Lessons from the Basque Country; Contrasting Basque Integrated Care Health Policy with the New NHS Long Term Plan

Introduction Basque country health reforms are credited with development of one of the most successful integrated care strategies in Europe. These reforms are based on “Health the People’s Right, Everyone’s Responsibility. Health Policy in the Basque Country 2013-2020” (HPBC). England’s NHS has stressed the need for effective integrated care to manage chronic disease and multi-morbidity. The NHS’s approach has been outlined in the “Long Term Plan” (LTP), published January 2019. The LTP’s effectiveness and implementation will be essential to the NHS’s ability to deliver effective integrated care. Objective We contrast HPBC (proven highly effective in practice) against the new LTP. Our methodological approach is a structured comparison of policy documents, semi-structured interviews with subject-matter experts and evaluation of published and grey literature. Target Population The LTP covers 55.62 million people. HPBC covers 2.2 million. Whilst there is a difference in population size, both exhibit similar baseline challenges (identified within the policies themselves) including multi-morbidity, health inequalities, unhealthy lifestyles and changing demographics. Highlights Development of both policies took a similar approach of cross-sector engagement. Both approaches stress significant baseline progress in life expectancy, efficiency and outcomes, whilst recognising chronic disease challenges. There are similar focuses on priority diseases including diabetes, cancer, obesity, domestic violence and mental health. A crucial difference is that HPBC outlines conceptual frameworks on which service transformation is based. The frameworks cover health, social determinants and implementation. The LTP does not reframe the conceptual framework, and whilst reduction of health inequality features heavily, it doesn’t have the same prominence. In contrast the LTP focuses more on leveraging digital health interventions. Building on the Basque conceptual frameworks there is the establishment of health as a personal asset and macroeconomic factor. There is a far stronger focus on civic “co-responsibility”. This extends to the Basque "Health in All Policies" approach demanding support from other social structures, whilst the LTP in contrast looks outwards explaining how it “Supports Wider Social Goals.” A key contrast is HPBC’s structured and itemised listing of quantitative indicator goals comparing status quo with end-of-plan targets, this includes health outcomes, core structural and intermediate determinants. The LTP expresses no such quantitative targets, but does include financial targets. Transferability This evaluation has international importance. For the NHS it identifies potential pitfalls and opportunities; for the Basque county it will help develop its next plan; for healthcare globally it allows a comparison of two contrasting approaches to integrated care delivery, providing support to the development of their own local plans. Conclusions Both healthcare systems outline ambitious plans for development of sustainable integrated care. The Basque model is centred on conceptual frameworks and an overriding focus on health inequalities alongside quantitative outcome targets. The LTP acknowledges the importance of inequality and focuses more on digital delivery of economically sustainable integrated care. It will be important to evaluate progress against these aims alongside the next iteration of the Basque Health Plan in 2020. This work forms part of an EASD/EFSD Trainee Albert Renold Fellowship