The three crossroads of the Spanish healthcare system

Patient organisation and participation, the technology transition and outcomes assessment are key to updating the 1986 system

The Spanish healthcare system is at a crossroads, with many different heads. Like a Hydra, you don’t know which one to cut off first at the risk of another one reappearing. And like the mythical creature, due to the complexity of the issue, there are as many different approaches as there are opinions. At the last meeting organised by Llorente y Cuenca on the subject, its report on this year’s trends in the sector was presented featuring different contributions centred around three key areas: the organisation of the system itself, with deep-rooted territorial inequalities and precarious patient participation; technological change, which goes beyond the use of applications, drugs or more complicated devices, and which involves digitalising processes; and the need to continually assess actions from the moment technologies are acquired or approved, either to rule it out or to develop it further.

1. System organisation

The current distribution of powers that concluded in 2002 left healthcare in the hands of the 17 communities. All except Ceuta and Melilla, which was in the hands of the Ministry of Health, and the coverage of public workers, acquired from Muface, Isfas and Aseju. These different actors mean that there is “a gap in health outcomes,” states Carina Escobar, president of the Platform of Patient Organisations (POP).  Francisco Javier Fernández, director general of the Official College of Pharmacists of Madrid (COFM) and former director of communications at Farmaindustria, believes that the “system is overstretched.” “For too many years now there has been no long-term planning and underfunding,” Fernández adds, and “the collapse of primary care” is a prime example. “The model of universal healthcare, of public management, makes it very difficult to improve the organisation and to innovate,” warns Carlos Alberto Arenas, vice-president of the Economy and Health Foundation (FES).

1.1 Territorial differences

Escobar stresses that “there is currently no universal or equitable coverage.” “Territoriality needs to be addressed. The chronicity strategy needs to be updated. Nothing is being done about prevention. Territorial cohesion is needed within and between autonomous communities. The difference in access to treatment and testing is not good.” And she shares a personal example. She is from the Canary Islands and is not even considering moving back to the islands so as not to lose access to the treatment she needs for her chronic illness.  Carmen Aláez, assistant to the General Secretary of the Spanish Federation of Health Technology Companies (Fenin), explains that there are biomarkers, for example, that are only funded in some autonomous communities.

1.2 Oral health

A perfect example of this situation is oral health, whose diseases are among the most prevalent non-communicable diseases in the world, affecting an estimated 3.5 billion people. In Spain, the public healthcare system generally covers basic aspects such as extractions, but leaves the rest up to private systems. And each autonomous community offers different services. There is increasing evidence that the health of teeth and gums affects people’s health (they have been linked to cardiovascular problems and diabetes, among others). Together with mental health, it is one of the therapeutic areas where there is clearly much room for improvement, which in turn, as patients fear, leads to very uneven developments. This is why specialists say that oral health services should be included in national health coverage plans, for free or at an affordable price.

1.3 Policy

“Politicisation is no good for any of us,” Escobar says, for whom the elections and the short-term thinking of the political parties prevent them from tackling more ambitious plans, despite their lobbying of the parties. Fernández highlights a fact that may be an indicator of the different governments’ neglect of this responsibility. “There have been 25 health ministers in 45 years of democracy, we have one every year and a half. There has to be long-term plans, with the need to invest in them.” In fact, sources familiar with the department’s history indicate that after the transfer of powers to the autonomous communities it was even considered that the ministry as it stood would disappear, and that it would be integrated into Social Affairs or another similar department. The subsequent crises, culminating in the Covid crisis, showed that a strong ministry was needed, “that could lead the change” and coordinate the health policies of the autonomous communities, as Aláez says.

1.4 Chronicity

“The strategy on chronicity is obsolete,” the POP representative and Aláez both agree. “Chronicity needs to be properly measured,” stresses Escobar. As she explains, this is currently done through prescriptions. If a patient is regularly taking a medication for a pathology, they are considered chronically ill with that pathology. But there are autonomous communities that record prescriptions by brand, and others by active ingredient, which alters the results. The solution, according to the president of the patient platform, is that there should be “a commitment from all the actors over several years.” However, this is difficult because there is “a leadership problem” in a system that is more inclined to hand over powers than to coordinate or fix them.  “Chronicity must be put on the agenda of political priorities,” Arenas emphasises.

1.5 Liquid healthcare

Arenas agrees with the diagnosis of his colleagues, “the system is overstretched, major reforms are needed and the model can no longer be simply patched up; the healthcare model needs to be transformed.” He sees “two drivers for change: involving patients and citizens in the institution and the organisation of hospitals and health centres themselves.” On the former, Carina Escobar fully agrees, “we need to move from informed consent to comprehensive patient information leading to shared decisions.”

In terms of the institution, she believes that it is difficult to achieve an “internal liquid organisation” because the national healthcare system “is hierarchical.” “It works by very closed services, whereas a liquid healthcare system would work by projects, by pathologies, with a matrix rather than a hierarchical organisation.” That is why she believes that reforming human resource management is a priority.

1.6 Comprehensive care

Fernández, representing pharmacists, prefers to talk about comprehensive care, a concept “that is to do with the change in the patient profile and the needs of the healthcare system.” “We suggest pharmacies becoming more involved in following up and monitoring patients, with greater dialogue and cooperation between community pharmacists and the primary and hospital levels of care. At the present time, after the pandemic and the collapse in healthcare centres, this issue is even more significant.”

1.7 Proactive medicine

The specialists agree that the challenge for the healthcare system today lies “in prevention and early detection,” as Fernández says. “We need to talk about health in the medium and long term,” Escobar emphasises. The pharmacists’ spokesperson adds that to do this we need to develop “plans with the big picture in mind and understanding the need to invest in them.”

2. Funding

All this need for prevention and measurement leads to an efficient use of healthcare technology, including medication. Along with the subsequent challenge of funding new developments. This leads to reviewing the model to decide which ones are paid for and how they are paid for, says Fernández, former director of communications at Farmaindustria, an association of innovative laboratories. The current situation, with increasingly specific products for specific patient profiles, which has an impact on their price, means that half of the medicines approved in the EU in the last four years are not available in Spain, he explains. “It is an issue that should be on the agenda. It is a missed opportunity. If it is a financial issue, the funding model needs to be discussed.”

2.1 Cost-benefit

Arenas says that, in this sense, the solution is to “work on purchasing medicines based on value.” For hepatitis C antivirals, their cost-benefit was demonstrated because they effectively cure the illness, he says, but for other drugs “it is more difficult to know” this relationship, and he proposes a payment “based on value and quality of life gained.”  Aláez adds that, for example, Sedisa (the Spanish Society of Health Directors) has developed a Health Outcomes Observatory that can be an example and guide for this rethinking.

2.2 Participation

Patient organisations are already involved in this process, but the POP president emphasises that “we want to have a say in decisions about access to therapies. This is very important. We are already involved in therapeutic positioning reports (TPRs), but then we don’t get feedback on why our suggestions are included or not.” Escobar says that to know the real value of a medicine “you need to ask the patient.” “Innovation must serve citizens,” and for this “it is important to have faster circuits” to allow for easier control. Pharmaceutical representatives are confident that the European plan for access to medicines will speed up procedures and reviews. Aláez adds the European-funded Inveat Plan (Investment in High-Tech Equipment), which the Ministry of Health launched to renew high-tech equipment in the national health system, to provide greater equipment density in areas where there was a shortage and to have higher quality and higher resolution data to improve patient care.

2.3 Digitization

All of the above have one thing in common: the value of transforming and digitizing the healthcare system and processes. As Aláez points out, it will help to improve connectivity, quality and efficiency, which will enable the automation of healthcare processes and the use of artificial intelligence to diagnose and treat patients.

2.4 Data

But this whole process needs to start with the quality of the data fed into artificial intelligence systems, where healthcare technology is essential, says Arenas. A high-performance healthcare system based on precision medicine, advanced therapies and artificial intelligence needs to be promoted.

Precision medicine has brought about a paradigm shift in the diagnosis and treatment of cancer because it opens up the possibility of gaining a better understanding of the disease and its prognosis on an individual basis.

2.5 Patients and the digital divide

It is impossible to talk about digitization without addressing the digital divide, where 40% of older people -those most affected by chronic diseases- do not have access to the Internet. “There are many examples of simple and intuitive systems and solutions such as a phone call that allow patients to be contacted and monitored remotely.” Arenas stresses that “clinical data are the property of the patient.” “Consent is very important.”

2.6 Transparency and measurement

A key part of digitization is standardising data in order to be able to compare, says Arenas. Both the pharmacists’ and patients’ representatives state that this is not the case even for parameters that have been monitored for years, such as waiting lists. “It is difficult to collect and there is a deficit of data from medical records,” Arenas states, who sees the European digitization strategy as an important opportunity.

2.7 Outcomes assessment

Aláez says it would be important to “introduce proper infrastructure and shared, interoperable systems with comprehensive dashboards to analyse data.”

It is also important to develop quality and health outcomes-based contracting models, which will also have a positive impact on innovation.

The diagnosis seems clear and shared. But specialists, such as those involved in this report, are not necessarily the ones prescribing the treatment. The actions are the responsibility of the regional governments, which makes them, in the best of cases (Escobar, for example), moderately optimistic that progress will come from concerted multi-annual plans.