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The Ribera Salud doctrine

19 julio, 2021 • By

Last Thursday we were informed about the Supreme Court’s (SC) ruling number 952/2021’s regarding reversions and the adherence to the 2012 Budgetary Stability Organic Law and that the fact that it, without a doubt, affects the case started by the Valencian regional government for the internalization of the management of the University hospital of Torrevieja.

But allow me to share my thoughts on the aim of this case, because I think that it is so important that it goes beyond the specific examples of La Ribera Hospital, that of Torrevieja or the healthcare concessions. It marks a before and an after in the Spanish economic system and in the concessional model in any sector, and creates what, from now on, we are going to call “the Ribera Salud doctrine”.

And what does this doctine, that has set the standard with the Supreme Court’s ruling, consist of? I have summarized it for you into some key points which are included in the Supreme Court judges’ document.

  1. The Ribera doctrine has managed to set a limit regarding economic populism in Spain. From now on, governments cannot make arbitrary decisions without opening an administrative record which includes the strict economic and budgetary impact and is backed up with data. With this ruling, we have made sure that in the future decisions of an ideological nature are not made, without explaining and justifying the economic implications of that decision to citizens, as well as how their internalization proposal will affect the quality of services, in a transparent way.
  2. This Supreme Court ruling voids the previous ruling from the Valencian Community’s High Court of Justice (TSJCV), which stated that a government could make unilateral decisions, without any type of study or analysis of the impact of these decisions. With the Supreme Court case, this ruling is now void, something very extraordinary in the Spanish legal system and very very significant for the concessional sector in general.
  3. And I’d like to add something else. The Supreme Court’s ruling states that PRIOR to making a decision and PRIOR to any communication regarding the internalization of a service (the end of a concession), the administration has to compile a comprehensive and substantiated file, which includes the evaluation of the economic and budgetary impact of this decision. BEFORE MAKING A DECISION.

From my point of view, it’s a historic ruling, which marks a before and after in terms of the guarantees of a democratic state, opting for the legal safety of concessionaire companies and guaranteeing the strictness and seriousness of the government when making decisions that affect any public service that citizens receive.

I feel proud for having taken this issue to the Supreme Court and for having managed to void the ruling of the Valencian High Court, which endorsed arbitrariness in governmental decision making, when it affects a public service. It has always seemed bad judgement to us at Ribera and now the Supreme Court has shown that we are right by voiding it.

Today Spain is a safer country, from a legal point of view, and a limit has been set regarding economic populism. And I am happy to have contributed to a stricter, more serious and more objective scenario than that which existed previously. In my opinion, it is not acceptable that a decision on the scale of the reversion of the administrative concession is justified by appealing to a government agreement, whether it be the Botánic agreement or any other, and regardless of which parties form it. Governing for all citizens is a responsibility which should be carried out with seriousness, objectivity and strict criteria and, above all, by justifying decisions with reports and data, decisions that affect so many families and, in this case, thousands of patients and healthcare professionals. What is more, this is during a pandemic and healthcare crisis.

Furthermore, we are asking for European funds to get out of a very severe crisis and it is not logical or reasonable to ask Europe for funds on the one hand and on the other hand to ignore the saving, in the case of Torrevieja hospital, for example, estimated by the region’s Court of Auditors to be 45 million euros.

I also want to place value on the social contribution of the Ribera group. We don’t want medals, but one thing is for sure, thanks to this ruling, that we have taken to the highest body within our judiciary, we have prevented other companies that manage public services from going through what we went through. The concept of company freedom, institutional loyalty between administration and a concession, respect and legal safety is essential, and even more so in a country in which public private collaboration is a reality in many sectors. And I’m talking about infrastructure, energy, water, care homes, education, MOTs and, of course, healthcare, since healthcare agreements exist in many Spanish regions.

I’m aware that we have been like David facing Goliath in this legal battle and, for that reason, I feel especially happy that the whole organization has defended affected patients and professionals, as well as our providers, subcontracted services, collaborators and, ultimately, all those who believe and appreciate that loyal, sincere and quality collaboration is also in the citizens’ interests. We have, I reiterate, simply defended the safeguards of the rule of law.

Lastly, I want to say that we trust that the contribution of the “Ribera Salud doctrine” to a great nation such as Spain allows us, and future generations, to enjoy a freer and safer country to invest in, create employment, generate opportunities and offer quality services to citizens. A country in which the ideology doesn’t put limits on freedom, in which attitudes and decisions that attack sectors such as subsidized schools, care homes, pharmacies or the healthcare sector disappear.

We trust, and we have never stopped trusting, in goodwill, dialogue and loyalty to find the best solution together with the administration, and to keep guaranteeing a responsible health model and the best public healthcare service for patients in the areas that we manage.

This is, and always has been, our vocation.


For responsible health

12 julio, 2021 • By

In today’s blog I want to share an interview that I had recently with  La Voz de Galicia.

The Ribera Group and Centene’s commitment to the Galician Community has been evident for several years. We manage three hospitals there: Ribera Povisa, in Vigo; Ribera Polusa, in Lugo; and since just a few weeks ago, Ribera Juan Cardona in Ferrol. And it is for that reason that in the interview I express, once again, the methods to make the healthcare system sustainable and I firmly reiterate that it would have been impossible to respond effectively to the pandemic without the collaboration of the private sector. We are committed to a responsible health model, and that is the key to facing the challenges of the system and guaranteeing its sustainability. 

You can read the interview below.

The third biggest North American insurance company, the giant Centene Corporation, has three hospitals in Galicia, through , their Spanish affiliate, Ribera Salud. The executive director for Europe, Alberto de Rosa (born in Valencia in 1962, “the 17th, October, like Pablo Iglesias and  Isabel Díaz Ayuso”, he insists), reflects on the challenges of the healthcare system after Covid.

– The pandemic has brought to light the need for strong heathcare systems. What role can private healthcare play?

It would have been impossible to repond to the pandemic effectively without the collaboration between private healthcare and public administration. The sector has collaborated loyally. It is a lesson from this pandemic: we should seek lines of communication. We must rethink the healthcare system and the role that we want private healthcare to play.

If public healthcare would not have coped with everything, as is said, it could be interpreted that what is needed is to strengthen it.

Everything has to be strengthened. We have a great public system, with values that we all want to keep: universal, free and with equality. But the society in which we live has to be taken into account. 22% of citizens decide to take out private health insurance, in addition to the public system. Why? Because people want the peace of mind of the public system but they want to have flexibility, the ability to choose, the immediacy and closeness of the private sector. We want a strong public system and in order to get that we need an outstanding private system.

-It is strange, because in the 2008 financial crisis the number of people taking out private health insurance also increased. If the system were strengthened and waiting lists were eliminated, would there be less people insured?

– I am one of those who likes to speak less and less about public and private. It is motto that I want to introduce in the group: a responsible health model.

– What does it mean?

We have to look at the challenges that the system faces. The fundamental aspect is sustainability, both in the public sector, financed through taxes, and private, financed because people pay for it. Some insist on making distinctions, when people have a clearer picture. To sustain the system everyone involved has to contribute.

-You speak about re-thinking the system. Share your thoughts. 

We have to advance to a more digital health system. We were the first group to implement electronic records and we’re implementing a health portal. We have a healthcare system that was designed in the 80s, and society is different. The hospital has to break down its walls and have  more to do with primary healthcare, social services and the patient’s home. 

– How can the system be made sustainable?

There are challenges such as the evolution of costs, ageing, new diseases, technology etc. I would propose going back to doing what was done at the start of the 90s, the April report, in which the healthcare experts pool their ideas.

– Do you like the methods that the April report proposed? It spoke about co-payment, public-private collaboration etc.

I have never advocated for co-payment, it can be unfair. There are other ideas that I agree with. A lot of things need to be re-thought.

-In the 90s, Ribera Salud started the Alzira model: the Valencian Community was responsible for the management of the whole area of health, hospital and primary. Is that the model?

There are a lot of grey areas in healthcare. The model was very interesting for some specific situations. It worked very well, allowing multi-million investments. There are other forms of collaboration that have worked incredibly well, such as Muface, in which civil servants choose between receiving healthcare in the public system or in private companies, or pharmacy offices, for example.

– The PSOE and Compromís government let Alzira’s concession expire and they have already announced the same for Torrevieja.

Three years later, Alzira’s return back to public management was a disaster. Public data shows that it costs the Valencian Community 80 million a year more than before. Waiting lists have tripled. Citizens had quality healthcare. In the middle of a pandemic, it would be worth not trying to fix something that isn’t broken.

  • «We want to work very closely with Sergas» 

In October, Alberto de Rosa left his position as CEO of Ribera Salud to become the Executive Director of Centene in Europe. He says that he only asked to keep one position: that of the president of  Povisa’s Nursing School trust.

– They have bought three Galician hospitals in less than two years. Why this sudden interest in Galicia?

We had a very close relationship with Povisa for a long time and expanding into Galicia acquiring Povisa was an extraordinary opportunity, one of which we feel very proud. When we expand into a community, we study if there may be other opportunities. Polusa (Lugo) and Juan Cardona (Ferrol) appeared and we’re happy. But the initial idea was to incorporate Povisa into the group. When we started in Galicia we were only present in two communities (Valencia and Madrid), now in four (with Galicia and Extremadura) and I can now announce that we will soon be present in five.

– Which? 

I’m not saying any more. In the countries where we are present we are going to commit to continuing to grow. 

– In Galicia too?

We’re open to any opportunities that come up, but I’m not going to say anything else.

– You took over Povisa in December and the pandemic came in March.

It was very fortunate for the group, which received a great deal of help from Povisa, and I also like to think for Povisa. Groups can help in situations like this.

– What kind of relationship would you like to maintain with Sergas? Your three hospitals have agreements.

I would like to work very closely with them, helping them and providing them with ideas and initiatives that could be positive. The concept of loyalty is important for us.


Nurses, the soul of the healthcare centers

6 julio, 2021 • By

Last Sunday I had the honour of participating as the keynote speaker in the graduation of the CEU Cardenal Herrera University of Valencia’s 17th year of nursing. It was a very moving ceremony and it filled me with pride addressing the new nursing professionals, one of which was one of my children. They are very well prepared and, above all, they are eager to demonstrate that their profession is vocational and that they want to take care of our health from now on.

You can see my speech below.

Dean, Vice-Dean, members of the CEU Cardenal Herrera University’s teaching staff and educational community, and especially new GRADUATES and their families who are following us at home.

It is an honour to address you as the keynote speaker at the CEU Cardenal Herrera University of Valencia’s 17th year of nursing graduates.

Dear nursing graduates.

Today is a day filled with emotion and one in which I share the happiness of both what you have accomplished and what you represent as professionals within the nursing group to which you have joined as of today. For these reasons, I want to express my sincere congratulations and appreciation.

Today you have come to the end of your initial preparation in this great profession and have reached the finish line. Carry out your profession and your vocation with bravery and limitless devotion. But my duty as THE KEYNOTE SPEAKER is to tell you that, in practice, TODAY IS NOT THE END OF ANYTHING, BUT RATHER THE BEGINNING OF EVERYTHING. The start of the route that you have chosen for your professional life, is a route that, without a doubt, is going to be passionate, but involves great RESPONSIBILITY.

Allow me to address you as a man in the street, as a healthcare manager, and also as the father of a student from this year’s graduation.

As a citizen I want to begin by expressing my deepest gratitude. Thank you, thank you, thank you so much. This tragic pandemic has placed value on many things, the most important of which is, without a shadow of a doubt, the role of all of the healthcare professionals facing the biggest crisis of the last century with bravery and dedication. You have started to form, and have already formed, part of history, the best part of our history, being those brave people that studied, finished their studies and faced a terrible pandemic. YOU ARE TERRIFIC.

This pandemic has brought to light the importance of your role in the system. We have been able to see over the last year how people come to our health centers worried and afraid, and IT IS YOU that have been there and YOU that continue to be there on the front line of healthcare.

I could tell you a lot of stories about what has happened in our health centers during these tragic months, stories that are lovely, tough, HUMAN, examples of vocation and devotion, of personal and professional involvement etc. but what I will tell you is that there has always been a nurse in each and every one of these stories. I feel such pride.

This is because, in addition to treating this treacherous disease that has had to be faced alone, nursing professionals have accompanied patients at all times, they have held their hand when they have needed it and have dried many tears but they have also given the encouragement and hope that all patients, and their families, need at difficult times.

YOU ARE THE HEART AND SOUL of the health centers!

Friends. Health is the most precious gift that we have, and you, as graduates in nursing, are a key part of health promotion, disease prevention and patient recovery, in other words, of ensuring the well-being of our society. This is all done with respect, generosity, humanity, dedication, a strong work ethic and continuous training to which you have committed yourselves with your life choice: your professional career.

The word RESPONSIBILTY in professions that are vocational and focused on taking care of people, implies COMMITMENT, RESPECT AND MATURITY.

Remember what I’m about to tell you now.

You are going to be responsible for our health at the most difficult and delicate times of our lives.

We are going to put our lives in your hands.

We will trust you with our fears, hopes, wishes and plans.

I ask that you always treat patients, that you always treat US, with enthusiasm and devotion. And with care. With a lot of care. Patients, people that have a health problem, feel fragile at times. Or worried. Or alone. And the nursing staff is key for them.

Always put the patient above everything else!!

As a healthcare manager I have learned a lot over the many years I have been in healthcare, the importance of nursing within the healthcare system. Not only are people putting their health in your hands but also organizations NEED you to stay connected to the needs of the patients. You are the main asset of a healthcare organization, and in order to achieve the objective of excellent healthcare, active, well-trained and committed nursing will always be required. Due to that, ongoing training is essential and should be something that always accompanies you throughout your professional career.

You are one of the essential professions within healthcare, with a role that has gained importance in recent decades. And you are going to be protagonists in the evolution and growth of the role of nursing, due to the importance of health and well-being in the 21st century society and due to your all-round view of the patient, their emotions and their environment.

Covid-19 has been the biggest tragedy that we have faced in the last century, but I do not want it to make us forget the big challenges that you are going to face. They are challenges that are already on the table, macro trends of the system itself exacerbated by this pandemic.

And I am referring to the ageing of the population, the chronicity of illnesses, the constant appearance of new technology etc. These are challenges that are going to keep putting immense pressure on the system, to which we have to add the consequences of Covid-19, with an increase in waiting lists, late diagnosis of diseases, etc.

The Bologna convergence with the degree, Masters and PhD, the development of the specialities and advanced practice nursing, together with the boost of new graduates like you, have to be the determining elements in obtaining the degree of recognition and value that nursing deserves in the healthcare sector and society in general.

I am sure of it and of your role in the future of healthcare.

You are the best in history!

Always remember that you have received the best training, and place value on commitment, courage and an eagerness to work.

To conclude, as a father, I would like to speak to you on behalf of all of your families that, unfortunately, cannot be present today and that are following us on television or on the computer at home.

I ask that you work with passion, giving the best of yourselves.

We are very proud to see you here today, reaping the benefits of your efforts. It is such a wonderful day for you, but also know that it is for us also, your families. We have suffered when you have had problems, we have been happy with your achievements, and seeing you here today fills our hearts with joy.

We never want you to lose the enthusiasm that you have today. Your work, responsiblility, commitment and humanity are very important for the patients that you are going to treat. And also for their families.

REMEMBER THAT YOU ARE PEOPLE THAT TAKE CARE OF PEOPLE. That is my motto. Give a smile, a friendly gesture, understanding, care and respect to those around you. I assure you that they are the perfect accompaniment that will make the training you have received in this magnificent University, CEU Cardenal Herrera University, shine even brighter.

Take care of us! Of everyone! That should be the main aim of your professional life.

And I’ve come to the end, friends. Really. For me, being the KEYNOTE SPEAKER of this graduation is a “gift” that I will proudly carry with me forever wherever I go.

And I promise you that I will work so that this year of graduates has all of the possible opportunities and the visibility that you deserve. Count on me!

A hug to each and every one of you with all of my admiration, gratitude and respect.

You are now nurses!! Congratulations and get to work, we need you!!


The example of Farnós

7 junio, 2021 • By

Joaquín Farnós, a person to whom the healthcare and politics of the Valencian Community and Spain owe a lot, has passed away. He was always a pioneer and, in my opinion, someone very ahead of his time. This is because he didn’t hesitate to defend projects, initiatives and management models in order to guarantee quality in public healthcare and the sustainability of the system with a long-term view.  Farnós represented a liberal, reformist and forward-thinking figure, who set a precedent and whose proposals have been inherited and kept by the parties that have had responsibilities within the Valencian Government since his time as Minister.

Farnós liked to innovate in the 70s, which were difficult years. He was a pioneer in the implementation of thermalism for rehabilitation and rheumatic diseases in the Valencian Community. And not only in a medical capacity but also on a political level. With a liberal, reformist and centrist spirit, as a peacekeeper and integrator, he contributed to the consolidation of democracy in Spain, from the foundation of the Union of the Democratic Center in Castellón to participating in the drafting of the Constitution in 1978.

Joaquín Farnós loved his home,  Castellón, but from there he was always committed to territorial balance. And during his time as the Valencian Government’s Health Minister he launched some incredibly pioneering initiatives. I would like to highlight three of them:

The first one is the emergency plan, which we now know as agreements to combat waiting lists. Although they already existed previously, with the Socialist party governments, the big achievement was to systematize them so that anyone on a waiting list for more than 90 days in the Valencian Community could choose between being operated on in their hospital or in a private clinic. This initiative was the first to break the dichotomy between public and private, with the health system as a whole serving the citizens. That measure, which at that time was highly criticized by those who like to repeat the “privatization of healthcare” mantra in almost any forum, was so successful that it has not only been maintained for 25 years, but has also spread to the rest of Spain and is implemented by governments regardless of the political party.

The second revolutionary initiative that  Joaquín Farnós launched was the creation of addendum C, which brought an end to the exclusivity of doctors in the public system. Before this addendum, doctors that earned their place in the public system could not work in the private sector.  Farnós, with his humanistic, open and inclusive vision, saw immediately that it was not necessary to impose how to work onto medical professionals, but rather that it was more appropriate to enable professionals and give them the freedom to choose whether they wanted to dedicate themselves exclusively to public healthcare or if they preferred to complement that with a period of time in private healthcare.

And last but not least, Doctor Farnós is and always will be the father of the well-known Alzira model, set in motion at Hospital de la Ribera. As a doctor and as a person who knew both the public and private system very well, he firmly believed that it was necessary to maintain values, quality and universality in the public system, but that it was also necessary to allow the private sector to take part in the management of those public resources, maintaining values but innovating prevention policies and providing flexibility in human resources or purchases, amongst other things. The important thing in the long term is to pool resources, opening and improving a system that is too bureaucratized and restricted. In order to achieve that, incorporating the private initiative, of civil society at the end of the day, is key.

Due to that Farnos was able to make the region’s dream a reality in just a year and a half and put an end to the promise that had been unfulfilled since 1982, after the extreme flooding in Tous, by constructing a hospital in Alzira to provide a service to the whole region of La Ribera. He will always be remembered for that.

I had the incredible fortune of knowing and working with Doctor Farnós for a while. One of the memories that I have clearly ingrained in my mind is that he was the first person that I heard say that he was the Minister of public and private. Joaquín Farnós always sought to unite, promote consensus, demonstrate the centrist and conciliatory spirit of the UCD and, with that, managed to unite right and left. He exuded the spirit of the April report, with a vision of the future of the public system above and beyond any ideology, because he was committed to the sustainability of the system, with his view always based on universality, excellence and innovation.

Doctor Farnós always clearly saw that there there are two types of people in life. There are those who propose, construct, create and work positively, always thinking about better services and a greater well-being for citizens; and those that live to destroy the present and even make an effort to change the narrative of the past, because, obviously, facts cannot be changed.

Today I want to advocate for the “ Farnós spirit” in this blog, to make him an example of an unbiased, modest and peacekeeping visionary. Thank you for everything, Joaquín.


Citizens lead the way

4 mayo, 2021 • By

The number of people taking out health insurance has steadily increased over the last decade. Almost thirteen million citizens in Spain (12,802,665 to be exact) currently have it in our country, according to ICEA, the Spanish Insurance Sector’s Studies Service, responsible for carrying out research and publishing all of the statistics. The number of health insurance policies has grown by 3.34% just in the last year and the average annual growth since 2015 has been 3.51%. And it is this data that has led me to share some of my thoughts in this new blog entry.

First and foremost, the private insurance sector isn’t experiencing the ups and downs of the crisis caused by this pandemic. And I’m referring to the figures. Rather, Covid has upheld a trend that already surprised many in the crisis of 2008 and that has now been affirmed: participating in and taking decisions about health management is a priority. Health insurance is not only thought of as a privilege or a luxury, but rather as a necessity. Regardless of their level of income, citizens value it as something that is becoming increasingly necessary.

Those who criticize private healthcare and try to put it opposite public healthcare show a complete lack of knowledge about the current society once again. They are still thinking about the same statist terms of their grandparents, and they use fixed expressions and the same old clichés, instead of realising that we live in an age in which the citizens have different criteria, priorities and wishes. I’m sure that the 12.802.665 people who have decided to take out health insurance hold public healthcare in very high regard. We are incredibly fortunate to live in a country with strong values, one in which no one is left behind when it comes to receiving any type of treatment in the public healthcare system. However, I also think that, despite that high regard that we all hold, especially in terms of the social nature of the system and the main public health centers of reference, all of these citizens  are willing to make a co-payment for peace of mind that, whatever happens, they’re going to be treated. And, what is more, quickly, and with quality care.

And why does this happen?

Firstly, because over the last few decades, health insurance companies have expanded the type of service they offer and have improved their own management and the services and assistance they offer to citizens. In addition, compared to our neighbouring countries, Spain provides quality health insurance which is accessible for broad sections of society. And the data that I gave at the start of my reflections confirms this. Together with accessibility and the high quality of healthcare provided, this has made health insurance a service that citizens want. This is because they also know that it is compatible with the treatment that they receive from public healthcare. It is complementary.

Secondly, I think that citizens are becoming more and more appreciative of having a private alternative, alongside the public system, because they realize that it suffers from organizational, bureaucratic and management problems from its own administration, since there are problems with accessibility, very long waiting lists, a lack of motivation from its professionals and obsolescence regarding the technological equipment in many of its healthcare centers. And, without a doubt, Covid has worsened those problems and will continue to do so in the short and medium term.

I can give you an example with which I am familiar. After Hospital de la Ribera moved to direct public administration, the number of health insurance policies in this area of the Valencian Community increased exponentially. When citizens have experienced a real loss in the quality of the service that they receive, with regard to before the reversion, they look for an alternative in the private sector, in order to guarantee themselves fast, quality and safe care.

However, I also firmly believe that health insurance is important as an accompaniment or an aid to maintain the public system, whilst guaranteeing access to certain services that our system is unable to offer. Private healthcare and health insurance play a key role, one that is good for the system, because it acts as a free co-payment that I think should be encouraged by the Government itself, with some type of tax credit. 

I’m a firm defender of freedom of choice both with healthcare and education. As citizens we want to participate and decide how to manage our health or our children’s education. It has been shown that it is much better for everyone to incentivize these freedoms rather than restrict them. Even the current Government has committed to this by bringing incentives to the table regarding a delay in retirement age. Why not do this in healthcare? These are effective measures to encourage a good use of public resources. 

I want to finish by pointing out that freedom of choice has also been a reality for many years in the civil service. At Muface, the officials can choose whether they want to be treated in public or private centers (the majority choose private, incidentally). The future is about placing people in the driving seat when it comes to decision making regarding their health.

P.S.Last week, parliament passed a non-legal proposal (NLP) for which the Government was requested to extend direct management to the whole public system, without looking into other ways. This NLP was approved by just one vote. There are people who have asked for my opinion and I don’t want to create a lot of controversy because the subject is clear. Years ago the Constitutional Count left it very clear that the Constitution protects both private or indirect management and direct management. Therefore nobody, not even through an NLP, can limit the current management models, because it’s the same as attacking the Constititution, even though we’re experiencing a time during which some endeavor to attack this text, in order to change the Spanish legal framework. Therefore, as the Constitution says, all management models are valid and these polemics are short-lived. I’m with the 1978 Constitution that has given us the longest period of prosperity and harmony in our history. And you?