Doctors and users pulling together


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Doctors and users pulling together

Doctors and patients represent the two fundamental cornerstones of any health care model and there is much more that unites them than divides them. Health care management shared by professionals and users is possible and benefits both parties. This is demonstrated by the co-management model developed at Barcelona Hospital by the cooperatives, Autogestió Sanitària and SCIAS, which has been operating successfully for 40 years now.

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This was one of Dr Josep Espriu’s convictions: that the two central players in the health care system are doctor and patient. On the basis of this, he created a new health care management model in which both professionals and users would have the same influ¬ence and degree of participation in key decisions. And in order to put this into practice he launched a co-operative movement which developed during 1970s and culminated in 1989 with the opening of Barcelona Hospital, which belongs to the Assistència Group.

The Assistència Group includes various organi¬sations but is essentially based on two co-operative enterprises: Autogestió Sanitària, which has around 5,000 doctors, and Societat Cooperativa d’Instal•la-cions Assistencials Sanitàries (SCIAS), which has 166,000 users. And while the doctors’ co-operative, Autogestió Sanitària, holds 70% of the shares in the insurance company, Assistència Sanitària Col.legial (ASC), the SCIAS users’ co-operative owns the Bar¬celona Hospital facility.

The insurer ASC is governed by a Board of Directors while the SCIAS co-operative has its own Governing Board although leading members of both boards meet every Wednesday afternoon so that the Group Commission can agree the most important decisions together. This is how health care co-management works, explains Lourdes Mas, Managing Director of SCIAS and manager of Barcelona Hospital: “All the basic management decisions about the hospital are referred to this joint commission of doctors and users. Once the decisions have been taken, the ASC directors present them to their Board of Directors, and the SCIAS directors put them before the Governing Board for them to be approved and formalised.” The Group Commission does not have its own legal status, which means that each resolution must be ratified by the boards of each organisation. Nevertheless the commission, which includes representatives of doctors and users and meets every week of the year is, as Mas describes, “the kitchen where everything is cooked up”.

Strategy is also agreed at the weekly meetings. «When we say “strategy” we are talking about the functioning of a new area, the price of the premium paid by the insured clients each month, the price of the annual increase in medical fees, the amount of money to be invested each year… All these decisions are always agreed by consensus,» says Dr Carles Humet, the Medical Director of Barcelona Hospital. This is confirmed by the Managing Director of SCIAS: “We sit down and talk, for example, about the investment budget, how we will agree the tariffs, whether or not to expand medical services, incorporate new technologies…”

Dr Gerard Martí, the Deputy Medical Director of Barcelona Hospital, indicates that one of the main advantages of the Assistència Group’s co-management model, compared with other public and private approaches is “that there are no political or social or financial intermediaries, which means the decisions are taken directly by those involved in the system: the professionals, the doctors, on the one hand, and the potential patients, or citizens or users, on the other”. “Within this model,”, continues Dr Martí, “major organisational, conceptual and operational decisions are taken directly by those involved in the system. The professionals work freely, and users can choose the professional they want to care for them within the system. We do not depend on any prevailing political approach or social trend. The purpose of the enter¬prise is not for profit, but for service”.

Converging interests

The Group Commission allows the interests of doc¬tors and patients to converge, allowing consensual solutions to every problem. Enric Sells, the Commer¬cial Director of ASC and a trustee of the Espriu Foun¬dation, explains as follows: “It may seem that they have contradictory interests: what the doctors want is to make a better living, while patients want the best price. The great virtue of this model is that both have to reach an agreement. And they establish that agreement both with regard to the doctors’ pay and the premiums to be paid in order to cover the doctors’ pay. And so that is the great secret: both sides come to an agreement. Problems are resolved by consensus”.

The Technical Director of ASC, Andreu Obis, says that consensus has been the basis of the concept of co-management from the very outset: “Users would be prepared to pay what is needed for the services they demand, and therefore have the right to speak and vote in the debates about offering these services as well as being able to pay the doctors fairly. It is a quid pro quo: “I want such and such, and you give it to me, and I am prepared to pay you this much”. That was the initial idea: to avoid any confrontation between the doctors and those receiving the service from them.”

Co-management is based on the idea that it suits both doctors and users to reach an agreement, be-cause both of them want the model to function well and to be a good quality. Lourdes Mas stresses this point: “It is in both sides’ interest for it to work well. We are not two parties to a contract, with contradictory interests, but quite the opposite. we both want this to work. And so the negotiations are much easier, because we both share the same interests. We don’t argue, we support one another”.

The Managing Director of SCIAS and Manager of Barcelona Hospital adds: “Problems can arise at any kind of company: the difference lies in the way that we address and manage them. The fact is that we manage them jointly, as doctors and users, all pulling together, not for one side to make money at the ex¬pense of the other, but for both to reach a satisfactory conclusion”. So consensus is fundamental in decision-making.

According to the Medical Director of Barcelona Hospital, “At times interests may diverge, and then what we do is to set out and discuss each side’s interests around the table, so that major strategic decisions can be reached by consensus”. Humet points out that “In technical issues, the doctors usually play a more prominent role but they need the approval of the users who ultimately are the ones who provide the money through the health insurance system”.

And so neither of the two sides has the last word and the only way to resolve issues is by mutual agree-ment, which demands that every position be clearly argued and explained. As Obis emphasises: “The aim is never to have a vote, to have one group outvoting the other, but always to reach a majority agreement without a vote. It’s a question of conviction”.


Both ASC and SCIAS are non-profit organisations whose main aim is not to generate an financial return but to achieve quality in patient service. The co-op-erative health model devised by Dr Espriu is based on the idea that the greater the number of members, the smaller the contribution they will need to make. A great deal can be achieved with very little, as the Commercial Director of ASC reflects: “Dr Espriu, our founder, said the secret was in collecting very little money from a lot of people. With a little money from a lot of people you can do a great deal. That is the secret, and the only one there is.”

Sells says that “both ASC and SCIAS need to generate a surplus to be able to function, but not exces¬sively so. In fact, at ASC we feel that if there is too much money left over then we have managed things badly because that means we have been asking our insured clients for more money than we need”.

“The most typical problems are always connected with money,” acknowledges Dr Humet, who nonethe-less asserts that every year “an agreement has to be reached to pay the professionals well, but at a reason¬able cost that the users can afford which relates to a typical family’s income”.

Quality guarantee

The first benefit of co-management by doctors and users is that it improves the quality of services. As the Commercial Director of ASC says: “Our model improves services, or at least that is what we aim for. And in fact what co-management does is to give both doctor and patient an active role in all health care processes and so in improving those processes”.

No problem is left unaddressed because, as Mas says, “we never neglect any issue because it will al-ways crop up again somewhere. Every aspect of care is tackled whether those raised by users or by doctors. Co-management covers the whole spectrum of our approach to health care”.

And so the model generates a high degree of sat¬isfaction among both patients and professionals. For patients, because it is based on the free choice of doc¬tor. As the Medical Director of Barcelona Hospital ex¬plains: “Patients choose the doctors that obtain the best outcomes, who treat their patients best, spend more time on them… And so an interest in doing a good job is an intrinsic element in being hired. Those who do their job badly will not be chosen, while those who work well will have more patients”.

Meanwhile, the doctors also feel comfortable with the Assistència Group health co-management model. This is confirmed by Dr Humet: “The doctors feel they are treated much better in this system than in others, with the result that when the Medical Association conducts its surveys into open-market insurance entities, Assistència Sanitària, which is the insurer owned by the doctors’ co-operative, is always the most highly rated by professionals. Because it pays better, it pays punctually, because decisions are taken in consultation with the professionals, etc. etc.”

Co-management in daily business

All the important decisions affecting the functioning of Barcelona Hospital are taken around the table shared by representatives of doctors and the general public.

There are numerous specific examples of these consensual decisions. Dr Humet cites a few of them: “the remodelling of the operating theatres, which took place last summer (ie one of the phases), taking advantage of the downturn in the surgical operations scheduled; other joint decisions include decentralisation and improvement of the oncology services provided to treat cancer, and the investment made at the hospital to refurbish a whole floor to house the obstetrics and gynaecology department”.

Obis comments on this last refurbishment: “We took the decision to do this, and on the investment that was needed… and that was decided by the users, who are the owners of the hospital, and the doctors, who are the owners of the insurance company. Of course when you are doing something like this which will make the department more attractive, more modern, more technical, but also more expensive, it is done fully aware that it will be good for the group’s image”.

The Managing Director of SCIAS and Manager of the Hospital mentions another example illustrating how, thanks to mutual agreement between the users’ and doctors’ cooperatives, a serious problem of over the hospital’s occupancy levels was resolved.

“We had a huge number of elderly patients with a wide range of pathologies, many of them chronic, and they were being repeatedly admitted (perhaps once a month or every two months, with seven or eight admissions per year). These individuals were occu¬pying a huge number of beds, and so SCIAS and ASC set about thinking what we could do,” explained Mas.

The solution was to create a new service known as PAPPA, the Pluripathological Patient Home Care Programme. “This service is handled by a number of doctors and nurses who go to patients’ homes,” explains the Director of SCIAS, adding that “the programme has been hugely successful: we are now dealing with 230 patients, who are constantly mon¬itored at home”.

A unique global model

The health care management co-operative model developed by the Assistència Group is the only one of its kind in the world, and so it attracts the interest of health care professionals and administrators in many countries. This is confirmed by Dr Gerard Martí who, as the Deputy Medical Director of Barcelona Hospi¬tal and a trustee of the Espriu Foundation, has the task of personally receiving international delegations who come to visit the institution out of interest in the co-management model.

“Over recent years we have been visited by delega¬tions from Brazil, Argentina, the United States, Canada, Japan, China, Korea, the Netherlands, the United Kingdom, Portugal and Italy,” says Dr Martí, adding that he himself has travelled many times to present the organisation, ie both the hospital and the group itself, in the United States, Canada and Italy.

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