by Manuel García-Goñi, Cristina Hernández-Quevedo, Roberto Nuño-Solinís and Francesco Paolucci

The growth of health care expenditure is a key policy concern in many countries, particularly in relation to underlying drivers such as ageing, medical innovation and changes in the burden of disease (for example, the increasing prevalence of chronic diseases). However, most health care systems in developed countries have been designed to ‘treat’ acute episodes, rather than to ‘manage’ chronic conditions. They are, therefore, not efficiently organised to respond to the changing needs and preferences of users, in particular, those with multiple chronic conditions.

With an ageing population, Spain too has been following international trends, with rising numbers of chronic patients over the last decade (currently at more than 15 million people); and a decrease in mortality rates associated with chronic illnesses such as diabetes, chronic respiratory illnesses, cancer, cerebrovascular diseases and cardiovascular diseases.

In our study (Garcia-Goñi et al, 2012, published in Health Policy) we use a framework provided by Ham (2010) to identify and analyse the ten key characteristics of a high-performing chronic care system (see Box 1) and we apply it to the Spanish context.

Box 1. Ten characteristics of a high-performing chronic care system (Ham 2010)

  1. Ensuring universal coverage
  2. Provision of care that is free at the point of use
  3. Delivery system should focus on the prevention of ill health
  4. Priority is given to patients to self-manage their conditions with support from carers and families
  5. Priority is given to primary health care
  6. Population management is emphasised through the use of tools to stratify people with chronic diseases according to their risk and offering support commensurate with this risk
  7. Care should be integrated to enable primary health care teams to access specialist advice and support when needed
  8. The need to exploit the potential benefits of information technology in improving chronic care
  9. Care is effectively coordinated
  10. Link these nine characteristics into a coherent whole as part of a strategic approach to change.

Our main findings show that it is possible to identify a transition towards a high-performing health system based on chronic care, with this Spanish NHS already meeting some of the pre-requisites outlined in Box 1. Other features, however, are still in their early stages of development or have been applied only in limited geographical and clinical contexts. Several other aspects remain to be developed, such as changes to the delivery model and placing greater emphasis on prevention and self-management by patients. Although the coordination of care is facilitated by GPs’ gatekeeper function, there is considerable margin for improvement, especially in the case of patients with complex clinical and social needs.

Given recent trends, it is expected that the ongoing development of a chronic care strategy by the Spanish NHS will significantly transform its current health care delivery model in the next few years. Policies responding to the current economic crisis, however, have also resulted in reductions in health expenditures, as well as the introduction of some co-payments, making access to some types of care more difficult for specific individuals. Although it is too early to ascertain, this search for short-term savings might compromise longer-term efficiency and equity. Therefore, the current economic context poses a new challenge for the development of a more efficient chronic care system and for assuring that the pillars and virtues of the Spanish NHS are not compromised.


García-Goñi M, Hernández-Quevedo C, Nuño-Solinís R, Paolucci F (2012) Pathways towards chronic care-focused health care systems: evidence from Spain, Health Policy, 108, 2-3, 236-245.

Ham C (2010) The ten characteristics of the high-performing chronic care system, Health Economics, Policy & Law, 5, 1, 71-90.

About the authors

Manuel García-Goñi is lecturer, Universidad Complutense de Madrid, Spain.

Cristina Hernández-Quevedo is Technical Officer at the European Observatory on Health Systems and Policies, LSE Health, London, UK.

Roberto Nuño-Solinís is director of O+Berri: Basque Institute for Healthcare Innovation, Bilbao, Spain.

Francesco Paolucci is reader, University of Northumbria Newcastle, UK, and fellow, Australian National University, Canberra, Australia.