Will austerity cuts dismantle the Spanish healthcare system?BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2363 (Published 13 June 2013) Cite this as: BMJ 2013;346:f2363
All rapid responses
Since the emergence of this crisis numerous studies and research projects have documented the negative health consequences associated with the restriction of rights and the imposition of “savings” on our precarious (in relative terms compared to countries with equivalent income levels) system of social protection and, more specifically, health care.
Simultaneously, many relevant forums have urged the public health community to reinforce evidence on how the economic crisis and measures imposed on “their beloved” were negatively impacting the health of individuals and communities. The evidence thus produced could be used to strengthen arguments when confronting the dominant political and economic discourse.
We believe there is strong evidence that: 1) universal health systems 2) high public financing and coverage for all 3) using primary care physicians as gatekeepers to specialists and other medical resources 4) without charging patients who visit their doctor (or applying only minimal charges) and 5) staffed by well-trained professionals -- which is to say, systems such as Spain’s up until one year ago -- are valued by those who use them and generate positive health outcomes. That evidence is already available to us (1-3).
We know that our societies’ dominant values include the possibility of being treated for an illness within a quality, accessible health system or confiding that predictable health risks are being taken into account and addressed by our public authorities.
But we also know that health, despite being an asset extremely valued by all, is not the only prism for interpreting reality and that other perspectives must also be considered, ones centered on our countries’ socially dominant values that have made it possible over time to construct a Europe concerned about providing its population with basic social rights.
And it is through that prism we believe it unacceptable to deny health care to an undocumented immigrant with an infectious contagious disease: not just because of an increased risk of transmitting the disease to the rest of the community (something which may or may not occur), but because it is immoral and violates our societies’ collective human sentiment, as well as the basic rights of any sick individual. These effects are not potential risks, they are facts. Working with excluded populations does not acquire relevance because of its proven effectiveness in diminishing social conflict and reducing collective health risks, but rather because it represents an attempt to address the needs of each and every individual who finds himself in such a situation.
We believe it necessary to broaden the perspective for considering which relevant information should be marshaled to support and sustain our public health systems. As we build an evidence base we would do well to consider how to challenge democratic political decision makers whose aggressive attacks on our collective values and desires are formally based on an analytical model centered on one specific underlying current – economic rationality – characterized by an attitude of “who cares about the other data?”
Aside from resorting to conspiracy theories as a key for explaining certain dominant trends, it could be that our own public health paradigms are “distracting” us - blurring our focus and diminishing our capacity to exert influence. Beyond supplying data to reinforce that which is already evident, perhaps we should be participating more actively in the vast network of social movements committed to forging new paths to preserve the values of justice, equity, and greater social control over political decisions.
Social values ascribed to by a majority of the population, hopes and fears harbored by Europeans, models for managing political conflicts between active citizens and professionals – that’s the kind of information we need most urgently in the midst of this crisis (4, 5).
(1) Starfield, B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac. Sanit. Volume 26, Supplement 1, March 2012, Pages 20–26
(2) World Health Organization. Research for universal health coverage. World health report 2013. http://www.who.int/whr/2013/report/en/index.html
(3) Rodrigo Moreno-Serra, Peter C Smith “Does progress towards universal health coverage improve population health?” Universal Health Coverage 1 Lancet 2012; 380: 917–23
(4) John R Ashton “We need a citizen’s coalition to save the NHS”. The Lancet, Volume 382, Issue 9886, Pages 17 - 18, 6 July 2013
(5) McKee M.; Stuckler D. “The assault on universalism: how to destroy the welfare state” BMJ 2011;343. Published 20 December 2011
Competing interests: No competing interests
Friends, Catalans, countrymen, lend me your ears
We come to bury our Public Health System, not to praise him.
The evil that men do lives after them;
The good is oft interred with their bones.
So let it be with the Catalan Public Health System. The noble Legido-Quigley et al
Hath told you the Catalan Health System was dismantled and is not transparent.
If it were so, it was a grievous fault,
And grievously hath the Catalan Government answer'd it.
We speak not to disprove what Legido-Quigley et al spoke,
But here we are to speak what we do know.
Above and beyond Julius Caesar words, this response is not intended to start an endless discussion with Legido-Quigley et al. We believe there is not any added value on that. Nonetheless, there are three specific points in which a clarification is needed because the public health community as well as the Catalan citizens deserves to know:
First, Legido-Quigley et al said that we cite unpublished data and urge the Catalan government to make them available for an independent analysis. This statement is false. All information regarding average price and total number of prescriptions, split by Regional Government, is fully available to citizenship on the website of the Spanish Ministry of Health (1). All information regarding waiting times by surgical procedure is published and updated every 6 months on the website of the Catalan Health Service. This information is open to citizenship since 2004. It is a shared effort and commitment of both past and current Catalan governments (2). Indeed, the Catalan Minister of Health presents himself the results, which has an high impact on mass media, to high to believe that Legido-Quigley et al have never heard or read about it(3). Catalonia is the first Autonomous Government in Spain that publishes meaningful health results indicators by health center, both in specialized care and primary care, as well as (starting from 2013) in long-term care and mental health care. Catalonia started this initiative in 2009 in order to drastically increase transparency. It has been highly valued by both the scientific community and the media (4). The Catalan Agency for Health Quality and Assessment (AQuAS) hosts a yearly public presentation in which the main results are made public and debated, with an attendance of roughly 600 health professionals and representatives of political parties, trade unions and patients’ associations leaders (5). All the information is available in open-data format, following high-end transparency standards in the website of the Observatory of the Catalan Health Care System (6).
Second, the authors state that even though the fact that all Spanish regions have faced similar reductions in transfers from the Spanish government, other regions has reduced their health budget in a smaller proportion than Catalonia. This suggests that autonomous communities are able to choose how to deploy the funds available to them, an utterly flawed statement. On one hand, per capita spending by region is directly correlated with total public budget per capita, which in turns depends on both the capacity of the region to generate value (GDP) and how taxes paid (directly or indirectly) to the Spanish government are distributed back to the autonomous governments. It is well acknowledged, both by the Spanish Government and the Catalan Government, that Catalonia suffer a fiscal deficit of almost 6-8% of Catalan GDP, which accounts for approximately 1.2 - 1.8 times the current Catalan healthcare budget (7-8). One may argue that this situation is common in richer regions of the European Union. However, when similar cases in regions with same per capita GDP are analyzed, total fiscal deficit never exceed 3% of GDP. It is fair to say that the Catalan Government has decided, both in 2011 and 2012, to increase the total weight of its healthcare spending over the total public budget. Without any doubt, a clear priority of the Catalan Government is the wellbeing and sustainability of the Catalan Health Care system, especially in such a difficult times.
Third, the authors ask the Catalan Government to unambiguously state that no parts of several large hospitals (like Hospital Clinic, Hospital Sant Pau, or Hospital del Mar) will be privatized. The Catalan Government has clearly answered this question where it needs to be answered, which is at the Catalan Parliament. There is not any public Catalan hospital facing dire privatization. We suggest Legido-Quigley et al to name just one case where this Government has privatized a public hospital.
Last, our fair expectation is that Public Health experts should better know which information is available (especially of this relevance) and proceed accordingly to it.
(1) Spanish Health Ministry website: http://www.msssi.gob.es/profesionales/farmacia/datos/home.htm (accessed July 10th, 2013)
(2) Catalan Health Service Website. Direct link to surgical waiting times: http://www10.gencat.cat/catsalut/cat/servcat_diagnostic_reg.htm (accessed July 10th, 2013)
(3) EL PAIS (Several articles); 4.10.2011; Los recortes de Salud disparan las listas de espera el 23% en seis meses; http://elpais.com/diario/2011/10/04/catalunya/1317690441_850215.html (accessed July 10th, 2013)
EL PAIS; 21.03.12; Las listas de espera aumentan el 43% por los recortes de Mas en sanidad; http://ccaa.elpais.com/ccaa/2012/03/21/catalunya/1332363175_584279.html (accessed July 10th, 2013)
14.01.13; La espera para ser operado en Cataluña crece en otros 11 días en un semestre; http://ccaa.elpais.com/ccaa/2013/01/14/catalunya/1358168395_432403.html (accessed July 10th, 2013)
(4) EUROPAPRESS; 13.07.12; La actividad hospitalaria cae un 2% en Cataluña, pero mantiene los estándares de calidad; http://www.europapress.es/salud/asistencia/noticia-cataluna-actividad-ho... (accessed July 10th, 2013)
(5) Public presentation of Results Centre (Central de Resultats): http://www20.gencat.cat/docs/canalsalut/Minisite/ObservatoriSalut/ossc_A... (accessed July 10th, 2013)
(6) Website of the Observatory of the Catalan Health System: observatorisalut.gencat.cat/ (accessed July 10th, 2013)
(7) Resultats de la balança fiscal de Catalunya amb el sector públic central any 2010; Departament d’Economia i Coneixement; Generalitat de Catalunya; Maig de 2013 http://www20.gencat.cat/docs/economia/70_Economia_SP_Financament/documen...(summary)%20(2).pdf (accessed July, 10th, 2013)
(8) Las balanzas fiscales de las CC.AA españolas con las Administraciones Públicas centrales; 2005; Ministerio de Economía y Hacienda; 15 de Julio de 2008. http://www.meh.es/Documentacion/Publico/GabineteMinistro/Varios/Balanzas... (accessed July 10th, 2013)
Competing interests: No competing interests
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.
Competing interests: No competing interests
The article of Legido-Quigley et al. uses, almost exclusively, examples referred to the Catalan health system although it deals about the Spanish one. As the authors should know, there are a lot of differences between those systems, some of them very important in the context of their paper.
The Catalan health system, since it reached its autonomy in the late eighties, is based on a hospital network provided by a majority of private non profit organizations which have publicly funded budgets through contracts with the regional government. According to that, in 1992 the proportion of beds in Catalonian hospitals receiving public funds was about 85% for acute treatment and around 100% in chronic and psychiatric areas. In 2010 the situation was still very similar with only 10% of beds for acute treatment in pure private hospitals. This is different from the majority of regions of Spain, in which, since 2002, when most of them got their autonomy for health care management, most of the centres are publicly owned, publicly funded and are staffed by civil servants.
According to that, when the authors comment about the population satisfaction with the Spanish system and its relative good performance before the budgetary cuts, they should agree that they are also speaking about the results of this “private system” held in Catalonia. Furthermore, this could be considered one of the “evidence based results” they claim to be lacking when they criticize the winds of “privatization” undergone in the country. As they could see in many official statistics, health indicators in Catalonia are better than those of several other regions, even if they have health budgets per capita much higher. For that reason, the authors should be more precise about what they meant by “privatisation in the Spanish system” and they should not put Catalonia in the same basket of “hospital privatizations” promoted in Valencia and Madrid.
One aspect in which many of the Spaniards surely will agree with the authors is that corruption is one of the worst problems we have to face in Spain, and not only in the health services area. Nevertheless, corruption cases in Catalonia, as well other important scandals affecting members of several regional governments, like Baleares Islands, Valencia, Andalucia, Madrid and even the Spanish minister of health, should not be related to the systems, but to the persons. Furthermore, many experts on public health and health economics talked about the unsustainability of the Spanish health system before the global economical crash. Among other important problems, and not only the budgets per capita, the efficiency of several health services in some of the Spanish regions should be improved. Thus fighting against corruption, rationing budgets and improving the efficiency of the health services are not only compulsory due to the present circumstances, but probably the only way to ensuring an acceptable good public health system for the future.
Competing interests: Working in the Catalan Department of Health but I am expressing my personal opinion as a public health specialist.
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.
Competing interests: No competing interests
We read with interest (but also with a dispassionate amount of disbelief) the article published by Legido-Quigley and colleagues (1). Although it makes a general description of the Spanish economic situation, together with some of the recent changes in the Spanish healthcare system, we would like to make several clarifications regarding the situation of the Catalan healthcare system, which seems to be a central aim of the paper.
Catalan public healthcare expenditure per capita was 1.150 € in 2012, representing a 38% share of the Catalan yearly budget and, together with private expenditure, an 8.7% of Catalan GDP (2011). Although Spanish regional governments, such as Catalonia, assume almost all competencies on healthcare (except for pharmaceutical regulation, border health issues, and international health relations), funding comes from a transfer from the central government. The weak situation of the Spanish economy has brought a lower income to the Spanish central government and, subsequently, lower transfers of funds to the regions.
Given the lower budget, “cuts” have materialized in four ways.
First and foremost, a 7% decrease in the salaries of healthcare workers in 2011 and 2012, on top of the 5% decrease established in 2010 by the Spanish government. This salary decrease has led to a lower purchasing power of health professionals, as it has been the case of all public workers (education, transports, social services, etc).
Second, a 6% decrease in the volume of activity reimbursed with public funds (mainly hospital discharges). As a consequence, waiting lists for elective surgery increased. However, due to a 2% increase in surgical activity in 2012, all non-elective surgical procedures as well as those related with severe conditions (e.g. oncology, ischemic heart disease) are under a maximum waiting time warranty from the public health system.
Third, a reduction in pharmaceutical expenditure, both in terms of average price and total number of prescriptions. In 2011, public pharmaceutical expenditure was reduced by 8,7% and in 2012, by an additional 14.1%.
Fourth, by means of discontinuing new investments in technologies and infrastructures. Our system is indeed in danger of suffering a drain of highly talented and well trained professionals, facing also a lesser ability to attract biomedical research like clinical trials and, above all, struggling to sustain the current high quality of our public healthcare.
Preliminary results of the impact of the 1€ fee on drugs (with upper limits on those using large quantities of medicines, but also with exclusions for seniors and people on low incomes) show that the number of prescriptions of pharmacological “low value” has decreased. The reduction of emergency care in primary care centres is part of a global health policy that started in 2008, restructuring all low-volume emergency care services in order to provide higher quality and more accessible services, by means of medical ambulances and telephone assistance 24/7. Finally, the number of beds in Catalan hospitals has not been reduced by 30% (as a matter of fact, four new hospitals started their operations in 2010) and there is not any public Catalan hospital facing dire privatisation.
Nobody denies the impact of the economic crisis on the health of population, mainly as a result of the worsened general living conditions. Higher unemployment rates, lower salaries, and lower public investment have a direct impact on health, beyond the impact of public healthcare system. As an example, suicides have increased by 10% between 2010 and 2011. However, the Catalan public healthcare system still provides the highest standards of care to all citizens. The health results are good ones (Table).
Opinions should better be based on facts. If not, they risk being considered demagogical to some extent. Unfortunately, we believe that the paper by Legido-Quigley et al shows a trend to the latter.
Our main goal is to improve the situation of the Catalan economy and of our public health system, mainly by being able of recovering and self-managing our financial resources: those that the Spanish Government does not fairly give back to Catalonia.
(Note: All authors are members of the AQuAS, the Catalan Agency for Health Quality and Assessment)
(1) BMJ 2013;346:f2363
(2) Institut d’Estadística de Catalunya, IDESCAT (2006, 2010-2012). (Catalan Statistics Institute)
(3) Enquesta de Salut de Catalunya (2006, 2010-2012). Departament de Salut (Catalan Health Status Survey. Departament of Health). www.gencat.cat/salut/esca
(4) Anàlisi de la mortalitat a Catalunya (2006, 2010-2011). Departament de Salut (Mortality Analysis in Catalonia. Department of Health)
(5) Registre del Codi Infart de Catalunya. Pla Director de Malalties de l’Aparell Circulatori (2006, 2010-2012). (Registry of Infarct Code in Catalonia. Circulatory Diseases Master Plan for Catalonia)
(6) Sistema online d’informació de l’ictus agut. Pla Director de la Malaltia Vascural Cerebral (2006, 2010-2012). (Online Information System of Stroke. Brain Vascular Disease Master Plan for Catalonia)
(7) Servei Català de la Salut (2006, 2010-2011). (Catalan Ministry of Health)
(8) Organització Catalana de Trasplantaments (2006, 2010-2012). (Catalan Transplant Organization)
(9) PLAENSA, Pla d'enquestes de satisfacció (2006, 2010-2012). (Satisfaction Survey Plan)
Competing interests: No competing interests