Health System Review PORTUGAL - APRIL 2018 - SNS

 
Health System Review PORTUGAL - APRIL 2018 - SNS
APRIL 2018

Health System
Review
PORTUGAL

Phase 1 Final Report

                       European

                          on Health Systems and Policies
                                  a partnership hosted by WHO
Health System Review PORTUGAL - APRIL 2018 - SNS
Health System Review

© World Health Organization 2018 (acting as the host organization for, and secretariat
of, the European Observatory on Health Systems and Policies). All rights reserved. The
European Observatory on Health Systems and Policies welcomes requests for permission
to reproduce or translate its publications, in part or in full.

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Health System Review PORTUGAL - APRIL 2018 - SNS
APRIL 2018

Health System
Review
PORTUGAL

Phase 1 Final Report

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Health System Review

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Health System Review PORTUGAL - APRIL 2018 - SNS
Phase 1 Final Report

Contents                          page

Introduction                        7

Background                          8

DOMAIN 1: HEALTH AND
ITS DETERMINANTS                    9

DOMAIN 2: NHS SECTORIAL REFORMS
AND HUMAN RESOURCES                15

DOMAIN 3: PERSON-CENTRED, BETTER
INTEGRATED NHS                     21

DOMAIN 4: NHS FINANCING            27

Conclusions and Recommendations    35

References                         39

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Health System Review PORTUGAL - APRIL 2018 - SNS
Health System Review

Abbreviations

  EU 	European Union
  GBD	Global Burden of Disease
  GP	General Practitioner
  IHME	Institute for Health Metrics and Evaluation
  IT	Information technology
  MoH	Ministry of Health
  NHP	National Health Plan
  NHS	National Healthcare System
  NPAPP	National Physical Activity Promotion Program
  OECD	Organization for Economic Cooperation and Development
  PPP	Public Private Partnerships
  WHO	World Health Organization

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Health System Review PORTUGAL - APRIL 2018 - SNS
Phase 1 Final Report

List of figures, tables and boxes

Figures                                                                                                           page
  Figure 1.	Fertility rates in Portugal 1960 – 2014                                                                  10
  Figure 2.	Evolution of Monetary Poverty in Children and the Elderly, 2006 – 2014                                   10
  Figure 3.	Population at risk of poverty by working condition in Portugal 2003 – 2015                               10
  Figure 4.	Unemployment rates in Portugal, seasonally adjusted, December 2016                                       11
  Figure 5.	Burden of Chronic Disease in Portugal, 2016                                                              11
  Figure 6.	Multimorbidity in Portuguese population, by age group and gender                                         12
  Figure 7.	Depression among PHC (NHS) users in Portugal by health region. DGS, 2016                                 12
  Figure 8.	Healthy life expectancy at age 65, in European countries                                                 12
  Figure 9.	Therapeutic cost of controlled diabetic patients in family health care units, by type of unit,
             and health region                                                                                        15
  Figure 10.	Long-term care services, by typology and health regions, 2017                                           16
  Figure 11.	Number of beds in Portuguese hospitals                                                                  16
  Figure 12.	Number of visits to the Emergency Departments (ED) per 100 population in Portugal 2002 – 2014           17
  Figure 13.	Doctors/nurses ratio in Portugal                                                                        18
  Figure 14.	Comparing health literacy across selected European countries                                            22
  Figure 15.	Health literacy levels by age and educational levels                                                    22
  Figure 16.	Health expenditure as a percentage of GDP                                                               27
  Figure 17.	Public Health expenditure 2010 – 2015                                                                   27
  Figure 18.	NHS expenditures in medicines in million Euros, 2003 – 2016                                             29
  Figure 19.	Out-of-pocket expenditure in the NHS market                                                             30
  Figure 20.	Number of packages dispensed in the NHS market                                                          30
  Figure 21.	Policy interventions related to medicines: Survey of measures taken in European countries
              during 2010 – 2015                                                                                      30
  Figure 22.	Average growth of the pharmaceutical market                                                             30
  Figure 23.	Expenditure on pharmaceuticals per capita, 2014 (or nearest year)                                       31
  Figure 24.	Average medicines prices, 2003 – 2017                                                                   31
  Figure 25.	Generics Share, 2010 – 2016                                                                             31
  Figure 26.	Number of MEAs celebrated in the inpatient and outpatient settings                                      32

Table
  Table 1.	Current and capital expenditure in health                                                                 29

Box
  Box 1.	Persons centred NHS upgrade – main dimensions                                                               24

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Phase 1 Final Report

Introduction                                                    First, the initial findings of the assessment were
                                                                discussed with a panel of national and selected
                                                                international experts and decision makers. The aim of
In November 2016, the Ministry of Health of Portugal,           this discussion was to identify key priorities and actions
the European Observatory on Health Systems and                  for strengthening the Portuguese health system which
Policies, and the Regional Office for Europe of the World       could serve as a basis for policy development and
Health Organization (WHO) initiated an assessment               policy implementation.
of the Portuguese health system in relation to its
                                                                For each of the four issues described above, a review
performance on key challenges and opportunities in
                                                                was made with the aim of framing the issue and
the post-financial crisis recovery period. The programme
                                                                describing the Portuguese context. Then, a review of the
of work included a review of the National Healthcare
                                                                ongoing responses was made, followed by a discussion
System (NHS) strengths and challenges. To provide
                                                                of further actions in order to face the challenges
focus, four key domains were used:
                                                                identified when the issue was made. Whenever possible,
•	Domain 1: Health and its determinants                        examples of good practices and international guidelines
                                                                were integrated in this report.
•	Domain 2: NHS sectorial reforms and
   human resources                                              The review was conducted by a team of international
                                                                and Portuguese health policy experts, and included
•	Domain 3: Person-centred, better integrated NHS
                                                                extensive consultation with stakeholders from
•	Domain 4: NHS financing                                      government, healthcare employees and academia.
                                                                The preliminary findings from this review formed the
In addition, the current Portuguese priorities were             basis for a policy dialogue in May 2017. This report
considered in the development of this report. There             presents the findings of this review, taking on board
is ongoing public health reform, aiming at revitalizing         the comments and contributions of Portuguese and
public health services and public health delivery in            international experts in the Policy Dialogue.
Portugal. A new strategy for the National Health Plan
(NHP) is also a priority. Efforts have been made to
provide more and better quality person-centred care
in the NHS as a part of the strategies of the New
Public Health. This could be achieved using a two-fold
strategy: focusing on the local implementation of the
NHP on the one hand and on the promotion of health
literacy on the other hand. However, achieving a more
person-centred NHS is strongly dependent on the
progress of key sectorial NHS reforms. Another priority
is the digital transformation of the NHS, allowing for
both professionals and users to access information
and also tools which contribute to integrative care and
people centredness. The digital transformation would
also contribute to increase the transparency of the NHS,
which is a good practice for governance.

                                                            7
Health System Review PORTUGAL - APRIL 2018 - SNS
Health System Review

Background

Similarly to other European countries, the health system
in Portugal faces substantial challenges. These include
demographic changes, patterns of deprivation and
childhood poverty, unhealthy ageing, multimorbidity
and physical inactivity and consequences of the financial
crisis in the Portuguese NHS.
This report is divided in to four domains:
•	Domain 1: Health and its determinants
•	Domain 2: NHS sectorial reforms and human
   resources
•	Domain 3: Person-centred, better integrated NHS
•	Domain 4: NHS financing

Each of these domains is further described below and
framed in the Portuguese context, together with a
summary of the key challenges encountered in each one
of them, followed by a summary of the main actions
already taken in Portugal and suggestions for further
actions to overcome the remaining challenges.

                                                            8
Domain 1: Health and its determinants

DOMAIN 1: HEALTH AND ITS DETERMINANTS

1.1 Demography                                                  In Portugal the number of babies born alive have been
                                                                decreasing in the last decades for several reasons,
Portugal, in line with other European countries, has
                                                                including the lack of policies that support parenthood
had profound demographic changes, reflected in
                                                                and, formerly, the economic crisis. Portugal had the
the increase in longevity and the elderly population
                                                                lowest fertility rate in the European Union in 2014,
and in the reduction of the birth rate and the young
                                                                1.23 babies per woman, and was also the Member State
population. The number of elderly people tripled in
                                                                that registered the biggest births fall from 2001 to 2014.
the last 20 years, and this trend is expected to increase
in the coming years. The population of Portugal
                                                                1.2 Childhood and overall poverty, and
rose to 10.57 million in 2010, but has since fallen to
                                                                employment patterns
10.34 million (Simões et al. 2017). The Portuguese
population is expected to decrease to 7.5 million               Studies conducted in several countries demonstrate
by 2080, with a sharp increase in the proportion of             the impact of child poverty in areas as diverse as
the older population. The number of births has also             physical and psychological health, education and
been decreasing in the last decades. Portugal was the           qualifications, aspirations and expectations, wages in
European Union (EU) country with the lowest fertility           adulthood, unemployment or dependence on social
rate in 2014 (1.23 children per woman) and was also             security (Eurochild & EAPN, 2013; UNICEF, 2007).
the Member State that registered the highest reduction          Children growing up in poverty are more likely to fall ill
in births between 2001 and 2014. The lack of policies           throughout their lives and to die younger than children
to support parenthood coupled with the economic crisis          growing up in better financial conditions; they are also
may have contributed to this reduction.                         more likely to suffer from a chronic illness or a disability.
                                                                The World Bank Group (UNICEF, 2016) notes the impact
Migration is also a key element in demographic changes.
                                                                of poverty on well-being, employment prospects and
The study “Migration and macroeconomic performance:
                                                                expectations of poor children. They can develop low
an exploratory analysis of the Portuguese case” found
                                                                motivation, have low aspirations, hopes and dreams.
that the current crisis may ultimately cause lasting
inflections in migration flows. In recent years there has       In Portugal, the phenomenon of child poverty was
been a gradual decline in immigration coupled with              studied by Bastos and Nunes between 1995 and 2001
a sudden increase in emigration. These changes can              (Bastos e Nunes, 2009). They confirmed the vulnerability
be attributed to a need to escape from the economic             of children and the increased risks of poverty, especially
crisis experienced by the Portuguese population.                among children who belong to single parents and in
However, this increase in emigration will have important        families where there is unemployment. Portugal has
consequences for the Portuguese macroeconomic                   historically had relatively high levels of deprivation and
performance in the long run, in particular through              poverty, and continues to have overall poverty rates
the “brain drain” associated with the combination               above the EU average. This is particularly the case for
of increased emigration, ageing of the Portuguese               children, and rates of child poverty rose significantly
population and a reduced immigration. Portugal faces a          during the financial crisis period. This contrasts with the
double challenge: preventing brain drain and attracting         lower and generally declining risk of poverty in older
qualified immigration.                                          people, as can be noted in Figure 1.

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Health System Review

Figure 1. Fertility rates in Portugal 1960 – 2014                                                          The poverty risk rate for the elderly population increased
                                                                                                           again in 2015, with 18.3% (17.0% in the previous
                                                                                                           year). On the other hand, a new reduction in the risk of
3.2
                                                                                                           poverty for those under 18 years of age was recorded
3.0
                                                                                                           in 2015: 22.4%, which is -2.4 percentage points (pp)
2.8                                                                                                        compared to 2014. The poverty rate for adults was
2.6                                                                                                        18.2%, down 0.6 percentage points from the previous
2.4                                                                                                        year (18.8% in 2014).
2.2

2.0                                                                2014 (1.23)                             Figure 3. Population at risk of poverty by working
1.8
                                                                                                           condition in Portugal 2003 – 2015
1.6

1.4
                                                                                           Portugal

  1960     1965    1970   1975    1980     1985     1990     1995        2000    2005    2010

Source: Pordata, INE, Indicadores Demográficos, Anual.

The child poverty rate in 2015 was measured by the
proportion of inhabitants with income lower than
5 268 euros per year (439 euros per month). In 2015,
families composed of 2 adults and 3 or more dependent
children and families with one adult and at least one
dependent child have the highest risk of poverty (42.7%
and 31.6%, respectively). (Report “Inequality of Income
                                                                                                           Source: EU-SILC.
and Poverty in Portugal, the social consequences of
the adjustment program” of the Francisco Manuel dos
                                                                                                           The risk of poverty for the unemployed population was
Santos Foundation, in September 2016).
                                                                                                           42.0% in 2015, maintaining the value registered in the
                                                                                                           previous year. The risk of poverty for the employed
Figure 2. Evolution of Monetary Poverty in
                                                                                                           population was 10.9% in 2015, unchanged from 2014.
Children and the Elderly, 2006 – 2014
                                                                                                           In 2015, the risk of poverty increased in the retired
                                                                                                           population, with a rate of 16.0% compared to 14.4%
30%
                                                                                                           in 2014 (+1.6 pp). However, it has maintained the
28%                                                                                                        decreasing trend observed in the series for this indicator:
      25.5%                                                                      25.6%                     minus 10 percentage points since 2003.
25%                                                                 24.4%
                  22.8%   22.9%    22.4%       22.4%
                                                                                          24.8%            If we consider the at-risk-of-poverty rate before social
                                                           21.8%
23%
      20.9%                                                                                                transfers, the rate remains almost stable between 2013
20%
                  22.3%                                                                                    and 2014 in the EU-28 while it rises a bit more in some
                                   22.0%
                          20.1%                20.0%                                                       EU Member States, with the largest increases registered
18%                                                                                                        in Belgium, Finland, Portugal (each 1.2 percentage
15%
                                                           17.4%                          17.0%            points) and Sweden (1.4 percentage points).
                                                                                 15.1%
13%
                                                                    14.7%                                  Finally, the report “Inequality of Income and Poverty
                                                                                                           in Portugal, the social consequences of the adjustment
10%                                                                                                        program” of the Francisco Manuel dos Santos
         2006     2007    2008     2009        2010        2011         2012     2013     2014             Foundation, in September 2016, concludes that one
                                         Children             Elderly
                                                                                                           of the most affected vulnerable groups were “young
                                                                                                           families with children” and that in “2014 it is possible
Source: National Institute of Statistics.                                                                  to verify that 58.4% of the poor population belongs to
                                                                                                           households with children.”
The “at-risk-of-poverty” rate in 2015 corresponded to
                                                                                                           Unemployment in Portugal is high by EU standards,
the proportion of people with an annual net monetary
                                                                                                           with only 5 of the EU 28 countries having higher
income, per adult, equivalent or less than 5 268 euros
                                                                                                           unemployment. This feeds both directly and indirectly
(439 euros per month). This threshold, or poverty line
                                                                                                           (through associated poverty) into health needs.
corresponds to 60% of the median (8 780 euros)
                                                                                                           Young adults are at particular risk of unemployment
monetary income.
                                                                                                           and precarious work. According to the Monthly
The risk of poverty is much lower among working                                                            Provisional Employment Survey, the seasonally adjusted
people, and unemployment is higher in Portugal                                                             unemployment rate (15 to 74 years) was 10.5% in
than the EU average. Additionally, rates of precarious                                                     December 2016, with a clear trend towards further
employment are high in Portugal particularly among                                                         decline, see Figure 4).
younger workers.

                                                                                                      10
Domain 1: Health and its determinants

Figure 4. Unemployment rates in Portugal,                         1.4 Multimorbidity and mental health
seasonally adjusted, December 2016
                                                                  Multimorbidity is closely related to age and socio-
                                                                  economic conditions and most adults attending primary
                                                                  health care have more than one chronic condition.
                                                                  Studies on the epidemiology of multimorbidity show
                                                                  that its prevalence increases with age, its onset is
                                                                  10 to 15 years earlier in those living in deprived areas
                                                                  compared with the more affluent ones and is strongly
                                                                  associated with mental health disorders (Barnett et al.,
                                                                  2012.
                                                                  Ageing means that more people are living with multiple
                                                                  chronic conditions (Rechel B, 2013). This has important
                                                                  implications for care delivery, since in most cases the
                                                                  treatment of one disease will be in the context of other
                                                                  chronic conditions. Figure 5 shows the distribution of
                                                                  the burden of chronic diseases in Portugal, with 41% of
Source: Eurostat                                                  the NHS users having multimorbidity (more than one
                                                                  chronic disease).
The percentage of the population in a precarious work
situation in European countries is 12.3%. However,                Figure 5. Burden of Chronic Disease in Portugal,
countries like Portugal, Spain, Poland, Slovenia and the          2016
Netherlands have a far higher rate, more than 20%,
young people are most affected because they cannot
find a permanent job.
Between 2000 and 2015, more than 75% of                                                         22%
employment contracts were considered precarious by
the International Labour Organization – the same rate
as in Spain, Slovenia and Greece. Precarious work has
                                                                                                                                         41%
several consequences, both for companies, workers and                      41%
                                                                  multimorbidity
the social economy itself, leading to less innovation,                                 8%

lower productivity, a risk to the sustainability of social
security systems, difficulties in accessing credit and
postponement in the decision to start a family.                                             11%

1.3 Obesity and physical inactivity
                                                                                                             18%
Levels of obesity are rising, related to both unhealthy
diets and low levels of physical activity. Of the                                  ■ No Chronic diseases   ■ 1 Chronic disease        ■ 2 Chronic diseases
population aged between 25 and 74 years old, 28.7%                                 ■ 3 Chronic diseases    ■ 4 or more Chronic diseases

are obese, and 38.9% pre-obese. There is a strong                 Note: Percentage of NHS users with chronic diseases.
socio-economic gradient with 43.1% of adults with
only basic education being obese, but only 14.7% of               22% of the population has 3 chronic conditions and
those with a university education. Portugal already               4% has 5 or more. Diabetes is an example of a chronic
has a system for identifying, managing and combating              disease which is associated with multimorbidity, posing
pre-obesity in primary health care to prevent it from             major challenges to health systems across Europe. The
developing into more severe clinical conditions (PAI –            rate of diabetes provides a useful indicator of the
Pre-Obesity / DGS). However, the system is still in the           success of population level interventions. In Portugal, the
very early stages of implementation and only 5.2%                 prevalence of diabetes in the adult population increased
pre-obese are registered in primary health care. The              from 11.7% in 2009 to 13% in 2013. It will probably
prevalence of childhood obesity at 8 years old in                 rise with population ageing and may increase as a result
Portugal, measured by the same method (COSI / WHO                 of higher prevalence of obesity. The mortality rate from
study) seems to be stable over the last 3 measurements            diabetes has been decreasing in the last years.
over 6 years.
Physical activity levels in Portugal are among the lowest
in Europe, in adults and particularly in teenagers. Up
until 2016, physical activity promotion did not have a
dedicated program at the Portuguese Health Ministry.
This was changed with the creation of the National
Physical Activity Promotion Program (NPAPP) which was
introduced in June 2016.

                                                             11
Health System Review

  Figure 6. Multimorbidity in Portuguese population,                                                                                       In 2014 the life expectancy at 65 years was 19.2 years
  by age group and gender                                                                                                                  (17, 3 years for men and 20, 7 years for women). The
                                                                                                                                           overall life expectancy at 65 years in 2015 was 19.3
                        90
                                                                                                                                           years (PORDATA, 2017).
                        80

                        70                                                                                                                 Figure 8 Healthy life expectancy at age 65, in
                                                                                                                                           European countries
% with multimorbidity

                        60

                        50

                        40

                        30                                                                                                                                 20
                                                                                                                                                           18
                        20
                                                                                                                                                           16
                        10
                                                                                                                                                           14

                                                                                                                                           Healthy years
                        0                                                                                                                                  12
                        [0;10]         [10;20]    [20;30]   [30;40]   [40;50]      [50;60]   [60;70]   [70;80]   [80;90]   [90;150]
                                                                                                                                                           10

                             ■ Men      ■ Women                            Age groups                                                                       8
                                                                                                                                                            6
                                                                                                                                                            4

                                                                                                                                                                16.3

                                                                                                                                                                       15.3

                                                                                                                                                                              15.3

                                                                                                                                                                                     11.9

                                                                                                                                                                                            11.7

                                                                                                                                                                                                   11.5

                                                                                                                                                                                                          11.1

                                                                                                                                                                                                                 10.3

                                                                                                                                                                                                                        10.3

                                                                                                                                                                                                                               10.1

                                                                                                                                                                                                                                      10.0

                                                                                                                                                                                                                                             9.7

                                                                                                                                                                                                                                                   9.4

                                                                                                                                                                                                                                                         9.2

                                                                                                                                                                                                                                                               9.2

                                                                                                                                                                                                                                                                     8.3

                                                                                                                                                                                                                                                                           8.0

                                                                                                                                                                                                                                                                                 7.9

                                                                                                                                                                                                                                                                                       7.8

                                                                                                                                                                                                                                                                                             7.7

                                                                                                                                                                                                                                                                                                   7.7

                                                                                                                                                                                                                                                                                                         6.2

                                                                                                                                                                                                                                                                                                               5.9

                                                                                                                                                                                                                                                                                                                     5.3

                                                                                                                                                                                                                                                                                                                           4.1

                                                                                                                                                                                                                                                                                                                                 4.0
                                                                                                                                                            2
                                                                                                                                                            0
 Mental illness has been identified as a problem that

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                                                                                                                                           ■ Total              ■ Male ■ Female
 from hospital treatment of mental illness and there
 is evidence, in some diseases, of an increased use of                                                                                     Note: Countries are ranked in descending order of healthy life expectancy for the whole population.
                                                                                                                                           Source: Eurostat Database 2017

 medication. As is common in EU countries, there are                                                                                       Source: Eurostat Database, 2017.

 identifiable gaps in mental health care.                                                                                                  Note: Countries are ranked in descending order of healthy life expectancy for
                                                                                                                                           the whole population.
 Portugal has the highest per capita prescription of
 anti-depressants in the EU, with 60% of the DDD of
                                                                                                                                           Selected recent and ongoing developments
 psychiatric drugs prescribed in the NHS, at a national
 level, of 341 604 888. The increase was 5% compared                                                                                       In the budget for 2017 the government introduced a
 to 2014 (the lowest in relative terms since 2011),                                                                                        new tax for sweetened beverages, the tax is based on
 and this value does not pose similar concerns to                                                                                          the sugar content (Law 42/2016, de 28 de November,
 those of the previous group. The antipsychotics, also                                                                                     articles 212.º, 213.º e 215.º). Whether this marginal
 maintained a growth trend (since 2013) but only 2%,                                                                                       increase in tax will impact on the consumer price and
 reaching 45 770 580 DDD, corresponding to 7% of                                                                                           the effect on consumption, is still to be seen. Moreover,
 the group of psychotropic drugs. Depressive disorders                                                                                     the Government introduced a law to ban sugary
 increased substantially in Portugal during the recent                                                                                     drinks and high density caloric food from the vending
 economic crises.                                                                                                                          machines in NHS facilities.
                                                                                                                                           A National Physical Activity Promotion Program (NPAPP)
  Figure 7. Depression among PHC (NHS) users in
                                                                                                                                           was introduced in June 2016, aimed at implementing
  Portugal by health region
                                                                                                                                           the recommendations laid down by the WHO European
                                                                                                                                           Region’s “Physical Activity Strategy 2016 – 2025” and the
                             12                                                                                                            DGS’s “National Strategy for the Promotion of Physical
                                                                                                                                           Activity, Health and Well-being 2016 – 2025”. The main
                             10
                                                                                                                                           priority of the NPAPP is to establish an efficient and
                                 8                                                                                                         well-resourced multi-sectorial platform that can engage,
    Percentage

                                                                                                                                           coordinate, and monitor national initiatives to promote
                                 6
                                                                                                                                           physical activity across all relevant sectors. NPAPP’s
                                 4                                                                                                         specific contributions to a national Action Plan will focus
                                 2                                                                                                         on the health sector, with the aim of physical activity
                                                                                                                                           promotion becoming an integral part of the national
                                 0                                                                                                         health system, especially among primary care units.
                                     2011                     2012                           2013                      2014

                                     — North — Centre — Lisbon and the Tagus Valley
                                                                                                                                           Public health campaigns to reduce salt and sugar usage,
                                     — Alentejo — Algarve                                                                                  as well as tobacco smoking have been planned.

 Source: DGS, 2016.
                                                                                                                                           A number of public health programs, within the National
                                                                                                                                           Plan Health framework are been implemented. For
                                                                                                                                           example, one of these national programs has been
1.5 Unhealthy ageing                                                                                                                       dealing with diabetes risk evaluation using FinDRisk
 While life expectancy has increased, data suggest that                                                                                    score. Its implementation in primary care units resulted
 relative to other comparable European countries, healthy                                                                                  in 1.2 million risk evaluations being performed in
 life expectancy has performed less well. While some of                                                                                    2014 and 2015 in asymptomatic people. The screened
 this may reflect measurement issues, and may reflect                                                                                      people with medium or high risk were then referred to
 past deprivation levels affecting this age group, the poor                                                                                a General Practitioner (GP) appointment. The national
 outcome compared to other countries is a concern.                                                                                         program to prevent diabetes developed an integrated
                                                                                                                                           care model based on a multidisciplinary approach.

                                                                                                                                      12
Domain 1: Health and its determinants

Key challenges – the way forward                                 The National Health Plan provides a very useful basis
                                                                 for actions tackling these challenges, but much more is
•	The health system in Portugal will require long term
                                                                 needed in terms of:
   strategies to tackle the health consequences of family
   deprivation, unemployment and child poverty which             •	Linking planning at national, regional and local levels;
   were exacerbated during the financial crisis.
                                                                 •	Closer working with NGOs and civil society to
•	Population ageing and unemployment coupled with                  implement public health plans, creating broader
   high migration of younger people of working age                  opportunities for public participation;
   contribute to an ongoing decline of the Portuguese
                                                                 •	Further modernisation of the public health workforce
   population. This affects the demand and the supply
                                                                    and providing stronger support for the development
   of health services.
                                                                    of the local public health units;
•	The majority of users of the NHS have one or more
                                                                 •	Wider use of health impact assessment to guide and
   chronic diseases which has important implications
                                                                    monitor public health actions.
   for the delivery of services: services are no longer
   provided adequately in single disciplinary approaches.
   The increasing prevalence of multi-morbidity also
   calls for more attention to be paid to improving
   quality of life in elderly people and community and
   home care settings. Closer collaboration between
   health care and social care organization is of
   fundamental importance.
•	There is a need for a particular focus on actions to
   improve healthy life expectancy, especially among
   older women.
•	Diet and physical activity are among the most
   pressing population health challenges in Portugal,
   calling for continuing the current investment on
   effective and more equitable health promotion and
   disease prevention policy and implementation.
•	Portugal has a strong record in development of
   health plans and strategies, and weaknesses in local
   approaches to implementation.

                                                            13
Health System Review

                       14
Domain 2: NHS sectorial reforms and human resources

DOMAIN 2: NHS SECTORIAL REFORMS AND
HUMAN RESOURCES

The Portuguese NHS is organized into five health regions           Figure 9. Therapeutic cost of controlled diabetic
and aims to provide access to all effective medical                patients in family health care units, by type of unit,
services on the basis of need. Though regulation,                  and health region
monitoring, control and financing of the public
health system are within the central administration                            EURO
competences, the principle of decentralization and                       500

autonomy in the operational management of health                         400
organizations has been granted since the establishment
of the NHS in 1979. However during the period of the                     300
                                                                  Cost

financial crisis, there was a set of actions and policy                  200
                                                                                 355     313      334   436    333      318     388    346     311   352   307   267    366   314     285

measures that significantly diminished the extent
of decentralization and autonomy of healthcare                           100

organizations within the NHS.                                             0
                                                                                       Alentejo               Algarve                 Centre            Lisbon and            North
                                                                                                                                                     the Tagus Valley
                                                                   Types of primary health care unit:
2.1 Primary health care                                            ■ non-reformed family health units
                                                                   ■ reformed family health unit, without performance related pay
                                                                   ■ reformed family health unit with performance related pay
Primary health care reform has been strongly focused               Source: BD NSCP (ACSS)

on transforming traditional health centres into network            Source: BD NSCP (ACSS).
functional units, such as family health units, community
health care units, others health specialties support units        2.2 Long term care
and public health units. Changes in family health care
units towards contracted self-managed units, with                 The National Network of Continuing Integrated Care
performance related pay, have been made progressively             (RNCCI) is defined as a response focused on providing
over the last decade. The main purpose is to create               care to people who, regardless of age, are in a situation
more autonomous and multidisciplinary teams in                    of functional dependency. The purpose of the Network
primary care, and incentives for better performance               is the rehabilitation and social reintegration and the
(e.g. better follow up of patients, notably chronic               provision and maintenance of comfort and quality of life,
patients, better pre and post-natal care, more cost-              even in cases where no recovery is possible.
effective use of medicines). By the end of 2017 there             In January 2018 RNCCI is characterized by offering
were approximately 390 non-reformed family health                 8 224 inpatient responses and 5775 home care
units versus 505 reformed one. Of the reformed health             responses for adults. It also offers 10 inpatients and
care units, approximately 235 benefit from performance            10 ambulatory responses for children with complex
related pay, while 270 do not enjoy that benefit yet.             chronic illness. Finally, it offers a diversity of inpatients
                                                                  home and care responses, totaling 197 beds / places, for
                                                                  young people and adults with severe mental illness and
                                                                  psycho-social dependence.
                                                                  Care for children with complex chronic illness and for
                                                                  young people and adults with severe mental illness was
                                                                  offered for the first time during 2017 and is therefore in
                                                                  the experimental year.

                                                             15
Health System Review

Figure 10. Long-term care services, by typology and
health regions, 2017

                                                                                                                                                                    Health Region
                                                                                                                                                                                    ARS Lisboa
                                                                                                                                                                                     and Vale
      Typology of Units                                                                                             ARS Alentejo                ARS Algarve           ARS Centro      do Tejo      ARS Norte       Total
      Convalescence Unit                                                                                                      135                       74                251           199           157           816
       Palliative Care Unit                                                                                                    14                        –                 –            129           26            169
       Medium Duration and Rehabilitation Unit                                                                                203                      138                735           720           742          2 538
       Long Term and Maintenance Unit                                                                                          431                      317              1 297         1 119         1 537         4 701
       Pediatric Support Unit                                                                                                    –                       –                 –            10            10             –
      Assisted Living                                                                                                            –                       –                13            14            27             –
       Home Support Team                                                                                                         –                       –                 8             8             8            24
       Integrated Continuing Care Team                                                                                        566                      750                846          2 072         1 641         5 875
       Maximum Support Residence                                                                                                 –                       –                24             –            24             –
       Moderate Support Residence                                                                                                –                       –                 8            16             –            24
       Residence of Autonomy Training                                                                                            –                       –                19             –            19             –
       Residence of Autonomy Training – Type A                                                                                   –                       –                 –            12             6            18
       Integrated Pediatric Care Unit – Type 1                                                                                   –                       –                 –            10            10             –
      Socio-Occupational Unit                                                                                                    –                       –                30            25            55             –
      Socio-Occupational Unit – Childhood
                                                                                                                                 –                       –                20            10            30             –
      and Adolescence
      Total                                                                                                                 1 349                     1 279              3 175         4 351         4 186         14 340

2.3 Hospital care
In Portugal, there are 113 public and 96 private hospitals.                                                                                                        In 2002, private hospitals provided 16.5% of the total
In 2013 there were 25,000 beds in public hospitals and                                                                                                             number of visits to Portuguese hospitals (around
10,500 in private hospitals. There has been a reduction                                                                                                            1.6 million visits), while in 2013 they accounted for 29%
of 1,659 beds in total since 2002, but a rise in the                                                                                                               (around 5.1 million consultations).
proportion that are private.                                                                                                                                       Portugal has rates of visits to emergency departments
                                                                                                                                                                   (ED) considerably higher than other OECD countries
Figure 11. Number of beds in Portuguese hospitals                                                                                                                  (OECD average 30.8 visits / 100 inhabitants). That
                                                                                                                                                                   pattern has remained fairly constant over the years;
                                                                                                                                                                   however the ED visits in private facilities have risen,
                                                                                                                                                     35 503        contrasting with a small decline in NHS ED visits. The
                                                     0
                                                  00
                                               40

                                                         37 162
Number of hospital beds in Portugal

                                                                                                                                                                   literature points out that part of the demand for ED
                                             0
                                           00
                                        35

                                                                                                                                                     25 029
                                                                                                                                                                   visits could be treated elsewhere more efficiently,
                                      0

                                                         28 733
                                   00
                                30

                                                                                                                                                                   namely in primary care by telephone-based services
                              0
                           00
                        25
                      0

                                                                                                                                                                   (McHale et al. 2013), these visits were designated as
                   00
                20
              0

                                                                                                                                                                   non-urgent or inappropriate. In Portugal a study found
           00
        15

                                                                                                                                                     10 474
      0

                                                         8 429
   00

                                                                                                                                                                   that up to 30% of these visits could be inappropriate
10
                                    0
                           00

                                                0                                                                                                                  (Pereira S, 2001). The ACSS access report states that
                    5

                                                         2002     2003   2004   2005       2006   2007      2008     2009      2010    2011   2012    2013

                                                                                   Total      Public hospitals     Private hospitals                               8.6% of the user and considered frequent users (4 or
                                                                                                                                                                   more visits in a year), those 8.6% represent 27.9% of
                                                                                                                                                                   the ED visits.

                                                                                                                                                              16
Domain 2: NHS sectorial reforms and human resources

Figure 12. Number of visits to the Emergency                                                                                                                            2.4 Public-Private Partnerships (PPP)
Departments (ED) per 100 population in Portugal
                                                                                                                                                                        The creation of Public-Private Partnerships (PPP) granted
2002 – 2014
                                                                                                                                                                        more autonomy to organizations by conceding the
                                                                                                                                                                        management of service units of care to private entities,
                                          80    72     73     71     73         73           75         74           75       75        74     71     72     74         or by the joint investment between them and the State
                                                                                                                                                                        (Barros, Machado & Simões, 2011). According to the
Number of visits to ED / 100 population

                                          70

                                          60                                                                                                                            current Portuguese PPP legal framework (Decree-Law
                                          50                                                                                                                            n.º 111/2012, of May 23rd), a PPP is defined as “(…) a
                                          40
                                                                                                                                                                        contract or union of contracts through which private
                                          30
                                                                                                                                                                        entities, designated as private partners, oblige, in a
                                          20
                                                                                                                                                                        durable way, before a public partner, to assure, upon
                                          10

                                           0
                                                                                                                                                                        payment, the development of an activity tending
                                               2002   2003   2004   2005       2006         2007       2008      2009        2010      2011   2012   2013   2014        to the satisfaction of a collective need, in which the
                                                                                                  Year in analysis                                                      responsibility for the investment, financing, operation,
                                                                          Total ED visits          NHS ED visits          Private ED visits
                                                                                                                                                                        and associated risks, falls, in whole or in part, to the
                                                                                                                                                                        private partner”.
                                                                                                                                                                        Research has shown that PPP hospitals are generally
Concerning the reorganization of the hospital network,
                                                                                                                                                                        efficient, in particular the hospitals of Braga and Cascais,
there is still a major gap of evidence regarding
                                                                                                                                                                        which presented outstanding positive results. However,
the efficiency gains obtained by the merging and
                                                                                                                                                                        it was not possible to identify statistically significant
concentration of services, hospitals and management
                                                                                                                                                                        differences between the results of the PPP and the
boards. Likewise, the internal and intermediate
                                                                                                                                                                        non PPP subgroups.
management of NHS hospitals also needs to be
improved, since their autonomy has been reduced by                                                                                                                      Results indicated that most PPP hospitals have on
the measures taken in the context of the economic and                                                                                                                   average a higher capacity for surgeries than the other
financial adjustment plan (Simões et al.,2017).                                                                                                                         comparable public hospitals, while they mostly present
                                                                                                                                                                        a lower than average percentage of hip fractures
Hospitals are paid on global budgets based on
                                                                                                                                                                        surgically repaired within 48 hours. Yet, all PPP
diagnosis-related groups, with the possibility to
                                                                                                                                                                        hospitals presented a higher than average percentage
reallocate resources across cost-categories. In addition
                                                                                                                                                                        of outpatient surgeries on planned surgical care for
to the transfers from the government, hospitals
                                                                                                                                                                        ambulatory care-sensitive conditions, which means a
generate their own revenue, through flat rate user
                                                                                                                                                                        better performance than comparable hospitals, with
charges for outpatient and diagnostic services, special
                                                                                                                                                                        significant statistical difference between groups. As
services (e.g. individual private rooms) and from
                                                                                                                                                                        far as the fulfilment of the maximum waiting times
privately insured patients. The contract covers several
                                                                                                                                                                        imposed by law is concerned, PPP hospitals presented
areas, like consultation, inpatient care, and emergency
                                                                                                                                                                        a better performance than comparable hospitals in the
care, among others. A new system of incentives for
                                                                                                                                                                        case of surgeries, but a generally worse performance
hospital performance was created in 2017, which
                                                                                                                                                                        regarding first outpatient appointments.
values comparisons and positive competition among
institutions, identifying the differences in care
                                                                                                                                                                        2.5 Human resources
performance and efficiency that now occurs in hospitals
with similar characteristics, providing operational                                                                                                                     In 2014, the Ministry of Health employed 124 260
levers to encourage improved performance. This new                                                                                                                      people, of which 97% were related to institutions
mechanism considers a set of objectives that are used to                                                                                                                providing primary and hospital care and 3% to central
make comparisons of performance among the hospitals                                                                                                                     and regional technical and administrative services.
of the NHS, organized in benchmarking groups, focusing                                                                                                                  Nurses are the professional group in healthcare with
on the areas of access, quality and efficiency.                                                                                                                         the largest number of workers, accounting for about
                                                                                                                                                                        one-third of all Ministry of Health (MoH) workers
Hospitals are reimbursed for the comprehensive
                                                                                                                                                                        (38 089), although numbers are low when compared
treatment provided to patients for several chronic
                                                                                                                                                                        to international standards. The next largest group is
diseases: HIV infection, multiple sclerosis, pulmonary
                                                                                                                                                                        medical staff (26 645, 22%), followed by operational
hypertension, different lysosomal storage diseases,
                                                                                                                                                                        assistants (24 600, 20%). In the case of medical doctors,
familial amyloid polyneuropathy and selected
                                                                                                                                                                        about 67% are specialists and 33% interns.
oncological diseases (i.e. breast cancer, cervical cancer,
colo-rectal cancer). The price for the comprehensive
treatment was based on the clinical guidelines for each
disease. It includes medicines, consultation, medical
tests, etc. The aim was to make providers familiar with
the guidelines and quality of care (Lourenço, 2016a).
The independent assessment for the HIV / AIDS showed
positive results.

                                                                                                                                                                   17
Health System Review

Figure 13. Doctors / nurses ratio in Portugal

                                                                                                                            EU average: 3.6
                                                                         20
        Practising nurses per 1 000 population, 2015 (or nearest year)

                                                                                  Doctors Low                                                                                      Doctors High
                                                                                  Nurses High                                                                                      Nurses High

                                                                                                                                       DK

                                                                         15
                                                                                                                            FI
                                                                                                                                                   DE
                                                                                                                IE    LU
                                                                                                                                 NL                 SE
                                                                         10                                           BE
                                                                                                                 SI          FR                                                     EU average: 8.4
                                                                                                                                      EU
                                                                                                           UK                               MT                           AT
                                                                                                                                      CZ                 LT
                                                                                                                       HU     EE
                                                                                                          RO                               IT                 Portugal
                                                                                                     PL
                                                                                                                     HR
                                                                          5
                                                                                                                       LV               ES        BG
                                                                                                                            SK
                                                                                                                                      CY                                             EL

                                                                                  Doctors Low                                                                                      Doctors High
                                                                                  Nurses Low                                                                                        Nurses Low
                                                                          0
                                                                              1                 2                  3                   4                   5                  6                   7
                                                                                                    Practising doctors per 1 000 population, 2015 (or nearest year)

                                  Note: In Portugal and Greece, data refer to all doctors licensed to practice, resulting in a large over-estimation of the number of
         practising
Source: OECD        doctors
             / European     (e.g. ofon
                        Observatory  around
                                       Health30%   in Portugal).
                                              Systems            In (2017).
                                                       and Policies  Austria and Greece, the number of nurses is under-estimated as it only
                                  includes those working in hospital.
Note: In Portugal and Greece, data refer to all doctors licensed to practice,
           Source:
resulting in         Eurostat Database.
             a large over-estimation of the number of practising doctors (e.g. of
around 30% in Portugal). In Austria and Greece, the number of nurses is under-
estimated as it only includes those working in hospital.

                                                                                                                                                 The emigration of Portuguese health professionals is
In the period 2002 – 2013, the number of registered                                                                                              also stimulated by the difficulty for recently graduated
nurses increased continuously, with a total increase of                                                                                          nurses, dentists and diagnostic and therapeutic
about 24,000 professionals. This increase was equally                                                                                            technicians to find employment, the low salaries
strong for both women and men (an increase of                                                                                                    offered in both the public and private sectors, heavy
58% for women and 56% for men compared to the                                                                                                    workloads, remuneration not being performance-related
base year). The ratio of nurses per 1,000 population                                                                                             and limited career prospects. Further, the dynamics
increased from 4.0 in 2002 to 6.3 in 2013. The number                                                                                            of medical school graduates and the retirement of
of doctors per thousand inhabitants also increased                                                                                               Medical Doctors will generate a surplus that may
in the same period, from 3.2 to 4.3. In 2014 the role                                                                                            not be absorbed by the healthcare system by 2025
of family nurse was created (Decree-Law 118/2014).                                                                                               (Santana, 2014).
From 2009 until 2015, the nurses Council estimates that
12.500 nurses emigrated (Pereira, 2015).                                                                                                         The occurrence of the burnout syndrome in Portuguese
                                                                                                                                                 health professionals is frequent, being associated with
Three quarters of nurses work in acute settings and a                                                                                            the perception of poor working conditions and reduced
quarter in the community. A further shift to community                                                                                           professional experience. The incidence of the burnout
settings will be needed if chronic diseases are to be                                                                                            syndrome shows regional differences which may be
effectively managed outside of hospitals.                                                                                                        associated with different and suboptimal conditions
The distribution of health resources does not match                                                                                              for health care delivery. At the national level, between
population characteristics. There is no correlation                                                                                              2011 and 2013, 21.6% of health professionals presented
between variables such as total number of physicians,                                                                                            moderate burnout and 47.8% burnout. The perception
nurses, hospital beds, primary care units, and the ageing                                                                                        of poor working conditions was the main predictor
index. Municipalities with a higher ageing index do not                                                                                          of the occurrence of burnout in Portuguese health
get more resources, resulting in more limited access                                                                                             professionals (Marôco, 2016). Promoting retention
to health care from those populations. Rural areas,                                                                                              strategies that increase satisfaction with opportunities
especially interior areas with low density of population                                                                                         for career advancement among Portuguese nurses
(and in many cases declining populations) are poorly                                                                                             has the potential to override individual characteristics
provided with skilled human resources (Simões, 2017).                                                                                            associated with increased turnover intentions
                                                                                                                                                 (Leone, 2015).

                                                                                                                                           18
Domain 2: NHS sectorial reforms and human resources

An improved strategy for staff retention and motivation            •	reduction in the medium term in the number of
is needed. (Ribeiro, 2014). Promoting retention strategies            people with functional dependency – adoption of
that increase satisfaction with opportunities for career              the strategy for active and healthy aging (already
advancement among Portuguese nurses has the                           submitted).
potential to override individual characteristics associated
with increased turnover intentions (Leone, 2015).                  Several initiatives of decentralization and autonomy
                                                                   in the health system have occurred recently. Examples
The discussion about skill mix in the NHS only
                                                                   include the change in the status of several NHS
emerged recently. Despite, the exceptional training and
                                                                   hospitals to public enterprises, and the creation of
qualifications of several health professions, the health
                                                                   Responsibility Centres, which increased the degree
system continues to be focused on physicians. As
                                                                   of autonomy in the day-to-day decision-making
an example, the recent created role of Family Nurses
                                                                   of organizations and services, especially in terms of
requires more government measures (Simões et al.
                                                                   acquisitions and recruitment. The XXI constitutional
2017).
                                                                   Government introduced the principle of free access
                                                                   and circulation (FAC) for users in the SNS (Order No.
2.6 Digital transformation
                                                                   5911-B/2016). With the implementation of FAC, the
The development of eHealth in Portugal over the years              patient who needs a specialty hospital consultation,
was an important tool to improve governance, and the               may, together with the family physician responsible
availability of data is now much better than a decade              for the referral, opt for any of the NHS hospital units
ago. Nevertheless, the available data are not always               where the specialty in question exists. Before, there
used to improve process and results. The eHealth                   was a network of pre-defined hospitals for referral
market started in the late 80s and it has been evolving            from primary care, based on the place of residence.
since then. Sometimes this is more market driven                   In principle this measure might increase efficiency and
and other times more centralized in public providers.              equity in the NHS. Simultaneously, the NHS started to
However, it is clear that Portugal is now in the forefront         release more information about waiting times. The
of eHealth in Europe. All the primary health care                  most recent estimates show that approximately 12%
providers have electronic health records, most hospitals           of referred patients chose another hospital than the
have electronic health records, there is already some              one previously assigned.
interoperability between different software.
                                                                   Key challenges – the way forward
Selected past and ongoing efforts
                                                                   1. F uture initiatives should take into consideration the
Current priorities for the primary health care reform may              balance between the central functions of policy
be summarized as follows:                                              guidance and monitoring; and the autonomy of
                                                                       delivery health care organizations. The decrease in
•	Enhancing primary health care response, by gradually
                                                                       autonomy and the centralization of decision-making
   strengthening their professional capacity in areas
                                                                       diminishes the capacity to find solutions adapted to
   such as oral health, psychology and nutrition and
                                                                       the different organizations, and their unique contexts.
   improving acute care management;
                                                                      Therefore, the decentralization of functions in the NHS,
•	Implementing a new contacting model for the                         from central services to hierarchically inferior levels,
   primary health care functional units, more adapted                  namely for regional health administrations, hospitals
   to respond to the current need to improve primary                   and health centre groups should be discussed in
   health care performance;                                            order to optimize (Gulbenkian, 2015). Recognising
                                                                       that some of the recent centralisation was a response
•	Improving the culture and tools for better health and
                                                                       to external pressures, it is necessary to define more
   clinical governance in primary health care, taking
                                                                       clearly what roles are useful at the regional level and
   advantage of further developments of the Business
                                                                       to develop the structures and systems to allow these
   Intelligence system now taking place.
                                                                       roles to be developed.
The following developments are taking place in the                 2. There is a need to improve the current pace of the
Portuguese long-term care network:                                     primary health care reform, in order to provide similar
                                                                       quality of care to the entire Portuguese population as
•	increase of responses in extension and diversity –
                                                                       soon as possible. Also, the integration of primary care
   a strategy of increasing the number of responses,
                                                                       network with other levels of care remains a challenge,
   with priority for home care, is underway. The diversity
                                                                       requiring measures to improve the continuum of
   of responses to areas that lack some specificity
                                                                       care and the efficiency of the health system (see also
   (strategy for the care of people with dementia –
                                                                       Domain 3).
   already delivered) is being prepared;
                                                                   3. An approach is needed to implement policy –
•	greater integration of the Network with social
                                                                       currently there remains a large gap between some
   responses – although the current response is already
                                                                       clear policy directions and the mechanisms for
   integrated, this needs to be deepened, namely with
                                                                       implementing policy and managing change.
   multiple social responses such as home support
   services and residential structures for the elderly;

                                                              19
Health System Review

4. T here is a need to clarify the policy goals in the
    interface of public and private provision, and to
    integrate the different sectors more effectively.
5. S ystematic evaluation and review of service
    delivery models will be useful and timely. Gaining
    full advantage of these new models may require
    more autonomy of providers and will have some
    implications for local and national governance
    arrangements and their balance. It is likely that the
    best options will involve further moves to integrate
    care provision and to simplify the ways in which
    people access care.
6. Despite significant changes in skill mix, service
    provision in Portugal remains very doctor centred,
    and there is a need for a wider set of skills and a
    better configuration of professionals to meet the
    growing needs of people with multiple and complex
    chronic diseases.
7. In line with most European Union countries, human
    resource policy making and planning for service
    provision and management needs to be placed clearly
    ahead of the needs curve.
8. T here is also a need to reduce outward migration of
    health care professionals and to examine in particular
    the incentives for retention and motivation of staff.
    While it can be difficult to compete on salaries with
    some other employers, the wider working conditions
    are important for motivation.
9. P ortugal can be proud of progress in terms of the use
    of information and communications technologies in
    the health sector. This provides a good basis both for
    more efficient operation of the system and also to
    further develop the role of patients and families. It is
    important to retain the focus on these developments
    as drivers and facilitators of better service delivery
    and to make the best use of the potential for wider
    use of the data in research, monitoring, quality
    assurance and service development.

                                                               20
Domain 3: Person-centred, better integrated NHS

DOMAIN 3: PERSON-CENTRED, BETTER INTEGRATED NHS

3.1 Healthcare integration                                         Although there are still challenges to be addressed
                                                                   regarding the success of vertical integration, recent
The European Commission stresses that it is necessary
                                                                   studies suggest that quality indicators such as
to offer alternative care models to improve quality of
                                                                   readmissions decreased after a vertical integration,
life, health care and reduce avoidable hospitalizations
                                                                   especially among patients with diabetes and
and costs. The integrated care model should be based
                                                                   complications (Lopes et al. 2017). Even though
on better coordination among health and social care
                                                                   improvements were not found for all institutions or
professionals, higher efficiency, improved healthcare
                                                                   condition-specific groups, this study shows that merging
processes, supported by information technology (IT)
                                                                   acute and primary care providers is associated with
and new organizational models and use of technologies
                                                                   reduced readmissions (Lopes et al. 2017). Vertical
for remote care (e.g. at home or at work).
                                                                   integration, in organizational terms, between primary
Care integration can be achieved with appropriate                  and hospital care, was introduced in 1996, as Local
structures and appropriate care integration and                    Health Units (ULS in Portuguese), covering only a
procurement tools. There has been some innovation                  geographical areas in the NHS. Since than a number of
in contracting and procurement in Portugal (Simões                 projects, within and outside ULS, aiming at improving
et al., 2017) that has provided experience in the use of           health care integration, have been implemented in
financing mechanisms that might be used as incentives              Portugal. These projects focus on different aspects of
for integration of care delivery, alongside the experience         health care integration, including case-management of
of integration of primary and secondary care delivery.             highly complex patients, tele-communication between
In Portugal, the integration experiences of health care,           hospital and primary health care settings, more
particularly between primary health care (PHC) and                 sophisticated referral systems between different levels
secondary care already exist, but little is known about            of care, home care follow-up of post hospitalization.
the effectiveness of these models in improving care                Interventions that include experts focused on discharge
delivery. This issue thus becomes important, not only              management, that include post-discharge rehabilitation
because it is relevant to assess if significant efforts to         and follow-up and those based on multicomponent
integrate care have been made in Portugal but also                 strategies were most likely to be associated with
because there is a particular experience of integration            significant reductions in hospital use for patients with
of PHC and secondary care which requires a deeper                  single conditions such as heart failure and chronic
knowledge, specifically the model of local health unit             obstructive pulmonary disease (COPD).
(ULS in Portuguese). Still on the issue of evaluation, and
especially the evaluation of health care integration, there        Remote monitoring of patients with COPD
is still a need for better methodologies and metrics
                                                                   One of the main objectives in the treatment of COPD
for measuring the integration of care and there is also
                                                                   is the prevention of hospital readmissions, as well as
a lack of consensus on the terminology and on the
                                                                   the improvement of survival. This program was already
concepts related to the integration of care.
                                                                   ongoing and this specific payment mechanism was
                                                                   applied in 2017, following a pre-established home
                                                                   protocol, according to the inclusion criteria and the
                                                                   objectives defined. Portugal has the second lowest
                                                                   asthma and COPD admissions in adults among EU21.

                                                              21
Health System Review

Telemonitoring program for status after acute                                                                             Figure 15. Health literacy levels by age and
myocardial infarction                                                                                                     educational levels
The 30 day mortality after admission to hospital
for acute myocardial infarction (AMI) in Portugal is                                                                                     0%                   20%                       40%                   60%                     80%             100%

slightly higher than the EU21 average. Appropriate                                                                         15-25 years    12.7%                                         53.6%                                              30.9%    2.7%

treatment and follow-up of AMI also reduces avoidable                                                                      26-35 years    11.8%                                  52.0%                                            32.4%             3.8%

readmissions and hospital stays, as well as improves
                                                                                                                           36-45 years    11.8%                              47.0%                                        34.9%                     6.3%
patient survival. In these terms, a 2014 Telemonitoring
                                                                                                                           46-55 years                                                                            45.2%
Program for status after acute myocardial infarction                                                                                      7.0%                       40.2%                                                                          7.6%

was developed. There are also implemented “vias                                                                            56-65 years    3.8%                 41.9%                                      39.7%                                    14.7%

verdes coronárias” that is a pathway for faster access                                                                     66-75 years    6.4%            28.2%                                   42.9%                                            22.6%

to hospitals with primary angioplasty.                                                                                      76+ years     2.3%    16.0%                                  46.6%                                                     35.1%

                                                                                                                                         0%                   20%                       40%                   60%                     80%             100%
3.2 Health literacy
                                                                                                                                Up to
                                                                                                                               Basic 2    2.0%               32.9%                                                   44.7%                         20.4%
When health literacy is compared across different
European countries, Portugal appears in a less                                                                                 Basic 3    8.3%                         48.9%                                               37.1%                   5.7%

favourable position (Figure 14).
                                                                                                                           Secondary
                                                                                                                                          14.4%                                 49.6%                                             33.6%            2.4%
                                                                                                                            education

Figure 14. Comparing health literacy across                                                                                   Tertiary
selected European countries                                                                                                 education     18.7%                                          48.5%                                            27.2%    5.6%

                                                                                                                                         ■ Excellent HL    ■ Sufficient HL     ■ Problematic HL    ■ Inadequate HL

   Portugal    8.4%                        30.1%                                        44.4%                17.0%         Source: ILS-PT, 2014, CIES-IUL/ Fundação Calouste Gulbenkian e HLS-EU Consortium (2012)
                                                                                                                          Source: ILS-PT, 2014, CIES-IUL / Fundação Calouste Gulbenkian e HLS-EU
    Poland     19.5%                       35.9%                                        34.4%                10.2%
                                                                                                                          Consortium (2012).
Netherlands    25.1%                       46.3%                                             26.9%           1.8%

    Ireland    21.3%                       38.7%                                        29.7%                10.3%

     Spain     9.1%                        32.6%                                        50.8%                7.5%
                                                                                                                          Selected recent or ongoing developments
    Greece     15.6%                       39.6%                                        30.9%                13.9%
                                                                                                                          Since 2016 new developments are taking place in
  Germany      19.6%                       34.1%                                        35.3%                11.0%
                                                                                                                          Portugal concerning people centeredness and better
   Bulgaria    11.3%                       26.6%                                     35.2%                   26.9%
                                                                                                                          health care integration. These can be summarized
    Austria    9.9%                        33.7%                                        38.2%                18.2%
                                                                                                                          as follows:
      Total    15.5%                       35.3%                                        36.2%                13.0%

              0%       10%   20%       30%         40%          50%        60%         70%
                                        Levels of health literacy by country and by total
                                                                                                 80%   90%      100%
                                                                                                                          NHS Portal
                                   ■ Excellent   ■ Sufficient   ■ Problematic    ■ Inadequate
                                                                                                                          In 2016, the new government launched the NHS portal,
                                                                                                                          with information mainly targeted for the user (3 million
Source: Pedro, Amarel & Escoval, 2016.
                                                                                                                          views in 1 year) aiming at better governance on the
                                                                                                                          basis of enhanced communication, transparency and
However two distinct groups can be identified in
                                                                                                                          accountability on health and health care. Users can
Portugal when it comes to health literacy: elderly
                                                                                                                          enrol into the “personal area” of the Portal in order to
people with lower education, and a highly educated
                                                                                                                          organize and manage their own health information and
young population. These two groups need different
                                                                                                                          receive relevant health information or take advantage
strategies as a health literacy target, (elderly people with
                                                                                                                          of more general information continuously updated, as
lower incomes and educational resources are the most
                                                                                                                          for instance waiting times in the emergency department
vulnerable group) in the use of health information in
                                                                                                                          and for surgeries. Mobile applications, linked to Portal’s
their daily routines. Figure 15 shows health literacy levels
                                                                                                                          information have developed.
by age and education levels.
                                                                                                                           Since early 2017 the Portal offers a health literacy
                                                                                                                           library and a new collection of thematic microsites
                                                                                                                           presented as attractive digital books, covering areas
                                                                                                                           such as “Preventing Falls”, “Healthy Eating Habits”,
                                                                                                                          “Winter Health”, “Positive Personal Relationships, Violent
                                                                                                                           Behaviours and Health”. Although details on the Portal’s
                                                                                                                           overall performance are not yet available, this is a step
                                                                                                                           towards more informed and active users.

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