Reference Centers for Concentration of Expertise and Improving Equity in Accessing Highly Specialized Oncologic Services

Key Contextual Factors

• Provision of care in Spain has been decentralized in 17 regions consequently, access to highly specialized services started to be unequal among different regions. The whole project was led by the Designation Committee, dependent on the Inter-territorial Board of the National Health Service. The Board prioritized specialization areas as it was not feasible to approach all the areas at the same time due to lack of resources.
• Oncology was one of the first areas to be prioritized. Since the very beginning, the Board considered the involvement of the clinical representatives from the regions as a key aspect of the project and established multidisciplinary expert groups[1]. Data from patient referral system were used as a starting point to define the conditions for which reference centers were needed. As there was a lack of evidence, definition of criteria and requirements for the reference center was carried out by clinicians by consensus.
• After designation of centers, clinicians representing reference centers define and propose to the Designation Board the outcome measures that constitute the monitoring system. Yearly, results from all centers are discussed among clinicians providing care to the same group of conditions and a report is submitted to the Designation Committee.

Key Components/Steps

• Provide legal framework for establishing reference centers of the Spanish National Health Service and Royal Decree 1207/2006, ruling the management of the Health Cohesion Fund
• Create Designation Committee, managing and coordinating the project. All decisions will be taken by consensus
• Identify conditions for which reference centers in the NHs are needed and defining the designation criteria that centers must fulfill
• Define HCP designation and evaluation procedure including a on-site audit to assess the fulfillment of criteria
• Define monitoring system, together with clinicians representing the reference centers
• Establish patient referral system for the reference centers and an economical compensation system for the healthcare provided
• Create an IT tool to manage the project. Technical officers from the Ministry of Health, regional authorities and representatives from the HCPs and treating physicians can access the IT tool.

Main Impacts / Added Value

• By means of this initiative, 14 oncological conditions were identified to require the designation of reference centers[1] 57 HCPs, based in 6 out of the 17 regions, have been designated to provide highly specialized care related to such conditions. Nearly 1.800 episodes of patients coming from other regions requiring healthcare for such conditions have been treated within these HCPs during 2019. These figures reflect the improvement in the equity of access to highly specialized care.
• All HCPs taking part in the project, with previously defined criteria and standards, have successfully gone through an initial on-site audit process.  They have reported yearly the outcome measures to the monitoring system in order to maintain their designation. Involvement of the national and regional healthcare authorities and clinicians and Healthcare Technology Assessment professionals, in the definition of criteria and monitoring system was of great added value to the project.
• The discussion of the yearly outcomes of the monitoring system with clinicians representing the reference centers is a crucial tool to get feedback about the development of the project, to upgrade designation criteria and for the yearly monitoring system.

Lessons Learned

• The joint management strategy among the national and regional health authorities facilitated consensus to decisions making, together with the involvement of professionals from all the regions. This has led to definition of criteria and requirements of the centers and the outcomes measures that will be reported in the follow-up and monitoring system. It could be serve as an example for other initiatives.
• The IT tools providing support to the patient referral system between regions fosters communication among them, follow-up of referred patients and increases the amounts compensated for the healthcare provided in the reference centers. Such IT tools should include communication between the clinician referring a patient and the one providing healthcare to that patient.
• IT tools will play a key role in the communication among clinicians, thus they should be encouraged. IT tool will facilitate networking among reference centers as well as the integration in the ERNs, which represent the current challenge of the project.

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