Portuguese health system is still too reliant on emergency care, finds review

BMJ 2012; 344 doi: (Published 13 January 2012) Cite this as: BMJ 2012;344:e379
  1. Tiago Villanueva
  1. 1Lisbon

The level of attendance at emergency departments in Portugal is about twice that of the United Kingdom and 50% more than in France, and about a quarter of patients attending don’t need immediate care, says a review of the country’s health system.

The report by the European Observatory on Health Systems and Policies says that despite the increased cost of emergency care “many patients prefer to go directly to emergency care services in hospitals or the private sector where the full range of diagnostic tests can be obtained in a few hours.” In contrast, the number of outpatient contacts is 4.5 per person per year, substantially lower than the European Union average (6.2).

The report shows that the number of doctors in Portugal (377 doctors per 100 000 population) is above the EU average (328 per 100 000 population), although the number of GPs is low (GPs make up only 23.6% of specialist doctors working in the Portuguese national health service, where general practice is considered a specialty). However, the number of nurses (534 per 100 000 population) trails behind that of most countries (the European Union average is 792).

Commenting on the report, José Manuel Silva, president of the Portuguese Medical Association, said, “It is possible and desirable to correct some distortions and improve the efficiency of the Portuguese national health service by investing more in primary healthcare and allocating a family doctor to each Portuguese citizen.”

Alexandre Gouveia, member of the board of the Portuguese Association of General Practice and Family Medicine, said, “Right now, current data allow us to estimate a need for 1000 family doctors in Portugal. This limited response at the level of primary healthcare leads to an added pressure on secondary healthcare and consequently to less cost effectiveness of the health system.”

The report shows that the Portuguese health system has made progress and achieved some good health indicators. Life expectancy has been closing in on the EU average (80.4 years) and currently stands at 78.2 years (74.9 years in men and 81.4 in women), and the infant mortality rate is 3.3 infant deaths per 1000 live births, below the EU average of 3.8.

Pedro Pita Barros, first author of the report and professor of economics at the Nova School of Business and Economics, in Lisbon, said, “Child mortality is an almost unique success story in the Portuguese context and is due to a longstanding and well prepared technical work and to perseverance in its enforcement, including difficult measures like closing down maternity hospitals that were too small.”

Still, the report points out that there are substantial inequalities between regions and social classes and that avoidable mortality from cerebrovascular disease, cancer, and traffic incidents remains high, particularly among men. “Avoidable deaths still have a lot to do with cultural factors and a lifestyle having too many mistakes, like excess alcohol and salt consumption,” adds Professor Silva.

Average waiting times for surgical interventions and the number of patients on waiting lists have been dropping, with the average waiting time currently standing at 6.9 months.

Professor Barros said that it will be challenging for the Ministry of Health to increase healthcare spending at a time when public spending is being curtailed because of the Portugese budget deficit, although there are also opportunities for the Portuguese health system.

“The European directive on patient mobility in the field of healthcare is an opportunity to rethink the system of provision of healthcare in an enlarged space, which forces one to work in another way: concentration of activity to gain economy of scale, reducing medical error and increasing quality, but being aware that it isn’t possible to be a European centre of excellence at everything, said Professor Barros.

“If Portugal managed to fight against tax evasion effectively, it would pay the debts of the national health service in just one year,” said Professor Silva. “The main solution for the biggest problem of the service, which is its funding, can’t be found in healthcare but rather in the global improvement of the economy and particularly in tax enforcement.”


Cite this as: BMJ 2012;344:e379