibilities at the AC level are planning, financing and provision of the health services, and public health. This has allowed the development of various models within the Spanish NHS (BOE, 2006). According to this design, the central government has the responsibility to promote coordination and cooperation in the health sector, as well as to ensure that the quality of all services is guaranteed and equity exists in relation to access to health care throughout the national territory. The government also reserves for itself certain competences regarding foreign health, international relations, pharmaceutical policies, research and high-level inspection (BOE, 1986). Table A27.1 shows some general indicators of the Spanish health care system. Spain’s health expenditures in total and per capita are above the EU average.

Table A27.1

Development of health care resources and utilization.

2.1. Primary care governance

Primary care in Spain has been played a significant role for more than five decades. Gatekeeping at the primary care level has been in place since the 1970s and was explicitly recognized in the General Health Act 1986. As a result of this Act, it was determined that the Spanish health system would be based on an NHS model. This also defined the primary care core activities and the geographical organization of primary care (BOE, 1986). Prior to this, the establishment of the specialty of family community medicine in 1979 was another element which facilitated the implementation of the primary health care reform. The starting point of this reform took place in 1984, after several ACs had their health services transferred and were able to develop new legislation in order to reorganize the health services around primary care (DOGC, 1985). This allowed the ACs to create their own legislation, resulting in a diversity of management and provision models of primary care in Spain (Navarro & Martín-Zurro, 2009). However, the main pillars of primary care in Spain defined in the General Health Act, such as gatekeeping, free access and multidisciplinary teams, had to be guaranteed in all the ACs. In the 2000s, a consultation process among the main actors in primary care was set up by the Ministry of Health of the central government, and a document regarding strategies for primary care in the twenty-first century was formulated (Ministry of Health and Social Policies, 2009). Currently, as a result of the recommendations of the Ministry of Health, various ACs have set up their own initiatives and have developed different strategies (PIAPC, 2010).

On the basis of equal access to primary health care, the General Health Act fixes the minimum distribution of health areas within the Spanish territory (BOE, 1986) and the ACs can adapt the number of health care infrastructures and ratios of professionals within the primary health centres to their territory, taking into account that these professionals are required to work in geographically based multidisciplinary teams. Quality standards for facilities and health care infrastructures are established at the AC level. Health care providers are contracted and monitored by the AC health services where they operate, however they can develop their own mechanisms in order to accomplish their objectives. Furthermore, these contracts, the length of time they are valid and the operational requirements follow different mechanisms and formulas in each AC. Quality indicators implemented in various ACs are mainly a mix of performance, accessibility and cost–efficiency indicators (Gené, 2009). Each health care provider is able to develop their clinical guidelines, protocols and mechanisms of continuing medical education (CME). Moreover, scientific societies and professional associations of primary care are the main actors contributing to both CME and the development of clinical guidelines. Health professional curricula and degree recognition, both for undergraduate and postgraduate education, are defined by the Ministry of Education at state level. However, recruitment of professionals is a responsibility of the ACs and health care providers. In order to be able to practise, each health professional is required to be licensed by a professional body, such as medical colleges or nursing colleges among others, which are decentralized to the AC level or to a province within an AC.

Citizen and community participation in the decision-making process is regulated by the General Health Act (BOE, 1986: Article 5.1) and implemented through health councils where the voice of the citizen can be heard. On the basis of the principle of democratic governance, various ACs have taken this further; citizen participation in the health councils is now legally recognized and their competences, functions and responsibilities are defined by a decree (DOGC, 2006: Article 4.3). One of the aims of these councils is the monitoring of the social impact and health outcomes of the public policy implemented in the community. Patients’ rights are safeguarded in areas such as informed consent, patient access and confidential use of medical files, and patient complaints, which are fully regulated and implemented throughout the whole country. Furthermore, specific primary care patient satisfaction surveys are regularly carried out and included in the evaluation and payment schemes for providers (Direcció General de Planificació i Avaluació, 2005; DOGC, 2004).

2.2. Economic conditions of primary care

Primary care expenditure in relation to overall health care expenditure was 14.09% in 2005 (OECD, 2005). However, 2009 OECD Health Data show that the overall expenditure on outpatient care as a percentage of health expenditure was 29.7% in the year 2007 (OECD, 2009). The two figures can be explained by the fact that in the outpatient data in the year 2007, hospital outpatient care was also included. The evolution of primary care expenditure has increased in the last 15 years in absolute terms. Nevertheless, the total percentage of primary care expenditure as part of the global GDP of the country varied from 0.91% to 0.85% of GDP between 1992 and 2005. This can be explained by real increments of 10% in the expenditure in hospital and specialized care, broadening the gap between hospital and primary care budgets. Disaggregated figures between ACs show the variability of the expenditure in primary care as a percentage of GDP ranging from 1.47% to 0.66%. Preventive care and health promotion account for 2.2% of all expenditure on health (Espasa, 2009).

Health care coverage, including primary care, is universal in Spain. All Spanish citizens and residents in Spain have free access to the public health system (BOE, 1986). There is a comprehensive free public health basket in primary health care with the exception of 40% co-payment for outpatient pharmaceutical products for all the population under 65 years old; nevertheless some drugs for specific health conditions have a minimum tariff.

Most primary health care professionals and personnel in Spain have civil servant status. There are a few exceptions regarding some ACs, in which less than 30% of professionals have contracting conditions other than that of civil servants. So, in general, the workforce at primary health care level is mainly salaried, with a wide range of supplements, from a variable salary (which takes into account geographical dispersion of the population, teaching and transportation) to various degrees of economic incentives introduced since 2003, such as professional career, achievement of quality indicators related to performance and cost–effectiveness among others (BOE, 2003). Some ACs have extended these incentives to all the personnel working in a primary health care team, from doctors to receptionists so as to reinforce the team work and to strengthen the multidisciplinary approach. Moreover, the average wages of medical professionals either in primary and hospital care are very similar. The same occurs with nurses and other health care professionals and personnel. The mean net income before taxes of a primary care physician ranges from €39 000 to €60 000 depending on the AC and variables mentioned (Magallón, 2009).

2.3. Primary care workforce development

The primary health care workforce in Spain is organized around a multidisciplinary team, with a gatekeeping function which provides the following services: prevention and promotion of health, acute and chronic care, home care and community care activities. The core of the team is made up of physicians who are family and community medicine specialists, paediatricians, nurses, auxiliary nurses, social workers, dentists and administrative staff. The team works closely with midwives, gynaecologists, public health professionals, pharmacists, radiologists, physiotherapists and laboratories. The coordination with other health professionals and health care levels is good and is currently strengthened with the support of information technologies (IT) and also thanks to the widespread implementation of the electronic clinical records in more than 97% of the practices (Borkan et al., 2010).

The main characteristic of primary care in Spain is the role that it plays in the health system, as specialist care cannot be accessed without a previous referral by the GP (BOE, 1986). The number of referrals is relatively low, as less than 6% of the encounters at primary care are referred to another level of care (Peiró, 2008). This is influenced, first, by the non-existence of barriers for family doctors to order laboratory and imaging tests in most ACs, and, second, by the qualification and training of these professionals (Violan et al., 2009). All medical professionals undergo a postgraduate specialist training of four years and nurses also have a university degree. In addition, continuing medical education is allocated within working hours and the establishment of a professional career for medical professionals has encouraged research in primary care. There is no division in the roles of practice nurses and district nurses in primary care in Spain, as the nurses working in primary care centres are responsible for home care as well. Currently, the role of the nurses is expanding and they play a key role in promotion, prevention and follow-up of chronic diseases, as well as involvement in community care and home care. In some ACs, nurses are authorized to prescribe a selected number of pharmaceutical products, which gives them a large degree of autonomy in the decision-making process and the care of patients (COIB, 2007). This is complemented by the support of social workers. The teams also include dentists, who are involved in prevention and promotion of oral health both in the primary care centre and in community activities.

In 2009, 38.1% of all medical professionals in Spain were family doctors, equating to 85 per 100 000 inhabitants, of whom 60.5% were over 50 years old and two out of three family doctors under the age of 39 were women (Barber & González, 2009). Fig. A27.1 shows general development in supply of some of the primary care providers. The workload of all the health professionals in primary care is 40 hours a week, excluding on-call hours carried out by family doctors and nurses in rural areas.

Fig. A27.1

How does the average income of mid-career health professionals relate to that of a mid-career GP?

Unlike many European countries, university departments in family medicine do not exist in Spain. The specialization period is carried out in family and community medicine teaching units, which are responsible for coordinating the postgraduate and specialization four-year programme of the specialty in family and community medicine. These teaching units are recognized by the National Medical Specialty Commission and the Ministry of Education (Violan et al., 2009). In 2005, the specialty in family and community medicine for nurses was approved, and currently the curriculum is under development (Violan et al., 2009).

Various family medicine associations and scientific societies exist in Spain for both doctors and nurses (semFYC, SEMERGEN, SEMG, AIFICC, among others). They are based on voluntary enrolment and the core activity of these societies is research and continuing medical education. Continuous professional development and continuing medical education are shared by various institutions. Registration and licensing is mandatory in order to be able to practise and are carried out by general professional bodies, called official colleges, for each profession, such as medical doctors, nurses, social workers, odontologists, physiotherapists and so on. These official colleges have province or AC authority.

Fig. A27.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period. Sources: OECD, 2010; Eurostat, 2010.

3.1. Access to primary care services

Access to primary care is guaranteed by law (BOE, 1986). Distribution of primary health centres and primary care professionals around the Spanish territory has been evenly implemented over the last three decades. Each AC has developed specific regulations for the distribution of primary care professionals and to guarantee the accessibility of primary care. Ratios of professionals in relation to the number of inhabitants and distribution in the territory have been defined (DOGC, 1985, 1990). In order to allocate resources, various mapping processes were carried out in each AC, in which the analysis of the existing situation and predictive models were used (see, for example, the Department of Health, 2008). This has resulted in an equitable distribution of facilities and personnel, which takes into account rural areas, socioeconomic and demographic conditions, and also the epidemiological status of the population. From the point of view of the distribution of professionals in the territory, recruitment has not been a problem, as this is based on a civil servant formula, according to a scoring process, in which professionals have no direct choice and are obliged to work in relation to their ranking. Because of this, no areas are left uncovered. Nevertheless, in the last five years, and due to a radical demographic change in Spain due to immigration, a need for more professionals has emerged. This has changed the ratio of Spanish and foreign doctors, and currently the majority of new licensed doctors in Spain are from Latin-American countries (Barber & González, 2007).

The average number of GPs available is 85 per 100 000 inhabitants, and evenly spread over the territory. This figure also includes paediatricians working in primary care. Similar data can be found regarding the number of nurses, as ratios of nurses and GPs per inhabitant are the same. Working hours are legislated at AC level. Opening hours vary depending on whether the primary health centres are in rural or urban areas. In rural areas they are open 24 hours, 365 days a year. In urban areas not all centres are open 24 hours, but there is always a primary health care centre on duty within a 30-minute radius. The most frequent working schedule is from 08.00 to 20.00 hours. Other after-hour provision systems exist, such as call-centre triage units, which coordinate and activate the most appropriate health care service for each consultation. It is always possible to contact health professionals. Appointments and consultations at one’s usual primary health centre can be made by telephone call, internet or directly at the primary health care centre (see Fig. A27.3). Group sessions and community activities are also carried out by the health centre. Patients have the choice of being seen by any of the health professionals in the primary care teams where they are listed, including the social worker. If a patient believes he or she has to be seen on the same day, this is also guaranteed and there are no waiting lists for these requests. In the case of an emergency, all patients are able to go to any primary health centre. There are no economic barriers to access primary health care in Spain, and no fees are charged to the patients (BOE, 1986). According to a national survey on accessibility carried out in 2007, 97% of the population found their GP easy to reach (IIS, 2009).

Fig. A27.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres.

Table A27.2

GPs’ involvement in delivery of various primary care services.

3.2. Continuity of primary care services

Patient lists for GPs and nurses exist in all ACs. Patients can choose both GPs and nurses independently. It is also possible to choose a GP or nurse from a centre outside the patient’s catchment area. In some ACs patients can choose any GP working within the AC (Catalan Health Service, 2006). In order to assure continuity of care, patients are seen by the same GP and nurse in most of the encounters (Gené, 2006). There is a single clinical record for each patient at the primary care level, and currently 97% of all clinical records are electronic (Borkan et al., 2010). The average time of a general practice consultation is 13.4 minutes (in Catalonia in 2009), and 30 minutes for those performed by nurses. GPs and nurses work as a team and the care of patients is shared. Most of the prevention and health promotion activities, home care and follow-up of chronic diseases are carried out by nurses, who arrange the patients’ health care plans together with the GP. Fig. A27.4 shows that patients are generally very satisfied with different aspects of their care provided by GPs (Direcció General de Planificació i Avaluació, 2005).

Fig. A27.4

Patient satisfaction with aspects of care provision.

Electronic clinical records for all the primary health teams have already been implemented throughout the country. This allows the sharing of patient information not only among the team but also among the out-of-hours services and other health providers. Safety and confidentiality instruments have been developed. In addition, in a few ACs, selected information from the electronic clinical record, digital images and prescriptions are shared among different health care levels and providers (TicSalut, 2010). Referrals and counter-referrals are always done either by printed letter or electronically. Laboratory tests and image tests are always reported, and in some ACs GPs have access to digitalized images done in hospitals and laboratory results are downloaded into the electronic clinical record. Continuity of care in a few ACs is extended to pharmacies and electronic prescription is fully implemented in some of them (TicSalut, 2010).

3.3. Coordination of primary care services

The gatekeeping system in Spain has been in place since the mid 1970s, but it was the health system reform in Spain in 1986 which contributed to the development of a strong primary care health system. The efficiency of primary care is shown by the reduction of referrals, as primary care retains 94% of the encounters. However, access to secondary care is possible in case of emergencies, as citizens can go directly to hospital Accident and Emergency departments (A&E) without a GP’s referral.

Multidisciplinary teams in primary care were one of the innovative formulas introduced in early 1980s in the primary care reform in Spain (BOE, 1984). The concept of a multidisciplinary team, working in the same centre with common goals, contributed to the rapid improvement in the health outcomes of the Spanish population (see Fig. A27.5). Taking into account health expenditure, with figures around 6% of GDP, compared with health outcomes, it can be seen that Spanish primary care is highly cost-effective (Bernal-Delgado & Ortún-Rubio, 2010). Another feature of Spanish primary care is the existence of paediatricians in the team. These are responsible for the health of children below 15 years old, while patients over the age of 15 are seen by family doctors. In most of the ACs, nurses have seen their roles expand and currently they are independent decision-makers in the health care process of their patients (DOGC, 1990). Prevention, promotion, home care and community activities are carried out in coordination between doctors, nurses, dentists and social workers. This coordination has been helped by the availability of time set aside daily for joint activities, which allows the development of team-building strategies, has facilitated communication among the team members, and has also made the running of CME and research possible. The implementation of this model has been made possible through a large investment in infrastructures and facilities adapted to the work of multidisciplinary teams, with spaces for meetings, group work and community activities.

Fig. A27.5

Shared practice.

Cooperation with secondary care and other services is standard practice, and electronic clinical records and IT systems have been a facilitator in this coordination. Catalonia has already implemented the shared clinical record between primary care and other levels of care, such as hospital and mental health (TicSalut, 2010). For example, three-quarters of all the X-ray and MRI images in Catalonia have been digitalized since the AC took over and can now be shared. Hospital discharge programmes, including primary care nurse liaison as coordinators of the process, and fast-check pathways for some early cancer detection have been implemented in various ACs (Agustí et al., 2006). Joint consultations occur more often and internet and phone advice from specialists is increasing.

3.4. Comprehensiveness of primary care services

Primary health care centres in Spain are equipped for minor surgery, as well as having equipment for diagnostic purposes such as spirometers, ECG machines, retinal digital cameras, and first aid material. Over 94% of total patient contacts are handled by various health professionals in the primary health centres without referrals to other providers. The scope of services in Spanish primary health centres offers a large range of services, from promotion activities and preventive assessment, to diagnosis and follow-up for chronic conditions. Screening for particular diseases, cancers or cardiovascular risk factors is also carried out by the multidisciplinary team. Home care and community care is also in the primary care “service basket”. Paediatricians and nurses perform most of the vaccinations. In some ACs pregnancy care is carried out by GPs and in others by midwives. Health education and promotion is mostly done either at single-patient or group sessions in primary health centres. Community oriented primary care methodology is commonly used to establish health care priorities and define actions jointly with the community, in which the whole team is committed (AUPA, 2010; PACAP, 2010).

4.1. Quality of primary care

Disaggregated data for most of the quality indicators are not available for the whole country. Regarding primary care prescriptions, data include outpatient prescriptions, which are not always issued only at the primary care level. The average of total prescriptions per inhabitant was 1.7 in the year 2009 and 35% of all DDD was for cardiovascular drugs. Just four pharmaceutical groups – digestive and metabolism, nervous system, respiratory drugs and cardiovascular diseases – add up to 77% of all DDD. Outpatient care accounted for 18.6 DDD per 1000 inhabitants per day of prescribed antibiotics in 2006 (ESAC, 2009).

Regarding the quality standard of drug prescription, a study carried out in Catalonia from January to September 2007 in the Catalan Institute of Health, showed that 91.1% of the drugs prescribed belonged to the list of drugs with proven efficacy. Prescription of generics is also increasing, but further studies should be carried out specifically for primary care (ICS, 2007).

In Spain the management of chronic diseases is carried out mainly in primary health care settings. There has been an improvement in the quality of the management in most of the chronic diseases analysed in the last five years. As an example, the crude percentage of the diabetic population aged more than 25 years with HbA1C higher than 7.0%, was 64% in 2005 and 19.2% in 2009. Furthermore, the percentage of follow-up visits for COPD and asthma, carried out at primary care, were 97.6% and 91% respectively.

The vaccination coverage ranges from 87.2% for diphtheria, tetanus and pertussis to 90.4% for measles, mumps and rubella and 95.2% for hepatitis B. In 2009, 57.4% of the Catalan population aged 65 or more were vaccinated against flu. The data are from the AC of Catalonia, which represents 15.77% of the Spanish population (Institut Català de la Salut, 2009/2010).

The number of hospital admissions for primary care sensitive conditions provides an insight into the quality of care provided at primary care level, as shown by the rates for Catalonia in the year 2008 (see Fig. A27.6).

Fig. A27.6

Number of hospital admissions per 100 000 population with a primary care sensitive diagnosis in most recent year.

4.2. Efficiency of primary care

Efficiency of primary care in Spain varies depending on a number of factors: how long each primary care centre has existed, socio-demographic conditions of the population, number of patients on a doctor’s list, and organizational characteristics of the primary care centre. It also depends on the AC and the degree of the implementation of IT support and electronic records. Professionals’ performance variability is decreasing (Institut Català de la Salut, 2009/2010).

Data shown in this section relate to Catalonia. Generally speaking most of the data do not vary much across the other ACs, but in order to provide accurate data, the authors have decided to analyse only this one AC, which represents 15.77% of the total Spanish population.

Regarding home care, there has been a comprehensive and multidisciplinary home care programme, involving GPs, nurses and social workers, since 1994. This programme has contributed to the rationalization of home visits and the follow-up of patients with chronic conditions who are not able to go to the primary health centre. The programme prioritizes a proactive approach, and this has resulted in better care and more efficient home visits. The number of home visits as a percentage of all GP–patient contacts in 2009 was 1.5%. This is a very low figure and it underlines the success of the programme (Departament de Sanitat i Seguretat Social, 1994). Telephone consultations are still not very common, mainly for cultural reasons (2.71% of all GP–patient contacts), although primary health professionals are available for telephone consultations and there is a constant increase of telephone consultations compared with previous years. Office visits to the GP lasted an average of 13.4 minutes in Catalonia in 2009. Since the introduction of the electronic prescription system in early 2010, 12% fewer patients have gone to the primary care centre for administrative issues, and the workload of doctors has improved. The average number of contacts per patient per year in 2009 was 4.3 (Institut Català de la Salut, 2009/2010).