The open wounds of the healthcare system in 2023
The debate around healthcare issues -always full of controversies- will remain active in 2023, with different aspects to take into consideration. Obviously, there is a continuity in issues reported in previous years (mental health care, aging or One Health which includes attention to the environment as a health prevention factor). But the hot topics that will appear in the public opinion this year will be the following:
As for the healthcare system, the most influential elections will take place on the autonomic level since the percentage that healthcare represents in autonomous budgets ranges from 23.83% of Navarra’s autonomic budget to 38.42% of Castilla y Leon’s (60% more), a remarkable difference that translates into a varied cost-per-habitant, which in turn ranges from 1,284 euros in Madrid to 2,015 in the Vasque Country, according to data from 2022. Juan José Rodríguez-Sendín, ex-president of the Collegiate Medical Organization states that, due to the electoral timeline, “although the system needs many changes, nothing will be done or, if anything happens, issues will be temporarily fixed up”.
To give an example, he believes that “resources will be invested to solve the dispute raised by primary care workers, but there will not be a behind-the-scenes plan that tackles the root of the problem”. At this point, talking about a State Pact for healthcare seems like a pipe dream. “It has been proposed for more than 20 years, but with the current political polarization it is impossible,” says Sendín.
As for José Soto Bonel, president of the Sociedad Española de Directivos de la Salud (SEDISA), elections are the momentum to insist on the professionalization of those responsible for health management, “trained for the managerial profile they occupy, and with the technical and transversal skills for it”. Although, more than convincingly affirming that this issue will be in the electoral debate, he insists that “the depoliticization of management and transparency must be true a fact, so that the manager’s profile is established as a management professional, a position subject to an objective evaluation based on results in healthcare, economics, professional participation and social leadership, within a code of good management”.
2.- Healthcare Expenses
Regardless of the electoral processes, healthcare expenses will continue to increase unless the economic crisis increases as in 2012, warns Fernando Lamata, former Secretary General of Health and former Minister of Health in Castilla-La Mancha. “And they have not yet recovered the levels reached before that crisis,” he adds. To which Carlos Alberto Arenas Díaz, vice president of the Economy and Health Foundation, contrasts the effort made –which must be maintained– to “recover the level of action prior to the pandemic”.
Lamata, however, doesn’t foresee “a strong commitment to healthcare, so the quality of public healthcare will continue to deteriorate, which will consequently impact on mortality and waitlists.” In fact, in 2021 there were 450,744 deaths compared to 417,626 in 2019, according to the INE. However, the impact of the expenses cuts and the pandemic overlap, the effect will be better seen in the medium term.
As for the number of people in a waitlist, this reached a record of 742,518 people awaiting an operation in June of 2022 (latest data from the Ministry of Health) but, the number of those waiting more than six months decreased slightly. This is due to the reactivation of procedures and healthcare activity after the pandemic, a process that should be maintained over 2023 unless an economic or health crisis (one more serious than coronavirus or another emerging pathogen) sets it back.
2.2 Pharmaceutical expenses
Anna García-Altés, president of the Health Economics Association (AES), points out that “the price of drugs will come out again in the public debate” and that it will focus on “the evolution towards an independent entity that evaluates the comparative effectiveness and the cost-effectiveness, to assess whether it is worth paying for all these new therapeutic advances”.
“Most of the increase in healthcare spending (which should be seen as an investment) is due to the price of medicines,” says Lamata, “which has risen by 5% in the last year.” He agreed with Sendín –both are currently members of the Fair Access to Medicines Association– in that “this increase is deducted from other line items, such as staff” and this is manifested in “the loss of quality reported by the CIS and the latest Healthcare Barometers,” says Lamata. That is why they insist that treatment values must be set with full transparency and that, as stated by the former president of the Collegiate Medical Organization, “the price that they must have is guaranteed with the corresponding benefit for manufacturers, but without the coercion that if you don’t pay, you leave someone untreated”.
The strikes and demonstrations held by healthcare workers, mainly in primary care, have reopened the debate surrounding their availability and education, which has returned to the forefront (this is a recurring theme every time there is a disagreement between the communities and the Ministry).
The current shortage of resources has several causes behind it. There is a structural one: both doctors and nurses (and other specialists such as psychologists or chemists) have a long training process, so those who started university approximately 10 years ago will finish their studies in 2023. Thus, the statement made by the Minister of Health Carolina Darias on December 19th, which confirmed that the number of primary healthcare positions have increased by 40% since 2018 will allow for a wider availability of specialists, but around this year (the residence medical internship lasts 4 years).
The option of training more specialists is not viable, no matter how many universities are opened. Residents, whether in medicine or nursing, need internships with tutors from the healthcare system who, in turn, must also be in charge of day-to-day care for patients. So the option here is to recruit medical staff from overseas, but for whom validating their academic and medical titles is not an easy or quick process.
In addition, some of these graduates do not want to practice in Spain nor dedicate themselves to the most demanded specialties, such as family medicine, due to the working conditions (schedules, workload, precariousness and salary) that they offered. An example of this is that in the last allocation of residents throughout spanish healthcare centers, there were 200 family medicine specialist positions left unfilled due to lack of demand. Also, there are about 4,000 students who each year do the paperwork to work abroad, although the Collegiate Medical Organization estimates that only half finally do so.
3.- EU crisis and presidency
The returning concern for the Covid situation in China is only the latest healthcare crisis –with a more local than global impact for the moment, unless more lethal mutations arose that could not be treated with our current vaccines. And more crises will follow, states Lamata. This is due to three factors, he adds: “Demographic pressure, climate change [again, the idea of One Health] and the easy mobility of millions of people”, which lead to more proximity between humans and pathogens in animals or other conditions, and make it easier for them to expand.
3.1. Resistance to antibiotics
In addition to potential crises due to new viruses, there is also the emerging crisis of frequent bacterial resistance to antibiotics. A striking and worrying case is that of gonorrhea that has already reported cases with barely any treatment options available in Spain. This problem can end up leading to 10 million deaths in 2050 if not tackled sooner, but still faces a lack of interest from big pharmaceuticals in developing specific treatments, despite the European Union’s efforts to foster research through incentives like extending patent terms for these and other products made by companies that invest in this health sector.
In these situations, Carlos Alberto Arenas Díaz, vice president of the Fundación Economía y Salud, stresses that “there should be investment funds available for health contingencies with high economic impact, such as an epidemic or the launch of a new drug or therapy that is effective but very expensive”.
3.2 The European Presidency
The next big threat could possibly arrive during the spanish presidency of the EU -in the second half of 2023- adds Lamata. “Until now, the EU had agreed that healthcare was a competence that belonged to each country, but Covid has kick-started coordinated actions like the joint purchase of vaccines”. In this context, Spain could lead collective initiatives like these thanks to its experience in shared management of care.
4.- Public Healthcare Agency
Unless electoral partisanship prevents it, 2023 should be the year that the Public Healthcare Agency will become a reality. However, there is one worrying precedent: something much simpler like the evaluation of the administrations’ behavior during the coronavirus crisis has not even been started already, two years after being announced. The Agency “must represent a cooperative and coordinating advance in epidemiological surveillance, vaccine coverage, data management and, with it, it must showcase an effort in transparency and good health governance”, states García-Altés. It can also play an important role in future European or worldwide crises, adds Lamata.
5.- Digital Care
“Telemedicine and information systems represent the main challenges in guaranteeing continuity of healthcare”, says Carina Escobar, president of the Plataforma de Organizaciones de Pacientes (POP). “In this sense, there could be certain additions to improve access to care, such as adapting digital health tools –like Shared Health Records (SHR)– to the specific needs and characteristics of people with chronic disease (mostly of an old age); and the promotion of territorial equity when accessing in-person healthcare services, which is especially complex for those living in rural areas”, she adds.
García-Altés exposes that “achieving a vision for equitable health and social care requires the expansion, at least in quantity, of digital health care”, but that this can be “relatively easy”. “Let’s keep in mind that we will not go back to a 100% in-person healthcare system”, she states. “Telephone care will be consolidated and in the end we will overcome the existing resistance to improve video care, as well as patient management through remote assessment”, she adds.
“Once the fear of data transferring will be overcomed, public management institutions (councils, regional healthcare systems) will go beyond the compatibility and interoperability of digital medical record systems: with due authorization from users, these platforms will start offering their personal data and its management for individualized “preventive” coverage. In this sense, the Community of Madrid has gone one step further and announced that public and private healthcare will share patient information.
In this context, Sendín is cautious of the integration of public and private data when the matter of a common digital medical record has still not been solved. He presents the example of a hotel doctor, who would currently not be able to access the medical record of a patient suffering from a heart attack. “Another thing would be that each patient had access to their records and were free to share it with whomever they wanted”, not like currently, where “patients only receive the information that those who control it want to give out”.
Lamata also warns that “even the interoperability between MUFACE public care and other services (such as ISFAS’ military health care) with public healthcare has not been resolved”, and he doesn’t believe that this will change this year. In any case, he insists that “data security is key” in these interconnections, but he admits that telemedicine, robotization and artificial intelligence will advance considerably and that “the big companies are already working on it”. Therefore he says that “coordination and control of public investment” in this matter must be enhanced. Otherwise, “the private industry will tend to monopolize innovation”, he adds.
5.1. Digital gap
Digitalization has a challenge, admits García Altés: “Avoiding the exclusion of collectives that need complex and chronic care”.
We must keep in mind that, according to the INE’s latest data, 25% of people over 65 years old did not use the Internet in the last three months, and 20% do not own a mobile phone with access to the Internet. It would seem logical to think that, as the younger population gets older, the digital skills of the older population will improve. But there are factors like a low buying power and the loss of abilities and functions (sight, psychomotricity, dementia in a higher or lower degree) which can lead to the possibility that those now younger than 65, who know how to use a smartphone, will lose abilities as they grow older.
In this regard, Soto Bonel points out that “in-person and individualized care must be brought back because it plays a key role in healthcare considering the population’s limited digital literacy. However, newer technologies cannot be wasted, since many patients can still be monitored telematically”.
The role that patients and other healthcare users play is growing and is unquestionable. It is no longer logical to have programs, plans, press conferences or public events in the sector that do not involve them. They are progressively more proactive, informed and demanding role leads Arenas Díaz to propose “offering schools for patients among healthcare services”.
6.1. A growing demand
The digitalization of healthcare on all levels pursues one goal: addressing a growing demand. In Spain, more than 21 million people older than 15 have been diagnosed with a chronic disease (54% of the population), reminds Carina Escobar, president of the Plataforma de Organizaciones de Pacientes. “In December of 2022, the POP published a new edition of the Patient Care Observatory, which analyzes the traditional healthcare model and suggests challenges and strategies for its transformation. In total, the study documents the existence of 24 challenges that must be addressed to improve the access to health and social care, which mostly center around planning and access to early diagnosis, care, treatment, innovation and research, as well as continuity of care, and health and social coordination. We believe that for the upcoming year, chronicity requires a new approach with an early detection of fragility and an interdisciplinary and coordinated system between health and social care centers, while always keeping in mind the equity approach”.
7.- Redefining the system
Despite the skepticism of some experts about the ability of the system to put such deep transformations into place and turn them into reality, both the POP and other organizations will upkeep the demand of a more “liquid and coordinated” system –and they expect it to become part of the agenda. “Refocusing our current model of healthcare towards chronicity fundamentally requires a digital transformation of the system, the stratification of the population and a boost for primary healthcare”, says Escobar, who states that “although all autonomous communities are working –or planning to work– towards strategically redirecting their current models of chronicity care, the important changes and challenges have still not been implemented”. “As far as continuous care is concerned, coordination, telemedicine and information systems pose the biggest challenges to ensure it”, he adds. To this end, “we must improve the coordination between professionals and care levels, to guarantee a well-adapted telemedicine to different chronic patients, create or improve shared information systems and develop and monitor indicators that will allow us to measure care coordination”.
In terms of treatment access, some of the most notable proposals are the initiatives that foster collaboration between community pharmacy and hospital pharmacy to enable community pharmacies to dispense hospital drugs and establishing unified criteria regarding the professionals who must prescribe medication to chronic patients. In this context, one data point stands out: “41% of patients who do not receive home health care believe they would have needed it at one point”. Along these lines, Arenas Díaz highlights the importance of having an “almost universal implementation of palliative care at home”.
As part of the much-needed rethinking of the system, SEDISA president Soto Bonel stresses that “2023 will still require organization changes in healthcare companies in order to answer to the new realities we face and to add value to patients, healthcare professionals, the healthcare system and society. Some salient new realities are the aging of the population, chronicity, declining birth rates and digitalization. Yet another new reality is the shift in social values, in the face of which we must reinforce primary care as a fundamental value of our healthcare system, which would in turn previously require an analysis of the new organization model that primary care needs”.
The list of resolutions and topics seems clear to professionals. The only thing to be seen here is in which election year these matters will be brought forth to political debate.
Emilio de BenitoSenior Advisor at LLYC