Will austerity cuts dismantle the Spanish healthcare system?

Trilla and colleagues take issue with some aspects of our paper “Will austerity cuts dismantle the Spanish health care system?” as they relate to cuts in the Catalonian health budget. We understand the interest that they have in defending the decisions that their employer (the Catalan Agency for Health Quality Assessment) has made regarding the Catalan health system. Throughout, they cite various unpublished data but we are dependent on information that is publicly available; we do not have access to the official records cited by the authors so we are not in a position to judge their rigour or veracity. If these data can elucidate the situation more accurately, we would urge the Catalan government to make them available for independent analysis.

In terms of specific points, the authors contend that the Catalan Government has been forced to cut its public health care budget because of reduced transfers from the central government. Yet all Spanish regions have faced similar reductions. The 10% reduction in Catalonia and the 7% cut in Madrid contrast with much smaller reductions in other regions, and even increases in Andalucía and Asturias. This suggests that autonomous communities are able to choose how to deploy the funds available to them.

We agree that per capita public health care expenditure was around €1,150 (€1,128), representing a 13% cut from 2011, and 7% below the Spanish average, at €1,2101. However, this means that even before the crisis, Catalonia was already spending less on public health than the rest of Spain.

In describing the cuts, the authors describe four ways that these have “materialized”, but unfortunately they do not describe the decision-making process. Has the Catalan government carried out a study that explores the impact of the suggested measures in terms of savings and the expected impacts on the health care system and on the health of the Catalan people?

The authors agree with our report that salaries for health care professionals fell by 3% in 2010 but provide updated figures indicating a further 4% the following year. Thus, we actually underestimated the extent of the cuts in Catalonia, with health care professionals experiencing a reduction of over 12% of their salary in two years (with the additional 5% cut from Central Government).

The authors also report, for the first time from any official body, that waiting times for elective treatment have increased in Catalonia, as suggested in the media reports we cited. They also maintain that there is a waiting time guarantee for non-elective care. Are there any data recording the waiting times for common procedures? This would be very useful in undertaking a precise analysis of the effects of the crisis.

Another area subject to cuts is in pharmaceutical expenditure, which has been reduced both in terms of average price and in number of prescriptions. We were unaware that the total number of prescriptions had decreased, and again, this report indicates the need for an independent analysis of pharmaceutical data. Trilla and colleagues suggest that the €1 copayment has led to a decrease in “low value” prescriptions. How is the criteria for “low value” determined? A recent systematic review conducted by two of the authors of the BMJ paper (currently in Press) highlights how damaging copayments can be for the health of individuals and, ultimately, for health systems when the complications of treatable conditions are not averted. The costs of implementing the copayment should also be taken into account, especially considering that the system was suspended after only a few months when it was deemed unconstitutional.

The authors also mention that by discontinuing new investments in technologies and infrastructures the system is in danger of suffering a brain drain and will struggle to sustain the quality of the public system. We agree with the authors on this point, and it is not in contradiction with the arguments made in our paper. Doctors and nurses in Catalonia reported instances where the quality of health care was already being impaired as a result of the cuts. In addition, health care professionals reported not having the time to conduct research, as staff on holidays or those who had retired were not being replaced. Senior health care professionals supervising trainees recognized that the quality of the training was decreasing, and they reported being worried about the negative implications for the future generations of health care professionals, who they believed will be less prepared to provide good quality services.

Trilla and colleagues state that a reduction in emergency services will improve the quality of health care as they will be replaced by medical ambulances and 24 hour telephone assistance. However, we have heard reports that all three services have deteriorated since the cuts were introduced. Health care professionals reported delays in ambulance services threatening the health of patients. They also reported waiting times for telephone assistance increasing. In light of those reports and the lack of evidence to the contrary, we do not understand the claim that a reduction on emergency services is beneficial for the functioning of the health care system. A study conducted by one of the authors of the BMJ paper2 suggests that distance adversely affects the use of emergency hospital services in regions with dispersed populations, which seems difficult to reconcile with the authors’ conclusions.

The authors also contend that hospital beds have not been reduced, but this statement contradicts what has been published previously in the BMJ3 and what we have heard from health care professionals and managers of hospitals.

Furthermore, the authors affirm that no public hospital faces privatization. Yet, this contradicts the direct experiences of our interviewees and media reports suggesting that this is indeed being considered4. Can the Catalan Government state explicitly that no parts of the Hospital Clinic, Hospital Sant Pau, or Mar i Pere Virgili will be privatized?

We welcome the authors’ acknowledgment of the impact of the economic crisis on the health of population, including the worsening of general living conditions and the increase in suicides by 10% between 2010 and 2011.5 We are also eager to see what policies the Catalan government is proposing to ameliorate these worsening conditions.

The authors conclude that the health outcomes are good, presenting selected indicators for Catalonia. From a scientific standpoint, however more comprehensive data is needed to give a fuller picture, including emergency room wait times and waiting times for priority procedures.

In summary, while suggesting that our interpretation is incorrect, the authors do not dispute any of the figures on which we base it. However, they do allude to unpublished data that are not in the public domain. We believe that the scientific community and media have the civic responsibility to demand transparency and provide independent analyses based on available data. These analyses are not meant to antagonize governments but to support their correct functioning. In that regard, we look forward to receiving this information and using it to help the Catalan people understand the evidence base contributing to, and resulting from the reforms being implemented.

1. Federación de Asociaciones para la Defensa de la Sanidad Pública, Informe sobre los recortes sanitarios en las Comunidades Autónomas (Report of the health care cuts in the Spanish Autonomous Communitites). 2012.
2. Sanz-Barbero, B., L. Otero García, and T. Blasco Hernández, The effect of distance on the use of emergency hospital services in a Spanish region with high population dispersion: a multilevel analysis. Med Care, 2012. 50(1): p. 27-34.
3. Garcia-Rada, A., Wages are slashed and waiting lists grow as Catalonia's health cuts bite. BMJ, 2011. Oct:d6466.
4. Sacristan, J., La Generalitat negocia con un grupo japonés privatizar el Hospital Clínic (The Catalan Government negotiates with a Japanese group to privatize the Hospital Clínic), in El Economista. 2013, 4th July 2013.
5. Lopez Bernal, J., et al., The effect of the late 2000s financial crisis on suicides in Spain: an interrupted time-series analysis. Eur J Publ Health, 2013: p. doi: 10.1093/eurpub/ckt083.

This article raises a number of important public health issues for Spain but also for other European countries experiencing similar financial restrictions in adopting austerity measures to their healthcare systems. It also presents a range of poignant ethical issues, particularly regarding the doctor-patient relationship and relationships between healthcare professionals and institutions are worthy of further exploration.

For example, Box 2 in the article which contains the personal accounts of frontline healthcare staff in Spain reveals not only the financial implications of the cuts, but also the ethical dilemmas experienced in the new austere system. Many of the quotes show that frontline health professional feels a strong moral obligation towards their patients. It is this sense of obligation that appears to form the basis of ethical dilemmas when they cannot be fulfilled. The article makes reference to the consequences of these ethical dilemmas. For instance a hospital consultant recalls: ‘I was responsible for a patient in a critical condition, and I couldn’t do anything. This was very painful, and I had a horrible time.’

The obligations described in the article are familiar to many health care professionals and stem from the particular relationship that exists between the doctor and the patient; however, the newly imposed measures have altered the parameters of this relationship. Doctors find it difficult to adhere to the professional and ethical standards which they previously upheld. A newly appointed GP in Box 2 confesses: ‘I had not seen a patient in 20 years. . . I am going to try my best, but I am aware that I am not competent to treat my patients properly.’ This quote clearly articulates the compromise doctors are expected to make regarding professional standards, and consequently ethical standards (non-maleficence, beneficence).

The implications of the new measures are not only seen at a financial level, but they have important ethical and professional components as well. Paying attention to the ethics of medical practice in the newly emerging healthcare landscape in Spain, and other European countries, would give a much more comprehensive view of the effects of austerity in healthcare.