Hospital planning in Portugal

1. Hospital planning in Portugal Jorge Simões Chair of the Portuguese Health Regulation Authority Lisbon, 22nd March 2011

2. Outline • The Portuguese Health System • The hospital sector in Portugal • The case of hospital networks • The Portuguese National Health Plan

3. Outline • The Portuguese Health System • The hospital sector in Portugal • The case of hospital networks • The Portuguese National Health Plan

4. The Portuguese Health System • Based on a National Health Service (NHS), that is: • Universal – for all citizens • General – all services for all citizens • (almost) Free of charge (at the point of service) – only minor fees to avoid overconsumption • But with private and public mix in terms of: • Funding of services • Delivery of services …however this mix had important changes over time

5. The Portuguese Health System • Private and public mix in delivery Proportion of total consultations in private providers, Portugal 2005 Source: Simões, Barros and Pereira, 2008

6. The Portuguese Health System • Private and public mix in funding (2006)

7. The Portuguese Health System • Effective solutions to rationalize resource utilization in the NHS appeared first in the late 90’s: • 1995-2002: NHS reform with emphasis in public and private sector complementarities • 2002-2004: • Corporatization of NHS hospitals • Public-Private Partnerships • Annual contractingbetween the Ministry of Health and each NHS hospital • Creation of the Portuguese Health Regulatory Authority

8. The Portuguese Health System • 2005-2010: • Creation of hospital centers (integration of hospitals) • Creation of the national network of integrated long term care • Reform of primary care reform

9. Outline • The Portuguese Health System • The hospital sector in Portugal • The case of hospital networks • The Portuguese National Health Plan

10. The hospital sector in Portugal • Definition of “hospital” • NHS hospitals: in legislation and contracts - common characteristics: • Inpatient care • Outpatient care (emergency or consultations) • Diagnostic and therapeutic modalities • For private: no legal definition of hospital • We use inpatient care as main characteristic

11. The hospital sector in Portugal • Network of hospitals • Geographical distribution • Biased in favor of urban areas • Concentration is higher for private hospitals • Correlation of nº. hospitals and population (unit=district): 0,96 Sources: ACSS, ERS

12. The hospital sector in Portugal Sources: ACSS, ERS

13. The hospital sector in Portugal Public hospitals in districts Private hospitals in districts Sources: ACSS, ERS

14. The hospital sector in Portugal The NHS public hospital sector • Scale of planning • National level • Typology of hospitals • Reflects the degree of technical differentiation of each hospital and area of geographical influence: • Central: higher differentiation + larger area • District: medium differentiation + medium area • Level-1: lower differentiation + smaller area • University hospitals: also provide clinical education and training to doctors, nurses and other health professionals

15. The hospital sector in Portugal The NHS public hospital sector Source: ACSS

16. The hospital sector in Portugal The NHS public hospital sector • Type of management: corporatization of NHS hospitals • SPA hospitals: under the direct administration of the Government • EPE hospitals: corporatized hospitals; remain public property but differ from SPA hospitals in terms of management instruments at its disposal (administrative and financial autonomy)

17. The hospital sector in Portugal The NHS public hospital sector • Public-Private Partnerships (PPP): • Service provided jointly by private and public parties, sharing financial, technical and operational risk; • Three alternatives in Portugal: • Only for management of hospital • Only for construction of hospital • For management and construction of hospital

18. The hospital sector in Portugal The NHS public hospital sector

19. The hospital sector in Portugal The NHS public hospital sector • Integration arrangements • Hospital Centers: groups of hospitals in the same geographical area that have centralized management (in the largest hospital of the group) and share administrative services and have coordinated services • 26 (65 hospitals) • Local Health Units: group of NHS health care providers that integrates hospitals and primary care centers of the same geographical area, that have centralized management (in the largest hospital) and have coordinated services • 6 (11 hospitals and 54 primary care centers)

20. Outline • The Portuguese Health System • The hospital sector in Portugal • The case of hospital networks • The Portuguese National Health Plan

21. The case of hospital networks • Hospital network definition • Integrated and hierarchical system that regulates complementarity relations and technical support among all hospital institutions in a region • Objectives • Granting access to relevant and timely health care for all patients • Optimizing resource utilization

22. The case of hospital networks • The anatomy of a hospital network • Points of provision • Number • Location • Type of services • Human and physical resources • Geographical area of influence • Patient and information pathways • Rules for patient referencing

23. The case of hospital networks • Design and implementation of a hospital network • Assess health care needs of populations • Make better use of already installed capacity • Adapt services to regional and local specificities • Integrate inpatient and outpatient care • Integrate in a national wide planning strategy

24. The case of hospital networks • Options of hospital networks • Option 1: patient referencing rules constitute access norms for legal enforcement • Option 2: hospital networks merely with programmatic/indicative nature

25. The case of hospital networks • Hospital networks in Portugal • 9 enforced by law

26. The case of hospital networks • Hospital networks in Portugal • 12 without legal definition

27. The case of hospital networks • Some facts (difficulties) about hospital networks in Portugal • Definition of rules and strategies that cannot be put in practice due to resource restrictions • Referencing rules are merely programmatic and indicative, and cannot be legally enforced • Incompatible with other planning instruments of the Portuguese NHS (e.g., contacts between hospitals and the Government)

28. Outline • The Portuguese Health System • The hospital sector in Portugal • The case of hospital networks • The Portuguese National Health Plan

29. The Portuguese National Health Plan • What is a National Health Plan (NHP) • It’s a strategic instrument that allows for coherent health policy alignment, with the scope of maximizing health gains for the general population.

30. The Portuguese National Health Plan • The 2004-2010 Portuguese NHP • Core strategic goals • Achieving health gains • Defining instruments for implementation • Starting point • Potential for illness absence • The Portuguese Health System

31. The Portuguese National Health Plan • WHO evaluation of the Portuguese 2004-2010 NHP Good: • The NHP was well received and promoted a broad consensus over health priorities • Portugal achieved many health targets • Most indicators showed improvements, with gaps to European averages declining • The NHP provided a comprehensive benchmark for organizing health system activities

32. The Portuguese National Health Plan • WHO evaluation of the Portuguese 2004-2010 NHP Not so good: • Poor link with governing instruments (contracting, regulation, performance indicators) • Future performance may be compromised by unhealthy life styles, unsustainable health system and large health inequities • This requires that the next NHP must be strongly oriented to the strengthening of the health system and to the achievement of sustainable health gains

33. More Health Value QUALITY ACCESS CITIZENSHIP HEATLH POLICIES The Portuguese National Health Plan • The 2011-2016 Portuguese NHP: Conceptual Framework • Maximizing health gains for the population through the alignment and integration of sustainable efforts from all sectors • Focus on access, quality and citizenship.

34. The Portuguese National Health Plan • The 2011-2016 Portuguese NHP: critical aspects • To constitute a reference for the health system • To embody a vision of health gains • To develop a model of health planning • To capitalize and improve the performance of all involved • To define mechanisms of monitoring and assessment