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.