Health: Medical Services in the Periphery and other matters

Autumn has finally arrived, bringing rain, colder temperatures, and wind. Will it bring calm, clarity of thought, and lucidity to the restless spirits that wander to the perdition of our souls ? Especially in a complex and difficult international context that the audacity and boldness of these restless spirits seem to completely ignore. We live in times of celebrating anniversaries, but also times of problems whose solutions require difficult decisions.

Created in 1975, in the midst of a hot summer, the SMP deserved the honor of celebration, as an anniversary, in an academic institution and with the presence of the Head of State, whose speech had raised expectations.

The SMP (Medical Service Program) had a great positive impact on extending healthcare to populations furthest from major urban centers. It was important. I didn't live through that experience. In 1975 I had already finished my surgical residency and in October of that year I went to London to specialize in vascular surgery. From that period, which so marked friends and colleagues, came stories and impressions that, from a distance and although unfamiliar with the camaraderie that united them, allowed me to appreciate them as an attentive and committed observer. A re-edition of the 5th division of the MFA (Armed Forces Movement) for the politicization of the populations? Or a useful experience as it was considered by numerous doctors established in the periphery, such as my father and my uncle, both in Ponte de Sôr?

The initiative and collaboration of the young doctors were generally well-received. They sympathetically commented that it not only eased their workload but also compelled them to study! For some young doctors, it represented lost time in their medical careers and a potential delay in competitive exams. Overall, it was an opportunity, reflecting a policy to combat the depopulation of the interior, fueled by the expectation that, once they completed their specializations, some would return and settle in the cities and towns where they had completed their primary medical training. This is a problem that has persisted into the third decade of the 21st century, in a country divided between a progressive and populated coastline and a depopulated interior, lacking specialized human resources. It will not be solved solely through special competitions, financial incentives, or benefits. Unfilled positions, shortages in specialized services, and the depletion of local expertise, forcing a significant displacement of patients for more specialized clinical care, are examples of this reality. And they are one dimension of the health crisis.

The SMP was simultaneously a good initiative and a missed opportunity, because there was no paradigm shift in the organization of postgraduate training that could have been made possible by the introduction of inter-institutional programs, whose objective would have been to promote and formalize the circulation of professionals not only from the periphery to the center, but also, obligatorily, from the center to the periphery, during the learning of specialties.

I was able to appreciate the advantages of this model in London during my stay. In Surgery, residents were required to complete at least one year of work in a peripheral institution, which gave them experience, greater autonomy, responsibility, and another subtle advantage: the creation of professional and personal connections and a potential increase in scientific and research cooperation. For many I met, it facilitated their settlement in a non-central institution, but one integrated into the group, with obvious advantages in terms of status and opportunities. There were a few examples in our reality, but despite their success, there was no courage for this organizational change. The consequences were the increasing difficulty for hospitals in inland cities to attract younger professionals, rejuvenate teams, and ensure differentiated service. And more patient transfers due to the impossibility of local treatment.

It seems irrefutable to me that inter-institutional collaboration, both in undergraduate and postgraduate education, constitutes added value. A challenge and an opportunity. As director of FMUL (Faculty of Medicine of the University of Lisbon), I promoted the continuity and development of cooperation protocols for teaching with peripheral outpatient and hospital institutions. But I was unable to implement this type of change in postgraduate training, perhaps due to inertia, prior institutional ties, and resistance to paradigm shifts. A lost battle! And now, in the present time, with the fragmentation of the National Health Service (SNS) into multiple Local Health Units (ULSs) with administrative autonomy and the atomization of training centers, it seems impossible.

Another issue dominating the public sphere. When the widespread use of doctors hired on a task-by-task basis from service providers was implemented to address shortages in emergency teams at major hospitals, driven by the need to manipulate public spending, warnings were issued about the error this represented and the risk of a temporary solution becoming organized, creating a market, rules, and needs that would preclude any future, adequate, logical, and effective solution. There was also the potential conflict in the hierarchy of responsibility between professionals on the institutional staff and those hired on a task-by-task basis, whose preferential functional dependence on the contracting company could prevail over the needs of the institutions. This was accentuated by the glaring discrepancy in financial compensation compared to professionals on the institutional staff.

Reality has surpassed imagination! What has been reported in the press, without serious and consistent refutation, reveals the grave distortion of the organization, its management, and its non-negligible costs. A flawed solution that has become entrenched has become indispensable due to the complacency of the institutions, as a union representative stated with crystal clarity, affirming that the reorganization proposed by the Ministry of Health would entail a risk of service paralysis. A clear warning to those who understand…! What to do then? Will there be time and opportunity for a consequential political compromise that provides support for a necessary new policy?

3. A serious and consistent Health Policy which has essential requirements.

The first: knowledge of the route, that is, clarity of objectives, lucidity in the chosen path, determination in its implementation, and objectivity in the indispensable evaluation. The second: courage, which for Churchill was the primary virtue, to face difficulties, not to yield on the essentials, and to accomplish. And an indispensable attribute: the capacity and talent to win and mobilize the hearts and minds of the protagonists, knowing how to incorporate them into the process, through the sharing of objectives and not through unnecessary confrontation. Essential to overcome the corporate interests that seem to prevail. And the third: intellectual humility and a spirit of public service, without seeking reward or power. And in the current circumstances, a political commitment that ensures continuity and coherence in action. Will it be viable?

Political debate is poor, circumscribed by clichés and soundbites to satisfy tribes and audiences; this compromise, which everyone recognizes as essential, was improbable, even though everyone acknowledges its necessity and urgency. The situation, which has been worsening since 2018, cannot continue and could lead to the implosion of a great public service, the National Health Service (SNS), whose sustainability, objectively assessed, has been on a downward spiral since 2018, a rapid decline. Analyzing reality objectively is crucial, and external evaluation is useful, and should not be invoked merely to confirm our expectations. Here, the maxim of surgical practice applies: believe what you see, more than see what you believe!

The National Health Service (SNS) has provided great victories over disease, incorporating knowledge, differentiation, technology, and modernization. But there are difficulties that challenge established conceptions and truths. Let's look at some facts:

1. Portugal is among the OECD countries where private spending on healthcare is among the highest, at 29% versus the average of 15% for those countries;
2. Public participation is lower than average in all sectors.
3. Overall spending on outpatient care is higher than average, but it lags far behind in long-term care – 8.5 times lower than the average for those countries – and is about 50% of the average for preventive medicine. Is this compatible with the demographics of our population, both current and expected in the near future? Obviously not.

Public spending on healthcare more than doubled in a decade, without overcoming the constraints in the provision of services. This has caused public alarm. Modern medicine is expensive, but the causes of this increase are also dysfunctional management, inadequate use of resources, waste, and an inadequate human resources policy. But when the need to contain spending is officially raised, through the rationalization of financial management and human resources, there has been widespread indignation. Is this the original sin of this organizational model, the so-called Beveridge model?

I believe that, finally, three realities are beginning to emerge:

1. There is an advantage in analyzing and studying other models of global organization, which will not be a crime against the National Health Service;
2. The need for profound reforms that will require openness to new perspectives;
3. The current trend of increasing public and private spending will not be sustainable, particularly in the international context we are experiencing.

The saga of emergency room visits, delays in consultations and surgeries are an epiphenomenon of the dysfunction of the National Health Service (SNS), which demands profound reforms and not ad hoc, case-by-case measures. The natural expansion of the private sector seen in the last two decades and the rule of governments with different backgrounds has altered the landscape of curative medicine in Portugal. Its organization incorporates primary, hospital, and continuing care, seeking an integrated service offering that favors client retention (the term "patient" is outdated). And professionals compete for better job offers, financial compensation, and more modern facilities.

Will the National Health Service (SNS) be able to compete? Certainly not with the proposed Local Health Unit (ULS) model, a pipe dream of the last socialist government. From its inception, it was clear that it was wrong, from the Executive Board to the fragmentation and atomization of a National Service. The current Ministry of Health recognized that the ULS model was not applicable to academic institutions. A working group was formed that produced a document approved unanimously. Nothing has changed so far. But it seems to me to be incompatible with the organization of Local Health Units.

There is a clear and dominant perspective in society: public contribution to healthcare spending is fundamental given the rising costs of modern technological medicine. It's a mark of civilization! But is the National Health Service (SNS) model the only solution? And the most effective one? For years, there have been calls for the creation of a National Health System that integrates the public, social, and private sectors. The private sector has been gaining ground due to the public sector's inability to reorganize.

But the creation of a National Health System, as its promoters advocate, will be a difficult and very demanding exercise. First, it requires the adoption of a common Evaluation Culture, the adoption of standardized practices, and common nomenclatures among the different partners. And in my opinion, two caveats: i) Maintaining the public status of the most distinguished Academic Medical Institutions; ii) the necessary resources so that they can be a beacon of quality, an engine of research and innovation, and a reference for the entire System. This does not in any way mean exclusivity for medical education, but rather the safeguarding of an unquestionable public dimension.

I share the conviction of the President of the Republic (intervention of 30/10) who, regarding the reform, used an expression with which I identify: the path of stones, for those who intend to cross the strong current of the stream. The stones will be simultaneously an obstacle and support for the exercise (stepping stones) . Will we have the courage and foresight to study them, analyze them, and use them as support to design a serious, balanced, and financially sustainable organizational model? And one that safeguards essential equity in a system that aims to be national and capable of ensuring an adequate response to the needs of the Portuguese population? There are steps that are fundamental to take, and which truly require informed and constructive dialogue with the various participants.

My generation missed out on this challenge, despite the effort and commitment of many to discuss a new path and a new perspective. It left an unwanted and difficult legacy, and an urgent and compelling challenge for future generations. I hope they succeed!