Healthcare transfers to the regions: a problem without governance of the National Health System

/in /by

 

 

 

On January 31, 2022, in the Ernest Lluch room of the Congress of Deputies, the document 20 years of the culmination of the process of health transfers in Spain was presented, a document in which prestigious protagonists of the transfers and other analysts participated. The book was sponsored by AstraZeneca and produced by BioInnova.

I had the honor of participating in said book with a chapter entitled Healthcare transfers to the regions: a problem without governance of the National Health System, which appears below

PDF of the article:

20añoslibro-IgnacioRiesgo

Healthcare transfers to the regions: a problem without governance of the National Health System

Health transfers: a long distance race with a final sprint

The first transfers of health care from the Social Security (INSALUD) took place in Catalonia in 1981, therefore during the UCD period in government and before the General Health Law (1986). The global transfer process lasted more than twenty years, although there were two well-differentiated periods, the first, between 1981 and 1994, in which seven communities received INSALUD transfers: Catalonia, Andalusia, the Basque Country, the Valencian Community, Galicia, Navarra and the Canary Islands, in this order. The conclusion was in 2002, with transfers to the remaining ten communities.

The first seven transfers were made in a long span of thirteen years, the last ten in a final sprint of eleven months.

Before the transfers of INSALUD services, surely because they were easier as they hardly had any resources, those of Public Health had been carried out, despite being the most debatable conceptually. The coronavirus pandemic has shown us the limitations of this improvised process.

Always, as it could not possibly be otherwise in such a complex process, the motivation and impetus for the transfers was of general policy and not so much for health reasons. Let us think, as an example, of how important the referendum in Andalusia in 1980 was, which in practice blurred the differences between article 151 of the Constitution, initially intended for Catalonia, the Basque Country and Galicia, and article 143, for the rest of the autonomies. That referendum activated the transfers to Andalusia, made immediately after the initials to Catalonia. Or the will of President Aznar to quickly close the process of health transfers, as has been told by some of its protagonists ([1]).

There are many discussions about whether health transfers were required by the Constitution or not. Although personally I think not necessarily (at least, as it was done, to the 17 autonomous communities), this is a debate that leads nowhere.

Surely, the most important reason for the transfers is that this approach was more consistent with a State of the autonomies as it was being constituted, in which it is logical that the services be transferred.

In any case, transfers are an irreversible process. It does not seem that some statements proposing to return Public Health competencies have the slightest viability, beyond political rhetoric ([2]). Therefore, the logical approach is to try to take full advantage of its potential, minimizing some possible negative elements, of disintegration of the National Health System.

The transfers were made without previously defining cohesion instruments

What do we mean by cohesion instruments? To certain organizations (generally known as Agencies), whose basic characteristics are a certain independence from political power, a high technical and professional level, and extensive participation in their governance by key agents, all with the aim of providing support strong technical approach to certain system problems.

These types of instruments have been implemented in many countries, even in some with highly decentralized health systems.

We refer, for example, to the Agencies for quality and clinical activity ([3]); drug evaluation ([4]); public health ([5]); evaluation of medical technologies ([6]); transparency and dissemination of information ([7]); promotion of e-health ([8]); promotion of patients’ interests ([9]); etc.

The Law of cohesion and quality in 2003, after having completed the transfer process, therefore a posteriori, wanted to address the problem of cohesion. But it did so with some instruments (service portfolio, comprehensive plans, High Inspection) that proved ineffective. Regarding the portfolio of services, an independent Agency was not added to guarantee its updating; comprehensive plans, while interesting, are of limited effect; and, as for the High Inspection, from the beginning it was not a useful instrument, given its rejection by the autonomous communities.

The main problem: the absence of a definition of what are and what are not attributes of the National Health System

It must be taken into account that health transfers are not only an administrative decentralization, but a political “devolution” ([10]), which means that communities must be able to define their own priorities and how to achieve them.

This means that uniformity is not a value of the National Health System, rather the opposite, diversity is a value.

Now, for it to be truly a System, as defined, and not a set of systems, the National Health System must have some common attributes, on which little thought has been given. Even without a rigorous legal analysis, we consider common attributes of the National Health System:

  • Universal coverage
  • Public funding
  • The common service portfolio
  • The mobility of professionals, which implies common training aspects
  • Some elements (not all) of the care model, such as the operation of primary care as a gateway to the system
  • Since the services must be open to the entire population throughout the territory, the sharing of certain clinical information, such as medical records, unless you want to do “anonymous medicine”.
  • Likewise, the implication in certain common decisions of the National Health System, what has now been called “co-governance”.

If all this is common, what is left to the powers of the autonomous communities? Many things: whether or not to prioritize health in the public budget, beyond a minimum that guarantees compliance with the portfolio of services; the portfolio itself, adding or not benefits to the common portfolio; the management model (from this perspective, the intention of the Ministry of Health to declare direct public management as “preferential”, included in the Preliminary Bill of Equity, Universality and Cohesion, in process when these lines are written, seems to us an attack on the powers of the autonomous communities); many aspects of personnel policy (remuneration framework, incentives, professional categories, selection and evaluation process, etc.); elements of the healthcare model itself; relations with the private sector, etc.

What is important is to be clear about the rules of the game.

Transfers and dissolution of INSALUD

It is not only that health services were transferred simultaneously to the ten communities that had not yet received them, it is that INSALUD was also dissolved.

With all its possible flaws, INSALUD was an important technical buffer. These functions were not replaced by anyone, since the Carlos III Health Institute, which could have assumed these functions, never did, beyond supporting research; and the Ministry of Health, very limited in its capacities, was never a technical body, but rather a political one.

Thus, the transfers were made without the communities having a technical body of reference, which is all the more serious since the majority of the communities that received the transfers had less than two million inhabitants and their administrations were under construction, with which its capacity to set up highly qualified technical bodies was more than limited.

Thus, the transferred health services were left to the exclusive discretion of a political leadership, not always aware of the complexities of the health world, which acted without technical checks and balances, an ideal breeding ground for all kinds of errors and wrong decisions.

Positive and negative effects of transfers

Before we get into these topics, we should mention what we don’t think are transfer issues. Sometimes the great differences in health financing of the autonomous communities or the inequities in resources, results and access as a consequence of the transfers are adduced. Nothing more uncertain. These problems were already there before the transfers and it does not seem that they have aggravated them either ([11]).

Among the positive effects, surely a more accurate understanding of the territorial problems of health, very difficult to understand from centralized organizations, which tend to see everything from the perspective of a certain uniformity. Also an incardination of health in regional projects, very important, since health must be framed in health policies, which are intersectoral by definition.

But, along with these positive effects, the negative ones are very evident:

  • We have already commented on the problems arising from the way transfers are made, without the existence of a technical support body, with the consequent dangers of this situation, due to excessive dependence on political decisions not nuanced by solvent technical support.
  • There has been a clear phenomenon of centralization in the Regional Health Services, with a brake on some ongoing movements of autonomy of health organizations (public companies, foundations, etc.) that were stopped cold, accentuating the more administrative features and bureaucratic of the system. The latest unfortunate episode of these characteristics is taking place in Andalusia, where the government of the Junta is dismantling the initiatives of public hospital companies, under the pretext that they were “chiringuitos”, but that conceals a distrust in the slightest autonomy of healthcare organizations.
  • A brake on reform initiatives. An unintended consequence of the transfers is that there was a parking lot for the great pending reform issues (management model, personnel regime, etc.). Let’s say that the Ministry was inhibited, since “everything was transferred” and the communities saw that as problems that did not concern them. The consequence is that many key issues are no longer on the political agenda.
  • Cohesion problems, due to the lack of adequate instruments. The absence of the creation of a general information system of the National Health System; the failure of medical record interoperability; the important differences in quality and results in the different autonomous communities; and, an extreme opacity of the health system as a whole, are just a few examples.

It is good to be aware of these problems, not so much to question the transfers, which seem irreversible to us, but to lay the foundations that allow us to take advantage of their full potential, minimizing their problems and guaranteeing the attributes of the National Health System.

“Co-governance” during the pandemic, although improvised and poorly organized, offers some lessons

During the pandemic, the use of the term “co-governance” became widespread. Regardless of the use of this concept to justify the inhibition of the central government in certain decisions, the truth is that the concept has a basis of truth: the limitations of the Ministry of Health to exercise leadership alone in the National Health System, if it is not by sharing it with other organizations, institutions and groups.

The mistake is to have applied “co-governance” only with governments (those of the autonomous communities, in the Interterritorial Council) and not with the group of agents in the sector. Making a play on words, we could say that there has been “co-governance”, but not governance, as this is interpreted as the participation of the different agents.

But it must be recognized that there is truth in the concept of “co-governance” and that, well defined, it can be a solution.

The false solution of giving executive character to the Interterritorial Council of the National Health System

Faced with the problems of a totally decentralized Health System, some ([12], [13]) propose giving executive powers to the Interterritorial Council, something that it never had since it was always a coordination body, not an executive one.

We believe that the problems of the Interterritorial Council of the National Health System are not the lack of enforceability of its decisions, but rather that of “feeding” its activity with two important “inputs”: those derived from the participation of all the agents in the sector and the information and technical positions from specialized technical bodies.

Giving executive powers to the Interterritorial Council of the National Health System will surely bring more problems than solutions and seems difficult for the autonomous communities to accept.

A forum where the government shares its decisions on the National Health System with the autonomous communities and where both the central government and the autonomous communities receive the “input” from both the representation of the main agents of the system, and the technical bodies seems to us something much more effective than a theoretical “enforceability of their decisions.”

A proposal: strengthen participation and implementation of cohesion instruments

The key element to take full advantage of transfers and neutralize the problems that have been detected is to provide the National Health System as a whole with a well-defined and mature governance model, based on a much greater participation of the different agents and to provide of cohesive organs.

Regarding participation, it would be a question of modifying the composition of the Interterritorial Council of the National Health System, giving entry to it to a citizen and patient representation; as well as professionals, mainly represented by scientific societies.

As for the cohesion bodies, they should be constituted through a multi-agency system, model AIReF (Independent Fiscal Responsibility Agency). At least the following:

  • Information, Evaluation and Quality Agency
  • Public Health Agency
  • Agency for digital transformation

This approach would make it possible to resume a reformist agenda, fundamentally in the two major issues forgotten in the General Health Law: the management model, so that health institutions move towards a more businesslike and less administrative operation; and the personnel system, in order to overcome the rigid statutory model and gradually set up more flexible forms of relationship between professionals and the system.ties

 

[1] Statements by Rubén Moreno, “Lights and shadows of transferences: 15 years later”, El Médico Interactivo, 3/22/2017, https://elmedicointeractivo.com/luces-sombras-transferencias-sanitarias-15-anos -after-20170322125517110945/ (accessed December 9, 2021)

[2] Vara proposes that the regions return public health competencies to the Government

El Periódico de Extremadura, 10/17/2014, https://www.elperiodicoextremadura.com/extremadura/2014/10/10/vara-propone-regiones-devolven-competencias-44585804.amp.html (accessed December 9, 2021 )

[3] Care Quality Commission, in the United Kingdom; National Agency for Quality Assessment in health and social organizations, in France; Institute for Quality and Efficiency, in Germany; National Institute for Health, in the Netherlands; Agency for Health and Social Services, in Sweden

[4] NICE, in the United Kingdom; Drug Evaluation Council, in the Netherlands; the Agency for Medicines, in Norway; the Agency for Medicines and Dental Products, in Sweden

[5] Public Health Agency, in France; the National Institute of Public Health, in Italy; the Norwegian Institute of Public Health, in Norway

[6] Agency for Medical Products, in Sweden

[7] Agency for information on hospital care, in France; the Institute for Quality and Transparency, in Germany

[8] ASIP Santé, in France; the Swedish Agency for e-health, in Sweden

[9] Healthwatch England, in the United Kingdom

[10] “Devolution” is the term used for this type of transfer to territorial entities with political autonomy.

[11] López-Casasnovas, G, Rico, A

Decentralization, part of the health problem or its solution?

Gac Health 2003; 17(4):319-26

[12] Martínez García, JM

Lights and shadows of the current health decentralization in Spain

Giménez Abad Foundation, June 26, 2019

https://www.fundacionmgimenezabad.es/es/luces-y-sombras-de-la-actual-descentralizacion-sanitaria-en-espana (accessed December 10, 2021)

[13] Appearance of the Collegiate Medical Organization in the Commission for Social and Economic Reconstruction of the Congress of Deputies, 6/2/2020

https://www.congreso.es/docu/comisions/reconstruccion/informes_comparecientes/390_20200602_DC_Sr_Romero_Aguit.pdf, (accessed December 10, 2021)

What if there was another pandemic?

/in /by

 

 

PDF of the article published in La Razón:

La Razón, ¿Que pasaría si hubiera otra pandemia?

On January 31, 2022, coinciding with the second anniversary of the diagnosis of the first case of COVID in Spain, which took place on January 31, 2020 in La Gomera (Canary Islands), the newspaper La Razón published the following article:

 

What if there was another pandemic?

A great crisis for a new government

The first case of COVID in Spain was confirmed on January 31, 2020, exactly two years ago. The new PSOE-Unidas Podemos coalition government had been constituted on January 7, 2020, therefore very few days before the appearance of the crisis. It was a government of ideological confrontation rather than management, with a precarious and heterogeneous parliamentary majority, which made any parliamentary initiative difficult, and unwilling to reach agreements with the opposition.

Possibly the worst of the political contexts to address a crisis of these characteristics, where technical competence, the ability to promote legislative initiatives and obtain the support of Parliament for certain measures and the achievement of wide-ranging agreements, were key.

Great health and economic impact

With data as of January 28, 2022, obtained from the Coronavirus Resource Center of Johns Hopkins University, Spain is one of the countries with the highest mortality from COVID. With 197.05 deaths per 100,000 inhabitants, excluding a few countries, such as the United States, Belgium, Italy and the United Kingdom, most of the developed countries and almost all European countries had lower mortality per 100,000 inhabitants than Spain. We refer to France, Portugal, Austria, Sweden, Luxembourg, Switzerland, Germany, Ireland, Canada, Holland, Denmark, Finland and Norway, to name just a few.

But it is that in economic impact Spain also stands out. In a recent report by The Economist published on January 1, 2022 and in which the evolution of different economic indicators during the pandemic in 23 countries is compared, it is concluded that some countries have performed especially well, such as Denmark , Norway and Sweden; United States reasonably well; other European countries such as the United Kingdom, Germany and Italy, clearly worse. But the worst of all was Spain.

Two phases in the management of the pandemic: from “single command” to “co-governance”

In its initial phase, there was too much trust in the well-known strengths of the Spanish system, some weaknesses of the system were not taken into account (such as the precariousness of Public Health), there was a late reaction, we faced serious problems in purchasing material , there was a high number of infected and dead professionals. For a long time we witnessed a shortage of tests and there was no general approach to carrier detection or tracking of those affected and there was a lack of special approaches for risk groups.

In the first wave, the Ministry of Health is awarded the “single command” of the crisis, based on the state of alarm. But this Ministry had been almost irrelevant for decades and had a weak management capacity, as evidenced by the purchases that it initially intended to address in its entirety. Nor did it articulate a dialogue and participation with the different protagonists of the sector. Serious problems of the information system were evident. The communication policy was not always successful.

Having overcome the state of alarm, in the rest of the waves, the government learned the lesson of the high costs of managing a crisis of these dimensions, and went from being the protagonist to being almost inhibited, improvising a so-called “co-governance”, which in the practice consisted of holding regular meetings with the autonomous communities, leaving almost all decisions in their hands, including some that, because they affected fundamental rights, were later annulled by the judges. Then “co-governance” without governance was invented, since the only interlocutors were governments, but not the rest of the groups, agents and protagonists of the sector, as governance is understood.

When the time came, everything was trusted to the success of the vaccination, which was shown to be an error in the face of the new “ómicron” variant.

Even with very high figures for COVID, both the Government and the SEMFYC are committed to “influenza-like approach”, that is, downplaying COVID by considering it similar to the flu, something rejected as premature by both the WHO and the European Union. It is hoped that COVID will become “endemic”, as if, for example, the malaria endemic had not caused 600,000 deaths in 2020.

What if there was another pandemic?

It seems clear that the pandemic is not an exceptional or unrepeatable event, what is usually called a black swan, but rather we live in a world where, in the last two decades, there have been epidemic outbreaks every three years (SARS, H1N1 avian influenza, MERS, Ebola, Zika, etc).

What would happen if, as Bill Gates warned last week or some virologists like Christian Drosten, a new pandemic arrives?

It would happen that the problems that we encountered two years ago have not been resolved: the Public Health Center that is announced does not respond to the approach of an independent Agency proposed by SESPAS and many other groups; governance of the health system has not been addressed; nor the participation of professionals; nor the relations between science and political decision makers; nor the information system; and, surely neither essential supplies. Everything is entrusted to the arrival of “Next Generation” funds, but without addressing the necessary reforms.

Healthcare: “co-governance” without governance

/in /by

 

See PDF of the article:

Sanidad: «cogobernanza» sin gobernanza

Article published in “La Razón” on December, 24, 2021.

During the pandemic, the use of the term “co-governance” was generalized. Regardless of the use of this concept to justify the inhibition of the central government in certain decisions, the truth is that the idea has a truth fund: the limitations of the Ministry of Health to exercise solo leadership in the National Health System, if It is not sharing it with other organisms, institutions and collectives.

The error is to have applied the “co-governance” only with governments (those of the Autonomous Communities, either in the Interterritorial Council or at the Conference of Presidents) and not also with the set of agents in the sector. Making a game of words, we could say that there has been “co-governance”, but not governance, as this is interpreted by the participation of the different agents.

The National System of Health needs a governance model, particularly after transfers and especially after its generalization in 2002, which were done without the previous creation of cohesion instruments, as well in other countries, also with very decentralized health systems. The Law of Cohesion and Quality of 2003 tried to introduce, a posteriori, some instruments of cohesion, but these were ineffective.

When we talk about governance, we refer to the decision-making process, especially in complex organizations such as the National Health System, where it is necessary to take into account two apparently opposed values: the preservation of general features of the system, which identifies it as such , and, at the same time, respect for the exercise of political autonomy in health by the Autonomous Communities.

In this complex framework of governance, it is necessary to ensure at least two things: an involvement of all agents of the sector (patients, professionals, companies linked to the sector, etc.) and having a permanent advice on very complex issues based on criteria of high and recognized technical and professional level. This is what in other countries have resolved with the creation of independent agencies on very varied problems: agencies for quality and clinical activity, medicine assessment, public health, medical technologies, transparency and dissemination of information, impetus to The e-health, promotion of the interests of patients, among others.

In the absence of this governance framework, with pandemic and without pandemic, the ideal culture broth is generated for all kinds of errors and wrong decisions.

Is why it should be proposed to advance in the governance of the National Health System, in the first place, articulating the participation of the different agents at all levels, but very particularly in a renewed Interterritorial Council, of preceptive consultation consultation Decisions And taking advantage of a multi-agency system, AIREF model, at least the following: Information, Evaluation and Quality Agency; Public health agency, and, agency for digital transformation.

This approach would allow addressing a reformist agenda, something absent in the National System of Health for years. Precisely to prepare for possible new pandemics, as well as to rethink the two major themes forgotten in the General Law of Health: the management model, for health institutions to advance towards more business and less administrative operation; and, the personnel regime, to overcome the rigid statutory model and ride more flexible forms of relationship of professionals with the system.

In health always have a lot to say governments. This happens in all countries. This is how it should be like that. Even in the United States, where,  for the first time in its history public health spending has exceeded the private in 2020. But health is not a subject only from governments. It is also a matter of patient associations, scientific societies, academic institutions, of companies linked to the sector, etc.

An improvised “co-governance”, which also comes and goes as the figures of the Covid evolve, designed rather to protect themselves from the wear of certain measures or the absence of them, is not the answer.

In summary, there can be no “co-governance” without mature governance in the National Health System.

Seniority or merits?

/in /by

 

 

Article published in the daily “La Nueva España” (Oviedo), June 2, 2016

Seniority or merits?

These days we are witnessing in Asturias an acute controversy following the incorporation into the Asturias Central Hospital, the largest hospital in the region, of 70 doctors based only on seniority criteria.

The reason for the controversy is that service chiefs have rejected the procedure, considering that the merits and needs of the hospital should have been evaluated, while unions rallied strongly in favour, reckoning that seniority is a good approach and a way to avoid arbitrariness.

I do not intend to fall into primary anti-unionism, but rarely has the negative role that unions have been playing in the public health sector over many years, to the point of becoming a serious obstacle to the necessary reforms, been viewed so harshly. The so-called “professional” unions are no exception, but often even adopt more radical positions. I am obviously not an advocate of the disappearance of unions, but of a union practice that is not incompatible with intelligence and common sense.

But agreeing with the service chiefs does not end the debate, if we don’t consider other points.

First, the statutory regime itself, which assimilates health workers in the public sector to civil servants, hyper-protectionist towards sector professionals. The concept of “tenure” creates asymmetry in professionals / management logic, in favour of the former, which often prevents the slightest management and change implementation. Moreover, the egalitarian culture, linked to the statutory regime, reluctant towards differentiation and individual and collective recognition is also very negative. Like many hyper-protectionist regimes they turn against the interests of those who are to be protected, especially the most active and motivated professionals, giving priority to the interests of the uncommitted. Thus no reform of the public health sector can be envisaged with the statutory regime, which should be declared extinguishable and, respecting vested rights, new recruitments made via the ordinary labour regime. Only then will the concepts of regular evaluation, promotion, career and variable compensation, which are so necessary, make sense within the context of a fully-fledged personnel management policy.

Another element that is implicit in the debate is the autonomy of hospitals and health centres. This is an issue that arose in the 80s and 90s of the last century, but was forgotten about with the healthcare transfers to the regions. With them came the hegemony without limits of the regional ministries and progress towards the autonomy of health centres was shelved. But there can be no modernization of health centres if they don’t have a minimum capacity for certain organizational decisions, personnel and adapting their healthcare offer.

Finally, the issue of governance, which includes a government / management separation. The managers run the company, while the government (council members) ensures that management is correct and that it goes in the right direction. And with the board intervening in the selection, evaluation and removal of the first manager of the centre. Only thus can a fully-fledged management system be guaranteed. A step in this direction is taking place in the Basque Country and in a recent resolution of the Assembly of Madrid.

Seniority or merits? Of course, merits, but only within the context of overcoming the statutory regime, autonomy of institutions and governance that understands the distinct role of government and management.

What is meant by industrialization of medicine

/in /by

 

 

New Medical Economics magazine has presented me with an interesting challenge, which I would like to thank them for most sincerely. To summarize the contents of my recent book “Doctor or robots? What lies ahead in medicine ” in about 800 words. [1]. Given that the book has nine chapters and more than three hundred pages, you can understand that the task is not easy.

The book’s title may confuse, but what it is about, in essence, is the industrialization of medicine.

It is part of the realization that medicine and health are today a major economic sector but whose core activity, the doctor / patient relationship is still handmade, that is, influenced by the personal characteristics of the artisan, in this case the doctor.

This, in pre-industrial times, in which the doctor / patient relationship was practically the only healing activity, it was understandable. I’m a man who is alone with another man, as on a desert island, said a famous Berlin clinician in the nineteenth century. But it so happens that, in recent times, the patient/ doctor relationship remains the core business of medicine, albeit now surrounded by a very diverse set of institutions and public and private companies (administrations, insurers, pharmaceutical companies, medical technology companies , hospitals, several laboratories, etc.). A whole complex sector in industrialized countries that ranges between 9-10% of GDP (18% in the US). Hardly a desert island, this doctor / patient relationship is now more like the crowded cabin of the Marx brothers in the famous movie “A Night at the Opera”.

There is a possible contradiction between this major industrial sector and the core business on which it is based, that is the doctor / patient relationship, determining largely, quality and cost of the offered care.

How will this great sector be established on a craft- based activity? As the industrial sector, institutions, companies, and patients require predictability in quality and costs, exactly what the artisanal sector cannot offer. So we say that in medicine industrialization occurs late in relation to other sectors.

What is industrialization ? Let’s start backwards, by what it is not. The word industrialization is a simple word that scares doctors , who often interpret it as depersonalization. But nothing could be further from the truth. Medicine is and always will be the application of general medical science to the characteristics and preferences of each individual.

What then is industrialization in medicine? It is the transformation that occurs in the doctor / patient relationship as a result of three phenomena: incorporation of technology, standardization of processes and change in professional roles.

The patient/ physician relationship will remain a private, not public, relationship, but, and here’s the big change, under scrutiny. The doctor no longer responds only to himself and to colleagues like in traditional professionalism, but to the set of institutions and companies operating in the health sector, that without being physically present in the doctor / patient relationship, bring value to the same and have a right to know and assess both the quality and the cost generated as a result of such relationship. The electronic medical record allows this scrutiny, impossible to do when the doctor / patient relationship was hidden in paper.

Of the three major components of the industrialization of medicine, the most difficult to accept and implement, and which will encounter greater resistance is the change of professional roles. It will be much easier to incorporate technology and process standardization. We assume that many of the tasks that are actually carried out by a doctor can be replaced by machines (computers and robots) and others can be carried out by many other professionals, mainly nurses. So, what is left as the doctor’s role? Something fundamental: communication with the patient and the orientation of complex cases. The doctor must engage in “narrative medicine,” helping patients to develop their own narrative of their illness. The great efficiencies we see in some Indian health institutions (Aravind, Apollo, etc.), which manage to carry out certain interventions at less than a tenth of the cost in Western countries, are brought about, precisely, by the judicious use of medical work, replacing what may be substituted by the work of other professionals.

This is the book. To situate this great change in the history of medicine; analysis of the drivers of this change; and its profound impact on professionals, institutions and health policy.

[1] Ignacio Riesgo

¿Doctors or robots ? What lies ahead in medicine.

Editorial Rasche, 2015

The cuts’ victims have been the professionals and the pharmaceutical industry

/in /by

 

Interview published in La Razón, November, 2014

“The cuts’ victims have been the professionals and the pharmaceutical industry”

He makes up the founder group of VPR, that stands up for Julián García Vargas, former Spanish Minister of Health; Xavier Pomés, former Minister of Health of Catalonia; and Ignacio Riesgo, three people with long and varied experience in healthcare. Their intention is putting their “know-how” at the service of healthcare institutions and companies that may be interested.

In your opinion, what fails in the National Health System in Spain?

It’s a healthcare system similar to any other of the European countries. All of them have the same problems: they were created for a different moment, basically the central years of the past century, when there wasn’t nor the current aging of the population, nor the predominance of chronic diseases, nor the great technological resources, nor a so demanding demand and, therefore, such an elevated expenses. All of them have to face reforms to be adapted to the new situation, what isn’t easy at all. But, inaction is not an option.

What are the strengths and weakness of this model?

The strengths are: well trained personnel; care network with good technological funding; basic equity in the access; and, high appraisal for the population. The strengths are important, but the weaknesses aren’t minor ones: problems of governance and leadership and absence of political will to face certain actions to modernize the system; financing, because healthcare is not only paid by taxes but by taxes plus debt; obsolete organizational and management framework; regulation of the labor conditions of the worker, similar to civil servants; lack of orientation towards chronic patients, that are the majority ones today; long waiting lists and scarce development of social services linked to the healthcare ones.

How could the mistakes been corrected in order to achieve a cost-effective system?

Any reform must be contemplated in the framework of a National Strategy of Health. There are elements that should be preserved, as the predominantly public financing; the universal coverage; the existence of a common package of services for all the national territory; the excellent network of centers we have; and, do not forget it, the industrial capacities (mainly pharmaceutical and medical devices ones) and of R&D created around the National Health System. But, there are also elements that should be reformed in depth: the management system; the personnel regulations, avoiding the regime that equals healthcare personnel to civil servants; and the coordination between levels and services, included the social ones.

How should and can coexist public and private healthcare?

This is a key issue. It’s necessary not only to coexist, but also to cooperate and to articulate both insurance systems. I can’t see a reform of the National Health System without collaboration between the public and the private sectors. That’s not easy, since private companies have to understand some public priorities and the public administration has to understand certain requirements of the private companies, everything under a long perspective and in a framework of legal stability. Having said that, the public sector needs reforms, but the private one needs modernization. I belong to a medical generation that has been historically criticizing the private healthcare sector, because it was the public sector the one that modernizes the medicine in our country. But we can’t jump from the tendentious criticizism to the complacency. To see things in perspective, most of our private sector is under the fee-for-service situation in the United States, previous to the managed care approach that spreads from the 70’ of the past century. This model has an incentive to do more, be it necessary or not, just the contrary of what we need. Managed care is the way our private sector has to go on if it want to play a major role collaborating with the public sector, something that is totally necessary. I don’t want to end this point without saying that the MUFACE system represents the germ of a substitutive model, which must be preserved and boosted.

Where should continue the cuts and where we have to invest?

The economic crisis was a total disgrace for our healthcare system. Healthcare expenses have been decreasing in absolute figures every year from 2009. The victims of the cuts have been the professionals and the pharmaceutical industry and, of course, the patients, who suffered worse services and longer waiting lists. There has been an authentic shock therapy, whose consequences someone will have to analyze. After seeing the forecast of the Stability Program (to go from 6.2% of GDP in public healthcare expenses in 2012 to 5.3% in 2017), I’m concern if the same cut techniques are going to continue and be applied on the same groups. The moment has come to split hairs. We have to deal with waste or avoidable expenses, understanding by avoidable expenses the ones that don’t give any value to the patients. All the analysis says that in healthcare systems between 20 and 50% of the expenses are wastes. And the main amount of avoidable expenses is the own medical practice (laboratory tests, imaging studies, medications, unnecessary hospitalizations,). It makes me laugh when I heard that healthcare expenses are going to be contained with a purchasing platform. Obviously, to be able to be effective against waste it is an absolute requisite to have a permanent alliance with the professionals. Without that, there is no option to contain costs without producing a degradation of the system. But that requires a very mature clinical leadership. Without underestimating the role of the Finance Ministry, I think it’s dangerous that in this task act only that Ministry, without the active intervention and commitment of the Health Ministry, willing to play the role of strategic leadership of the National Health System, not living back to the system with the pretext that everything has been transferred to the Regions, as has been happening in the last few years.

Concerning healthcare professionals, what can we do to avoid their emigration?

First thing we should say is that Spain doesn’t have a deficit of doctors, although it has a deficit, and very important, of nurses, which is paradoxically compatible with unemployment in nursing. The current medical education policy forces a high number of new medical graduates to unemployment or emigration. It has been a total madness that our country has 40 Medical Faculties, 12 of them created in the last five years.

The training of the Spanish professionals is quite good, but how could it be improved?

The MIR (interns and residents) system is one of the assets of the National Health System. I think that the recently decree developing the core subject group is going to be a real improvement.

The announced Law about Professional Orders, how can influence the development of the profession?

Apart from the Law, what we need is Professional Orders inspired on the criteria of the “new professionalism”, in other words the values of transparency and accountancy, against the values of the “old professionalism” of autonomy and auto regulation.