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Primary Care Innovation Plan: Implementation

Partner Institute: 
University of Barcelona
Survey no: 
Joan Gen Badia
Health Policy Issues: 
Public Health, System Organisation/ Integration, Funding / Pooling, Quality Improvement, Responsiveness
Reform formerly reported in: 
Primary Care Innovation Plan of Catalonia
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes no no yes no no
Featured in half-yearly report: Health Policy Developments 12


13 out of the 60 sub-projects identified in the Primary Care Innovation Plan for Catalonia were priorized for implementation in so-called pilot territories. Main issues are the decentralisation of managerial responsibilities to primary care teams, competence improvement for nurses and clerks, integrated care for complex chronic patients and community health.

Recent developments

Initial documents presented the Primary Care Innovation Plan as a global reform of the whole health system (see also report "Primary Care Innovation Plan of Catalonia"). Innovation was aimed to better orient health services to community and personal health needs. For this to be achieved a higher integration of different levels of care was desired together with an integration of public health, community programmes and primary care services. The Innovation Plan also aimed to increase patient choice and professional leadership and accountability in service management.

In the implementation phase, the comprehensive approach was abandoned because the project faced the opposition of healthcare provider enterprises and lacked real support from the responsible of the Department of Health. The absence of real political will is shown in the lack of a specific budget for the implementation of the project, despite the high increase in healthcare expenditure in the region: The Catalan Department of Health doubled its annual budget from 2003 to 2009.

Only 13 out of the 60 innovative ideas identified in the initial plan are selected for implementation in pilot territories called "advanced zones".  Innovations are focussed on decentralising managerial responsibilities to the primary care team professionals, on enlarging professional competences of nurses and administrative staff, on improving coordination between public health services and primary care teams and on improving the quality and the integration of services delivered to complex chronic patients.

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low very low very high
Transferability strongly system-dependent neutral system-neutral
current current   previous previous

The Primary Care Innovation plan for Catalonia was initially thought as a strategy to modernise the whole Catalan Health System. Unfortunately the Department of Health was unable to overcome the resistance of the powerfull private and public hospital providers. The plan is nevertheless being implemented, but at the cost of being much less innovative. Currently it has been reduced to some innovation projects that anyway would have spontaneously appeared in the health system because they respond to population health needs or to the demands of the professionals. Innovative ideas such as the publication of regional evidence-based guidelines or increased choice and voice for patients were being dropped from the plan. 

The economic crisis and the foreseen change in the regional governement next November might be an opportunity to finally push forward the keay ideas of the original Primary Care Innovation Plan for Catalonia. 

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes no no yes no no

Initiators of idea/main actors

  • Government: Government is officially supporting the project in the discourse, although it is not its priority. Funds initially allocated to project implementation were removed because of the financial crisis.
  • Providers: Providers that receive most of their income from the hospital sector fear a reform that might tip the balance of power and of budget from hospital to primary care.
  • Payers: In the official discourse Catsalut also supports the project, although it is not a priority for the organisation.
  • Patients, Consumers: Although the innovation plan aimed for a higher patient involvement in the decision making process, the truth is that patients have already been absent in both the design process and in the implementation phase.
  • Scientific Community: Some professional organisations such as FOCAP (Forum Catal d'Atenci Primria) with a little support in the sector support the Innovation Plan, so do the scientific societies; the professional colleges and the trade unions do not have an opinion.

Stakeholder positions

Despite the lack of specific financing and the opposition from most of the stakeholders, the regional Department of Health and the Health Service Commissioner (Catsalut) wanted to continue with the Primary Care Innovation Plan in order to avoid being seen as losers in the public opinion. Catsalut is interested in the plan because it provides a new and fresh discourse about the new roles and activities to be carried out by hospitals and primary care providers. The plan provides the topics to be discussed by commissioners and providers in the commission of providers in the local territories. Such a commission was recently launched in every local territory, although it lacked a specific purpose or a clear content until now.

Initial leaders of the Innovation Plan, well known in the region for their strong positions in favour of primary care, were removed and replaced by others with more professional profile and more loyality to the Regional Department of Health. The new directorate conducted a priorisation process for selecting those innovative ideas that more likely could be implemented. Topics better accepted by hospital providers and by primary care teams were selected. Some innovative projects carried out by primary care teams, such as the process of decentralisation of managerial responsibilities to the 90 public primary care teams of the Catalonian Health Institute, became part of the innovation plan (usually the Catalonian Health Institute runs decisions centrally).

In this implementation phase the Innovation Plan is more collaborative and more bottom-up orientated. Nevertheless the Plan continues ignoring the voice of patients and the opnion of patient organisations. Chronic patient care was also priorised because the improvement of this service was accepted and demanded by both primary care teams and hospital care providers.

Actors and positions

Description of actors and their positions
Regional Department of Healthvery supportivesupportive strongly opposed
Employer Organisationsvery supportiveopposed strongly opposed
Catsalut (Catalan Health Service)very supportivesupportive strongly opposed
Patients, Consumers
Consumer Organisationsvery supportivesupportive strongly opposed
Scientific Community
FOCAP (Forum Primary Care)very supportivevery supportive strongly opposed
AIFIC (Primary Care Nurses Society)very supportivesupportive strongly opposed
CAMFIC (Catalan Society of family Doctors)very supportivesupportive strongly opposed
ProfessionalColleges (Doctors and Nurses)very supportiveneutral strongly opposed
Trade Unionsvery supportiveneutral strongly opposed
current current   previous previous

Influences in policy making and legislation

No legislative change has been undertaken so far, even though many people understand the necessity to recognise by law the enlargement of the professional competences of nurses. The lack of legislative changes prevents the implementation of some advanced nursing procedures such as for instance the possibility to prescribe.

Legislative outcome


Actors and influence

Description of actors and their influence

Regional Department of Healthvery strongvery strong none
Employer Organisationsvery strongstrong none
Catsalut (Catalan Health Service)very strongvery strong none
Patients, Consumers
Consumer Organisationsvery strongvery strong none
Scientific Community
FOCAP (Forum Primary Care)very strongweak none
AIFIC (Primary Care Nurses Society)very strongweak none
CAMFIC (Catalan Society of family Doctors)very strongstrong none
ProfessionalColleges (Doctors and Nurses)very strongvery strong none
Trade Unionsvery strongvery strong none
current current   previous previous
FOCAP (Forum Primary Care)AIFIC (Primary Care Nurses Society)CAMFIC (Catalan Society of family Doctors)Regional Department of Health, Catsalut (Catalan Health Service), Consumer OrganisationsProfessionalColleges (Doctors and Nurses), Trade UnionsEmployer Organisations

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

In the advances territories, innovations have been implemented in three main areas:

1. Decentralisation of managerial responsibility/expansion of competences. Increase the managerial responsibilities of primary care team professionals. The project born inside the largest public provider (Catalan Health Institute) currently involves 90 primary care teams. This project also promotes changes inside the teams oriented to increase productivity and efficiency. Nurses are enlarging their professional competences in the management of acute diseases as well as in the care of chronic patients. Administrative staff also increases their competence and relieve doctors from some bureaucratic tasks that previously burdened the consultation.

2. Management of complex chronic patient. In a proactive process primary care teams and hospitals identify chronic patients at high risk of being admitted to hospital. A specific and personalised intervention program is organised for them with the aim to prevent unnecessary hospitalisations. Such patients receive a more active home care service provided by both the primary care team and social services. Liaison nurses ensure coordination with hospital and community providers. Key aspects of this sub-project are the co-leadership of local projects between primary care and hospitals, integration of information systems between primary care and hospitals, and common (hospital and primary care) indicators for evaluation and financing. Providers in the territory sign the "Accessibility Agreement". The document shows how the providers are going to organise themselves for better meeting the goals established by the commissioner (Catsalut).

3. Community orientation. Some primary care teams are encouraged to rapidly and easily assess the needs of the community they serve and to conduct a community intervention in coordination with the public health services.

Monitoring and evaluation

The implementation of the project started February 2010 and evaluations are scheduled for next year.

Expected outcome

Current reforms already undertaken may have a limited impact on professional and patient satisfaction and may reduce some unnecessary hospitalisations of complex chronic patients.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low low very high
current current   previous previous

Expectations about the impact of the reform on quality, equity and cost efficiency are reduced because of the changes introduced in the plan in the current implementation process.


Sources of Information

Interviews with current leaders of the plan: Lourdes Camp, Carmen Cabezas, Joan Carles Contel.

Catsalut. Pla d'innovació d'atenció primària i salut comunitària (PIAPSC). Accessible at 

Reform formerly reported in

Primary Care Innovation Plan of Catalonia
Process Stages: Policy Paper, Idea

Author/s and/or contributors to this survey

Joan Gen Badia

Health Policy Monitor representative in SPAIN

Suggested citation for this online article

Joan Gen Badia. "Primary Care Innovation Plan: Implementation". Health Policy Monitor, October 2010. Available at