EU

Maria Jesus Montero, Minister of Health for the Government of Andalucía, champions the

actions and initiatives of the region’s dynamic public healthcare system…

The best of health

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A ndalucía, the southernmost region in Spain, is

well-known across Europe due to its colourful

landscapes and cultural heritage, as well as the

beauty of its beaches and golf courses. That is why we

welcome more than 21 million tourists every year. However,

the region is also home to 8.4 million inhabitants, who are

supported by an exceptionally dynamic, proactive and

modern public healthcare system.

Excellent healthcare as a citizen’s rightThe regional healthcare service of Andalucía fulfils all the

basic features of the Spanish National Health System:

universal coverage that is tax-funded and consequently

without direct charges for patients, except for a small

copayment for drugs on ambulatory care, which account

for, on average, less than 4%. In addition, the regional

government – which has been in charge of healthcare since

1984 – has deployed a wide set of new rights on quality

aspects of care. Based on the principle that citizens must be

at the centre of the system, the role of the public healthcare

network has evolved from being merely a provider of

services, to a guarantor of the quality of healthcare.

In this way, in 2002 Andalucía was the first region in Europe

to set a maximum waiting time for elective surgery:

120 days for more than 700 procedures, such as cataract

surgery. When a surgeon indicates an intervention, the

patient is registered in a database and receives a report to

check their waiting time with, or alteratively they can also

find out this information via the telephone or through a

special webpage. If the time of planned surgery exceeds the

limit, the patient has the right to undergo the procedure in

a private clinic and charge the costs to the public service.

Currently, the average time for elective surgery is 43 days. In

the same way, there is a limited waiting time for diagnostic

tests (30 days) or specialised consultation (60 days).

Furthermore, new rights include a second medical

opinion for severe diseases, pre-implantatory genetic

diagnostic (PGD) tests for couples with severe inherited

diseases, and some specific rights for hospitalised children

and end-of-life patients – such as an individual room,

amongst others.

Professionals’ commitment to the systemAchieving excellence is a main objective, and professional

development is promoted through personal continuous

training, providing incentives and motivation through

the acknowledgement of high performance. This strategy

enables teamwork based on multidisciplinary and multi-

professional approaches, providing more autonomy and

responsibility to achieve objectives.

‘…new rights include a secondmedical opinion for severediseases, pre-implantatorygenetic diagnostic (PGD) testsfor couples with severe inheriteddiseases, and some specificrights for hospitalised childrenand end-of-life patients…’

Each healthcare worker can certify the quality of their

activity through a programme from the Agency for

Healthcare Quality Certification. All the programmes are

based on professional performance. A certification of

excellence is earned through demonstrated improvements

in the usual clinical practice, and this certificate is a

prerequisite to career progression and increased salary. So

far, more than 13,000 professionals in Andalucía, mainly

doctors and nurses, are enrolled in this programme.

Accessible, efficient and extended careAccessibility in primary care is a main feature of our system,

and an enormous effort to improve it has been made in

the past 25 years. Currently, there are 1,136 primary care

centres and 360 auxiliary offices, whereas there were only 33

in 1986. More than 6,000 family physicians act as gatekeepers,

and each one has 1,400 people assigned to them on

average. The physicians work in multiprofessional teams,

together with community nurses, paediatricians, dentists,

physiotherapists, midwives, epidemiologists, veterinarians,

and auxiliary and administrative personal. An extended

network of services is provided at this level, including

dental care, rehabilitation, home care, minor surgery and

many others.

E-healthOne of the most striking achievements in Andalucía is the

massive use of ICT for healthcare. A single electronic

health record for each citizen is available, anywhere and at

anytime. A centralised physician appointment system,

meanwhile, is available by internet, phone or SMS. Using

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their individual health smart card, patients can receive

their medication directly at any pharmacy in the region

during the ordered treatment period. Moreover, pharmacists

are able to network with physicians for drugs interactions,

contraindications, compliance or warnings. For example,

doctors can share all clinical information, as well as the

lab tests and diagnostic images, between hospitals and

primary care.

Last year, we had 105 million e-prescriptions and 95 million

appointments. Consequently, when a patient wants to

obtain an appointment, they can simply visit the Health

Department webpag, where following an identification

procedure, they can select the most convenient option in

their physician’s agenda. One million appointments are

made using this easy and free procedure every month.

‘One of the most strikingachievements in Andalucía isthe massive use of ICT forhealthcare. A single electronichealth record for each citizenis available, anywhere and at anytime.’

Home care and citizen servicesA complementary strategy has been oriented to provide

more information directly to citizens and several tools to

improve self-care. A call centre, ‘Salud Responde’ (Health

Responds), provides phone appointments; information on

services and centres; personal counselling on specific

health conditions; activation of second medical opinion

procedure; and information on living wills and many

other topics, such as waiting times; a tobacco cessation

programme line; AIDS information; and a translation

service for foreigners. Within this latter specification, if an

individual needs clinical care and does not speak Spanish,

we use the phone-translation service. Using a regular

phone (landline or mobile phone) and ordinary earphones

(one for the doctor and the other one for the patient), a

call to ‘Salud Responde’ activates a procedure that enables

a direct translation for patient and doctor, under safe and

confidential conditions. The service is available at any

point of care, 24/7 for 11 languages and from 08:00 to 18:00

for a further 40 languages, including all the European

ones. The most used so far have been English, Arabic,

German, Chinese, French, Romanian and Russian.

There is also ‘www.informarseessalud.org’ (‘to be informed

is healthy’), which contains many videos, documents and

applications containing information on diseases, healthy

habits, recommended physical activities, and diets,

amongst others. This is coordinated with a ‘Patient’s

School’ for people with chronic conditions. This initiative

is intended to improve self-management for some

common chronic diseases (for instance, diabetes and

cardiac insufficiency) and provides skills and evidence-

based knowledge.

Furthermore, there is a specific professional – the liaison

nurse – who is in charge of home-based highly complex

patients. This nurse visits the patient at home, plans their

care needs and assures them when objectives are achieved

in coordination with the corresponding primary care

centre team.

Healthy ageing16% of the Andalucían population are older than 65 years

of age, and this percentage is growing due to the increase

in life expectancy. Moreover, Northern Europeans are

choosing Andalucía as a place for their retirement. We are

therefore promoting many initiatives to improve elderly

people’s health and wellbeing. Under the motto of ‘healthy

ageing’, many programmes support physical activity, self-

management and active lives. Furthermore, a number of

initiatives support disabled or dependent people, such as

the family carer supporting programme.

Health in all policiesCurrently, one of the most relevant governmental strategies

is addressed to broaden the field of health promotion,

prevention and protection following the ‘Health In All

Policies’ approach. We work together with other regional

government departments and agencies to promote a healthy

view of other policies and initiatives, such as transport,

housing, education, economic activities, and others. Currently,

we are passing a law on this issue at the Regional Parliament,

which I think will constitute a milestone.

Results, costs and challengesAndalucían results in terms of life expectancy or avoidable

mortality for amenable care are good given our per capita

income. The regional public health expenditure is relatively

low (€9,390m; 6.67% of the Region GDP) in comparison to

the OECD average, with a very broad network of services

and the cutting-edge technologies available: transplantation,

human assisted reproduction, robotic surgery, genetic

counselling, etc. Moreover, patients’ satisfaction is very

high (90%) at both hospital level and primary care level.

As Minister of Health, it is my opinion that we have to face

a number of challenges in the coming future. First of all,

management of chronic patients should be improved,

reinforcing their autonomy with organisational measures

and telemedicine services and devices. Secondly, we need

to facilitate professional excellence, supporting high-

quality training and promoting a friendly and professional

environment. Thirdly, sustainability is an unavoidable

task for all health systems. Finally, we need to increase our

research to foster new treatments for diseases, as well as

increase our social and economic development.

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Public Service Review: European Union: issue 22

Maria Jesus MonteroRegional Minister of Health of AndalucíaGovernment of AndalucíaTel: +34 955 006300www.juntadeandalucia.es/salud