Last weekend the Club de los Viernes held an open house in Madrid, which I had the pleasure to attend. The agenda included a conference on the future of healthcare, with recognized speakers, gathered at a round table where the current challenges faced by this sector were highlighted, such as the involvment of the Public Administrations. This was the contribution that I made and that I would like to share also in my blog and reflect on it.
(…) I think there is indeed a general consensus about public health being an asset of Spanish society. Yet, the true asset lies in the values of our public health: free, universal, available to all, accessible…However, we have to question the management of public health. Is it the best that it can possibly be?
I don’t think so. Above all, we can’t manage such a complex system, to which we dedicate roughly 9% of the GDP, just as we did 50 years ago. There are many people, with their new policies, who put forward suggestions that are quite old and, generally speaking, have previously failed. And it isn’t an ideological assertion. Pressure regarding the cost of state welfare is something that both Spain and the rest of the world face. Issues such as the appearance of new diseases, chronicity, new technologies and ageing are global. And in each country we see reforms being introduced.
…Reforms that I think have three points in common. Firstly, the introduction of public values, whereby a basic service is given to all citizens in a sustainable way. This is done because it is essential that we manage well in order to give our children the possibility of benefiting from it in the future. Secondly, there are increasingly higher levels of specialization. This, as far as I’m concerned, is very important. I equally believe in the importance of mobile phones, which nowadays the whole world carries around. It’s technology that is available to everyone and it will have a strong presence in the future of medicine and will influence innovation more than big hospitals that were constructed 20, 30 or 40 years ago, or even those built recently.
Thirdly, we have to move towards much more flexible models. The level of specialization and the response that we will have to provide to the problems that we are going to face in the coming years is not on Spain’s agenda. The United States have introduced reforms through Obama Care. The United Kingdom have created their Five Year Forward View. Holland, Argentina…many countries are introducing reforms. Yet, Spain insists on not doing so and on maintaining the status quo that is only going to lead to the decline of the public system.
I reiterate: this is not an ideological issue. Of the four pillars of the welfare model: education, health, pensions and unemployment, two at least are directly related to the demographic. The pension debate is still on the table. Politicians say that it isn’t a problem, but we all know that it will be. And we have to face the health problem with new ideas and new approaches to new challenges. It isn’t ideology, it’s demographics.
I would also like to talk about the citizen’s capacity to choose as it is clear that the State seem to monopolize decisions. However, when the citizen is given a choice, they are clear about what they want. We have an example of public-private collaboration every year with the Muface model, a model in which the citizen values choosing for themselves rather than having decisions made for them by society as a whole. What is more, 85% of them decide to opt to receive care through private companies. And in the last few years, with budget restrictions, until the unions of officials asked the government to increase the price of these “wicked private companies” that look after their health.
And if we now shift our focus to co-payments, they already exist in Spain. A quarter of the population has private health insurance which they can use to be dealt with quicker. And, if not, they can use the public health system. This truly sets Spain apart from other countries and it is an authentic co-payment that is not acknowledged by the government, despite the fact that it results in public health savings.
The big “defenders of public health” seem to want more and more citizens to have private insurance because of cost restrictions that are involved in a complicated situation.
I appreciate what has been said about the Alzira model. I’m not going to add anything further. However, I would like to make a few comments about the attitude of the citizens when they have the ability to choose and when we ask them what their priorities are regarding the health system. A few weeks ago the Valencian government presented a survey showing public preferences in relation to health. Although it may not seem true, the first priority was the reduction in time spent on waiting lists. The second was the hiring of more doctors. The third, a reduction in cost and co-payments. The fourth, the dedication of more resources for disease prevention. A mere 5% had the overturning of contracts as a priority. Does this seem strange to you? It doesn’t to me because for 15 years we have been reiterating that citizens care not about who manages them but how they are managed. Citizens want quality public and accessible services that give solutions and make their lives easier.
At the same time, we are in a debate about concessions and a public-private collaborative model, a collaborative model that forms part of other areas of our lives like water. When someone turns on a tap, they don’t wonder about whether the water is public or private.
The pharmaceutical model is a public-private collaboration, as is health and social care. And there are many other areas…The concentration of attacks on these models from quite sectarian sectors is difficult to understand because sometimes they even go against their own information. Due to this there is a need for transparency in the system. Those who believe in quality and sustainable public health agree that transparency is essential.
Less than a year ago, the Valencian government asked the public auditor to study the public private collaboration model and this generated five conclusions. Firstly, in terms of Valencian taxes, they were savings of 25%. Secondly, the satisfaction index for the service was higher. Thirdly, better care quality. The fourth point was that rather than 120 days on a waiting list, it was now 40. And the fifth, was that it was double the investment per capita. Do you think we received any praise? No. What we did in fact receive was a notification for the termination of the contract.
For this reason it is important for politicians to think about citizens when they speak about health and that they make informed decisions based on consensus.
Predictions for the future? We are in need of a new human resources model. If it is our main asset, we have to make it a focal point in our system. Technology. We greatly need to introduce technology into the system. The future is not in these big buildings. It is at home, connecting people and providing easy access to both the citizen and the professional.
The re-organization of the system. Integrated health models in hospitals and Primary Care. The sharing of services between hospitals. In Madrid there is a lot of expertise in the central laboratory and six hospitals with which they are connected that we are fortunate enough to manage. And with savings of 50%.
Not all hospitals have to do everything. There are capitative models which are capable of aligning themselves with the public Administration objective, which is to achieve the best state of health for the population. What is more, these models can align with all agents in the system.
There are three words that are fundamental at political and institutional level.
Transparency in the system. If we pay taxes, I want to be told how they are being used. Governance of the system. Less politicization, more professionalization. And a new role for the Health Ministry. Because this country cannot continue having 17 mini health systems. What it needs is a coordinated, managed health system in 17 autonomous regions. Thank you very much”.