Pride of belonging

Several factors have been described as motivators of the Welfare State. From their interrelation, results are obtained that conclude in an improvement in the quality of life of its inhabitants, highlighting for its relevance: health and education. The predominant healthcare systems in Europe differ basically depending on whether or not co-payment is made at the time of using the services. The maintenance is made by the General State Budget and is the predominant, fortunately, in Spain. There may be extra differences between CCAAs and this affects not the quality, but the quantity of benefits protected for users.

The pivots on which the system rests are:

1-Patients. The economic maxim that the population makes rational use of resources is not always fulfilled. There are certain imbalances that are often attributable to human nature, or are threads acquired from the system’s own innate dynamics. Thus, it is difficult to understand that in the use of hospital emergency services, an excessive percentage of patients are classified in triage 5, meaning that their preferred place of care should be a different center than the one selected. Stewardship involves minimizing unnecessary demand (eg IRA)

The question arises if this can be prevented with health education measures. And the answer is: yes, but. The rhythm of life conditions us in such a way that tomorrow forces us to act today. And even more so considering that the average wait to be treated in a CS is 8.8 days (Spain) and such insane waiting lists that Saint Job would be dethroned as a symbol of patience

2-Doctors. Various organizations (Ministry of Health, OECD, World Bank) offer information on the number of doctors with very variable figures, because each organization measures different aspects, resulting in the unit of analysis not being comparable. In addition, the comparisons must be relativized, depending on variables that condition them such as geographic dispersion, hospitalocentrism, spending capacity and others.

Comparisons between countries are (almost) irresponsible because they also depend on the model that each country adopts to meet the health needs of its population. The fact that Italy (Source: World Bank) has 100% more doctors than Spain does not mean that the quality indicators in results are 100% better; far from it. Among the OECD countries, Spain ranks fourth in number of doctors/inhabitants, behind Austria, Norway and Lithuania.

Since the year 2000, the number of doctors in Spain has increased by 27%, while the population has increased by 8.5%.

In Spain there are 4.8 doctors per 1,000 inhabitants (Health Barometer 2022). Madrid (6.0) and Navarra (5.4) present rates well above the national average. The rate of physicians for early care is 4.4 per thousand, much higher than previous years. But we are in a country of contrasts, also in health aspects: in primary care 0.8 per thousand and 2.5 in hospital care

In the media, managers respond with “there are no doctors” to the complaints accumulated day by day in the operation of the system, mainly due to unstoppable waiting lists or unpaid absences. But are there really no doctors? There have never been as many as today, nor have there been as many medical schools (46) as there are today. So they don’t want to work? The answer is complex: there have never been so many doctors who emigrate to other countries (4,130 suitability certificates in 2021) and/or are poorly distributed (INE data: Navarra (5.4), Catalonia (4.8), Madrid ( 6.0).

If we base ourselves on the waiting list for some specialties, we do see bottlenecks, while in others the management is more agile. Relying on the waiting list to classify a certain specialty as deficient in human resources is to limit yourself to counting butterflies in the ocean

In primary care, it is common to agree on a clear deficit in economic resources (ADSP: 211 euros per inhabitant and year) and doctors (0.8 per 1,000 inhabitants) with similar data between CCAAs. This medical deficit is already observed in origin: they choose to carry out this specialty (almost) “by force” since they are the last places chosen. That there are no stimuli to carry it out entails an absence of pride of belonging; Several factors work against them: ignored by their peers, abandoned by managers, deflated by patients, insane workloads, paltry salaries, little time for training and no time for research activities. In no case should silence be an option and the loneliness of the manager transform into team captain

3-Waiting lists. They have their own entity; result of the lack of glue between the parts. They are both the cause and the effect of the inaction of some and the fatigue of others, mediating variables such as satisfaction, over-requests, unjustified excess of complementary tests, etc. with tangible results of more or less 14 million users who have opted, like a cry, for private insurance. The quality of primary care is well valued (7.8) but the delay of weeks/months in specialized hospital care entails extra pain and concern (Source: SNS; Navarra-109 days, Madrid- 56 days) And it is that when the pain tightens, Sancho Panza transforms into Thor.

4-Managers. It seems as if the aforementioned only have brave ideas (a very common term) when they are in opposition. If they are in power, the authority disappears because they are limited to survive and avoid any risk activity. Serve as an example that in the opposition everyone is positioned against the so blissful productivity, which is forgotten when they touch power; they even increase the budget in this activity

For years they have practiced the military parade as a method of action, distancing themselves more and more from the needs of the population.

Primary care is the paradigmatic matrix on which the system rests, its cornerstone. Strengthening it by restoring the pride that this entailed and fighting against its exhaustion should be one of its main objectives. And this requires promoting research, training and authority. It implies taking far-reaching measures that turn primary care not only into something desirable, but also represent a pride of belonging, in the antipodes of the current hospital-centric situation.

In macro terms, they are limited to activating the proliferation of medical schools, often with adjusted quality standards and promoting the arrival of medical professionals outside the European area without approved specialty titles. The misguided sense in a black hand that longs to return to the 80s.

They don’t want to be the heroes of applause, but neither do they want to be the pagan villains of management inactivity. Making changes in the service portfolio is unavoidable

Maintaining the public health system is a guarantee of the Welfare State, a cushion against social inequalities, but this implies substantial changes in the resolution of conflicts, already entrenched. The active participation of the links in the chain is the guarantee of a realistic diagnosis of the situation and of an adequate development of the available treatments. The Toledo Pacts on health represent a benchmark for action.

catharsis vs. charity.

The author is a doctor. Navarre Health Service. Osasunbidea

Pride of belonging