Sustainability and Future of the Spanish Healthcare System

Author: Tanita Rósenova Sábeva

Tutor: Xavier Martínez-Giralt Dept of Economics and Economic History Universitat Autònoma de Barcelona

Presented: Bellaterra, May 2013

Introduction Spain has recently seen major social protest defending public healthcare in the country. The reasons for it are the direct result of the global economic crisis which plunged Spain into a recession. The country is hard-pressed to save money and the budgets for basic services such as healthcare and education have been reduced in the last 2 years. To obtain more financing some of the regions implemented unpopular measures. The spending cuts and prescription co-payment which affected healthcare in Catalonia as well as the privatisation of 6 hospitals in Madrid are good examples as they caused a considerable public uproar and mass demonstrations on the streets. Efficiency gains and the need to save are the main reasons given by the incumbent authorities for all the recent modifications affecting healthcare but this explanation does not seem to be enough.

Looking deeper into the issue, two very important concerns arise. The first of them is the direct problem of the restructuring of healthcare personnel caused by the privatisations and budget constraints. Many people in weak positions are likely to find themselves in very precarious work conditions. The second concern has to do with the erosion of trust in politicians which is widespread around the country. The part politicians played in causing some of the past excesses in Spain is hard to overlook. Now that savings must be mustered at all costs to pay off those excesses the mistrust focuses on the people connected to the reforms. Rumours are hard to ignore, especially when some of the managers-to-be in the private hospitals have links to the governing political party.

With this in mind, the reason for expenditure cuts and sacrifices becomes more interesting. Going through the official documents, the sustainability of the healthcare system is mentioned repeatedly as the cause for the various reforms limiting coverage and changing the functioning of the service. Allegedly, unless public spending on healthcare decreases notably, the stability of the system will be in jeopardy. This work aims to discover if the public healthcare system in Spain is indeed unsustainable or whether there are other interests at play fuelling the debate.

Index

Introduction 3 1. Background 7 1.1. Historical perspective 7 1.2. Defining Sustainability 8 2. Organisational structure of healthcare in Spain 11 2.1. Guiding principles of the Spanish National Health System 11 2.2. Organisation of the Spanish National Health System 11 2.3. Functional Organisation of the NHS 14 3. Resources of the Spanish Healthcare System 16 3.1. Hospital resources 16 3.2. Rates of usage for specialised care 20 3.3. Primary Healthcare resources 21 4. Comparison of resources across OECD countries 23 5. Performance of the Spanish NHS: 2000-2011 comparison 25 5.1. Public satisfaction indicators 25 5.2. Objective performance indicators 26 5.3. Health indicators 28 6. The financing of Spanish Healthcare 29 6.1. Healthcare expenditure in absolute values 31 6.2. Financial circumstances of the Autonomous Regions 32 6.3. Breakdown of public healthcare expenditure 34 6.4. Financial trouble in the NHS 35 7. Sustainability Analysis of the Spanish NHS 37 7.1. Priority analysis 38 7.2. Current measures taken to address short and long-term problems 39 8. Outlook to the future 41 8.1. Reforms for the NHS 41 8.2. Key points for the reform 42 8.3. The case for public-private agreements 43 9. Conclusion 45

Annexes 46 Annex I – Detailed breakdown of hospitals in Spain, sorted by functional control type 47 Annex II – OECD data for selected healthcare indicators 48 Annex III – Selected questions from the “Healthcare Barometer” 53 References 61

Figures and Tables

Figure 1: Broad classification of responsibilities in the Spanish NHS 12 Figure 2: Hospital distribution in 2012 17 Figure 3: Distribution of hospital beds in 2012 18 Figure 4: Distribution of hospital personnel in 2009 19 Figure 5: Healthcare financing breakdown by financing agent, year 2003 30 Figure 6: Healthcare financing breakdown by financing agent, year 2010 30 Figure 7: Healthcare expenditure evolution over the period 2003-2010 31 Figure 8: Healthcare as percentage of GDP, evolution over the period 2003-2010 31 Figure 9: Per capita budget in Spain’s Autonomous Regions, 2010 33 Figure 10: Healthcare Budget per capita in Spain’s Autonomous Regions, 2010 33 Figure 11: Public healthcare expenditure classified by expenditure item, 2008 34

Table 1: Hospitals sorted by functional control type 16 Table 2: Available beds in Spanish hospitals sorted by functional control type 17 Table 3: Distribution of healthcare personnel in Spanish hospitals, evolution over time 18 Table 4: High-technology medical devices in Spanish hospitals, evolution over time 20 Table 5: Healthcare usage indicators, evolution over time 20 Table 6: Primary Healthcare centres in Spain 2004-2011 21 Table 7: Quality indicators for specialised care in Spain, 2000-2011 27 Table 8: Waiting times (days) for specialised interventions and consultations 27 Table 9: Life expectancy at birth and mortality rate per 100 000 population, 2000-2011 28

1. Background 1.1. Historical perspective When does the issue of healthcare sustainability arise? Since most of the healthcare spending in Spain comes from the public budget the first thing to consider would be fiscal sustainability.

The first formal attempt to regulate fiscal policy in Spain took place in 1992 with the signing of the Maastricht Treaty. Within the European Union framework all countries were to adopt economic measures in order to converge to a similar level and make the Union more stable as a whole. Reference values were established for deficit (3% of GDP) and debt (no more than 60% of GDP). The European Commission was appointed as supervisor, reporting progress and breaches to the European Council which, in turn, could impose fines or implement supporting programmes to deviating Member States.

For 10 years the economic situation progressed smoothly. Spain managed to reduce its debt level and deficit was well under the 3% threshold. The prize for this solid economic behaviour was to be included in the Monetary Union, the next step towards economic integration in the EU.

After the adoption of the Euro the Spanish economy was buoyant and further improvements were reached regarding debt and deficit. For the years 2005-2007 there was a current account surplus and debt was reduced to 36.3% in 2007.

When the financial crisis reached Spain in late 2008 it collapsed the construction and financial sectors and by 2010 their growing trouble had caused unemployment to soar to 20%. The Government tried to boost growth by increasing its own spending and creating temporary jobs, mainly on infrastructure building and renovation. This was done under the name “Plan E” and lasted through 2009 and 2010.

The final result was a great increase in debt levels (from 40% of GDP in 2008 to 61% in 2010) with almost nothing to show for it. The situation was worsened by the monetary constraints inherent to Spain’s membership of the Eurozone. The economy was almost free falling and debt levels reached 69% of GDP by the end of 2011. Ultimately this put Spain at the centre of the recent sovereign debt crisis, eroding confidence in its leaders and causing interest rates on sovereign bonds to soar.

It was in this turbulent environment that the European Union decided to act, setting a course for the recovery of its Member States. The emergency policies at the national level were deemed unsuccessful and contrary to the European goal of working towards European economic integration. In order to return to the integration path a strategy called “Europe 2020” was approved in 2010. It built on the Lisbon Strategy approved in 2000, meant to improve competitiveness across the EU, and defined new

7 objectives: growth and jobs created in a stable economic environment. Within the context of Europe 2020 all member states have to work with the best possible coordination to ensure a speedy recovery from the crisis.

Sustainability of public finances is a very important part of Europe 2020. All EU countries, but especially the ones most affected by the sovereign debt crisis, have to take drastic measures to reduce deficit and debt. A benchmark of 2.6% of GDP was set for annual deficit reduction in the case of Spain (for the period 2011-2013). This measure is considered essential but not superior to all other concerns. Social discontent, unemployment, education levels and research stagnation also have to be addressed. Thus, the additional detail on the guideline specifies that taxes should not harm growth, age-related spending (including healthcare) should be reformed and expenditure should be focused on the aforementioned areas of economic and social interest.

The reports and articles concerning the recent healthcare reforms don’t talk about fiscal sustainability but rather about the sustainability of the public healthcare system. The policy-makers of the European Union also seem convinced that age-related public spending must undergo a reform. Following a logical reasoning, since healthcare represents a big share of the State budget any small modification multiplied by the sheer volume of the service could mean a big saving. However, healthcare is a complex public service and sustainability has different implications depending on the definition we associate with it.

1.2. Defining Sustainability When first conceived, sustainability was a term associated with the environmental problems that the Earth is facing, used to explain the depletion of resources. Whenever a given resource is being exploited at a rate faster than its recovery rate we refer to this exploitation as “unsustainable”.

Nowadays the concern about resources is present everywhere. No matter what, when considering a long-term strategy, resource sustainability must be an integral part of it. For this reason the definition can be considered too general. The economic point of view is necessary for a better analysis.

Definitions of economic sustainability vary despite the wide usage of the term. It would seem that the common notion of it is considered sufficient for discussion. Thus, I will try to describe my own understanding of economic sustainability as best as possible. Simply put, economic sustainability consists in the efficient and environmentally responsible use of available resources to maximise the long-term objectives of an organisation or State. It is usually associated with financial gains (or growth of the economy) but complications arise with some activities – like the provision of healthcare.

Publicly provided healthcare is a loss-making service by definition. Resources are pumped into it but results are almost impossible to quantify since they mostly translate into a general state of well-being. The long-term objectives of a healthcare system are different from those of a private company or even a government and the economic point of view falls short – it doesn’t take into account the social factors involved.

A comprehensive definition of a sustainable healthcare system, provided by the Alliance for Natural Health (2008), is the following:

“A complex system of interacting approaches to the restoration, management and optimisation of human health that has an ecological base, that is environmentally, economically and socially viable indefinitely, that functions harmoniously both with the human body and the non-human environment, and which does not result in unfair or disproportionate impacts on any significant contributory element of the healthcare system.”

This description encompasses three types of sustainability: environmental, social and economic. It also voices a concern for all the people involved in the healthcare system, including the contributors who fund it. For all its detail though, this description is vague in the sense that it doesn’t give any clues as to what is considered unfair or disproportionate.

What would happen if society was willing to sacrifice more to enjoy the current level of healthcare provision or to improve it? Their willingness would make the economic impact acceptable and the system viable. It serves to illustrate a less orthodox point of view. Reinhardt (2001) considers that, for the issue of healthcare and benefits, sustainability is all about the distribution of money. Depending on the morals of a society a level of sacrifice will be considered viable or non-viable. Sustainability, he argues, is an issue of what the members of society owe to each other.

So far the definitions seem out of reach for a practical work such as this one. Defining fiscal sustainability might be of help since it provides a possible benchmark for the economic sustainability of State-financed services such as healthcare. Dr. Anne-marie Boxall (2011) states the following in a research paper concerned with the sustainability of healthcare in Australia:

“[F]iscal sustainability in public finances means that governments must be able to pay for all their financial obligations without making radical adjustments to taxes or shifting the burden of debt onto future generations.”

Therefore, if there was a growing trend in healthcare spending over and above GDP growth its fiscal sustainability could be questioned. If healthcare expenditure

9 constituted a contributing factor to a mounting debt (with no perspective of recovery since the service makes a loss) then future generations would be worse-off for it.

As has been argued, it is easier to talk about sustainability than to fully understand its meaning and content. Going from the moral to the purely economical, the concept is elusive. For the purpose of this work, I propose working definition for a sustainable healthcare system resulting from a blend of the definition used by Dr. Boxall (2011) to explain fiscal sustainability and the one provided by the Alliance for Natural Health (2008). Thus, we refer to a sustainable healthcare system as:

“A complex system of interacting approaches to the restoration, management and optimisation of human health that is environmentally, economically and socially viable indefinitely and which does not result in unfair or disproportionate impacts on any significant contributory element of the healthcare system. Economic viability must be achieved without the Government making radical adjustments to taxes or shifting the burden of debt onto future generations.”

The key words are “socially viable” and “indefinitely”. It is easy to see that in the short term the Spanish Government will have to abide by the European directives and strategies, and the deficit and healthcare objectives will be synchronised with those of other Member States. However, the essence of the concept is the long-term and the objectives of the healthcare system. This means that reforms must look to the future after the current crisis and find a strategy which allows them to achieve a more efficient healthcare provision without detracting from social well-being. The foreseeable future should substitute for “indefinitely”, suggesting a period of at least 10 years when considering the sustainability of the healthcare system.

The present work will look at the immediate causes for concern and analyse the sustainability of the National Health System within the pre-defined framework. It will also evaluate some of the short-term measures taken to deal with the problems. Finally, it will recommend a course of action based on the analysis undertaken previously.

2. Organisational structure of healthcare in Spain Healthcare provision in Spain is organised following the NHS-Beveridge model, integrating private and public entities. The main healthcare providers are:

 The National Health System  Private insurers and mutual funds  Private professionals (dentists, etc.)  Charities and other not-for-profit entities

The National Health System is by far the most complex organisation and the only one that strives to cover the entire population. It is the only public provider of healthcare.1 To gain some insight into its functional model an organisational analysis is necessary.

2.1. Guiding principles of the Spanish National Health System Article 43 of the Spanish Constitution of 1978 establishes the right to health protection and healthcare for all citizens. The principles and criteria enabling the exercise of this right are materialised as follows:

 Public funding, universal coverage and free healthcare services at the time of use.  Defined rights and duties for citizens and public authorities.  Political decentralisation of healthcare devolved to the autonomous regions.  Provision of comprehensive healthcare, striving to attain high levels of quality duly evaluated and controlled.  Integration of different public structures and health services under the National Health System.

2.2. Organisation of the Spanish National Health System Over time healthcare competences in Spain have changed hands: at first the State managed the whole system but this responsibility was gradually transferred to the 17 Autonomous Regions the country is split into. The process ended in 2001 when the last 10 regions accepted competences from the State.

The objective of this structural change was to bring healthcare closer to the citizens. Seeking their participation ensures that quality changes take the users’ expectations and needs into account first and foremost.

Clearly a reform of this magnitude brought about its own complications. The chief concern was to maintain standards across the country and to ensure constant communication between the Central Administration and the regional bodies

1 The National Health System draws on the resources of the private sector at need, in order to reduce waiting lists and to have extra capacity in reserve. 11 responsible for healthcare management. These tasks fall onto the Inter-territorial Board of the NHS.

The NHS Inter-territorial Board

The Inter-territorial Board of the National Health System is the body responsible for the coordination, cooperation and liaison among the Central and Autonomous Region public health administrations. Its responsibility is to guarantee that all Spanish citizens receive the level of health services that they are entitled to without discrepancies throughout the territory.

Its main organs are Board itself and its Delegate Commission, integrated by high representatives of the Ministry of Health, Social Services and Equality and the regional Departments for Health. Many sub-committees work closely with the Board in order to provide it with relevant information and working groups can be created at its discretion to investigate matters of interest.

A third important organ is the Consultative Committee which provides a link to the people most involved in the NHS – employers and employees. It has representatives of both trade unions and employer’s organisations and has an advisory role.

Figure 1: Broad classification of responsibilities in the Spanish NHS

Source: National Health System of Spain, 2010

Central Government It is represented by the Ministry of Health, Social Services and Equality in all matters regarding health. Thus, the Ministry is the ultimate coordinator for the dependent bodies concerned with the individual regulatory, management and control objectives.

These are:

Healthcare Regulation and Coordination:

 General Directorate for Public Health, Quality and Innovation: its functions include detailing the regulation framework on epidemiological information, health promotion, disease prevention, occupational health and environmental health and ensuring its effective implementation. This General Directorate also holds responsibility for the inspection of the NHS and the local Health Services and for the provision of relevant information on the NHS.  General Directorate for Professional Planning: responsible for the coordination and planning of the human resource requirements of the NHS. Its duties are to study the current organisation and its future needs and emit proposals for the management of specialised health education and the planning of the active human resources.  General Directorate for Basic NHS Services and Pharmaceutics: establishes the services that the NHS will provide to the public. o National Transplant Organisation: coordinates the assignment of organs, tissue and cells throughout the territory ensuring that the basic principle of equality is fulfilled.  Spanish Food Safety and Nutrition Agency: responsible for ensuring the highest possible safety degree for food and for promoting healthy nutrition.

Foreign Health:

 General Directorate on Public Health, Quality and Innovation: regulates the provision of epidemiological information and all foreign health issues in accordance with EU treaties and agreements. Its responsibilities include overseeing the implementation of the regulation.

Pharmaceutical Policy:

 General Directorate for Basic NHS Services and Pharmaceutics: responsible for pharmaceutics policy, it establishes the public prices for medicines and other healthcare products and how they are to be dispensed. It is also responsible for the public financing of medicines and medical products.  Spanish Agency for Medicines and Medicinal Products: responsible for the evaluation and the authorisation of medicines and medical devices for use in humans and animals. It also performs quality control on the medicines and devices and has the obligation to inform the public of all relevant issues.

Management of INGESA:

 General Directorate for Basic NHS Services and Pharmaceutics o National Health Management Institute (INGESA): this entity manages the healthcare services in the autonomous cities of Ceuta and Melilla. This is the only direct managerial responsibility of the Central Government.

Governments of the Autonomous Regions

They have the responsibility of organising healthcare within their jurisdiction. Each of the seventeen Autonomous Regions has a Department for Health which regulates and plans the provision of healthcare and its own Health Service which acts as provider or purchaser of services. Other non-health administrations in the region which collaborate with the Department for Health are under its guidance and responsibility.

Each autonomous Government is free to organize its Department for Health into as many bodies as it deems necessary. The simplest is the Cantabrian Health Department with three separate bodies: the Secretariat General, a General Directorate for public health issues and a General Directorate for healthcare planning. None of them manages resources directly, since that function is reserved for the Health Service. The latter is organised into four branches, one manages primary healthcare and the rest have part of the territory assigned to them.

By contrast, the most complicated organisational chart belongs to the Comunidad Valenciana Health Department. It has an Autonomic Secretariat, a Sub-secretariat which oversees the territorial divisions and also 6 General Directorates and 16 Sub- directorates responsible for multiple areas covered by bodies called “Services”. The regional Health Service is included in the count, so the difference is smaller than what the first impression suggests, but it is nonetheless considerable. The regions of Catalonia and Madrid present similarly complicated organisations. Catalonia in particular is burdened by many territorial divisions and some public enterprises and independently managed bodies which add to the complexity. This is due to the historical evolution of the territory and of healthcare provision in the region.

2.3. Functional Organisation of the NHS The Health Services are the bodies responsible for the management of the health centres and facilities in their respective regions. These centres can be classified into:

 Primary healthcare centres: they cover basic services and are available within 15 minutes of any place of residence. They provide home care when necessary. The professionals in these centres have a close relationship with their patients. They fulfil a gatekeeping role: only they can refer patients to specialist treatment. It is also their responsibility to provide follow-up care after it has 14

been completed. Because of their proximity to the population, promoting healthy habits and disease prevention is also a responsibility at the primary healthcare level.  Specialist healthcare centres and hospitals: they provide specialist care in the form of inpatient and outpatient care. They also provide complex diagnostic tests following referral from primary healthcare centres.

These centres are organised in Health Areas, with at least one hospital per area, and basic health zones where primary healthcare centres are based. The criteria for the dimension of a health area or zone are mainly geographic, demographic and social.

The regional Departments for Health are free to establish different management types for these centres but they have the ultimate responsibility on them. This has led to multiple systems of public-private cooperation in the ownership and management of the facilities. This is especially valid for Specialist Care centres which entail a much bigger investment.

Public-private interaction models within the NHS

 “British model” for hospital management: a private entity builds a hospital at the commission of the public authorities and manages all of it except the healthcare personnel. It receives annual payments from the public budget until the investment is recovered.  “Alzira model” for hospital management: similar to the British model but including the management of healthcare personnel. The public administrations pay a stipulated amount per inhabitant of the Health Area covered by the hospital until the investment is recovered.  Contracts with private hospitals for the provision of services: a privately owned and managed hospital contracts part of its capacity to a Health Service. Then the NHS can send patients there for diagnosis or inpatient care whenever the public resources are insufficient. The private hospital receives the amount stipulated in the contract (usually fees for the individual treatments and tests). This is called “concierto” in Spain and many private hospitals have such agreements, be they for-profit or not-for-profit centres. When hospitals have 50% or more of their capacity contracted to the NHS they are usually considered as part of the basic NHS network. Their management is sometimes transferred to the Health Services. In all cases the NHS’s influence on them is high.

There are other, less extended models. The reasons for their existence range from the historical to the experimental. The organisational landscape in Spain means that depending on the Autonomous Region the prevalent model for the provision of healthcare services can vary greatly.

3. Resources of the Spanish Healthcare System 3.1. Hospital resources Number of Hospitals

Based on the National Hospital Catalogue, published annually by the Ministry of Health, Social Services and Equality, the evolution of the number of hospitals in Spain has been the following:

Table 1: Hospitals sorted by functional control type2 Charity Charity Other Non- Year Public MATEP3 (Red TOTAL (Church) charities charity Cross) 2004 301 24 8 57 56 333 779 2005 300 24 8 58 58 335 783 2006 301 23 8 58 58 340 788 2007 309 22 8 56 56 349 800 2008 319 20 6 55 59 345 804 2009 330 21 6 53 57 336 803 2010 328 21 5 54 62 324 794 2011 327 21 5 53 59 325 790 2012 327 21 5 54 59 323 789 Source: Personal compilation based on data from the National Hospital Catalogue (2005-2013)

About half of the private hospitals have a contract with the NHS, be it for diagnosis or for other services. When studying the performance of the NHS it is important to take this fact into account in order to analyse the public coverage better.

 7% of all the private hospitals classified above are integrated into the Hospital Network for Public Use. They have a 100% contract with the NHS.  Around 40% of the remaining private hospitals have contracted some of their services to the NHS.  An estimated 20% of all private hospital activity in 2010 was generated by NHS patients.

2 Functional control: the entity exercising functional control is defined as the one which has the right to determine the general hospital policy and nominate its administrators. It is usually the entity that contributes the most to the financing of the hospital. This is not the same as ownership or management type, because by virtue of given contracts a privately owned hospital could be financed in more than 50% by a public entity.

3 MATEP (Mutual Funds for the coverage of Workplace Accidents and Professional Illnesses): considered not-for-profit private organisations since they cover civil servants and are financed with Social Security contributions.

It is interesting to note that starting in 2008 the number of private hospitals has been diminishing steadily while the number of public hospitals increased sharply in 2008 and 2009. The main consequence is that since 2008 the overall capacity of the system remained fairly stable. The balance is of only 11 hospitals less even though the number of for-profit private hospitals diminished to below 2004 levels.

Number of available hospital beds

The number of hospitals is not indicative of their size. The amount of resources that they possess is a better indicator of levels of service provided. A widely cited figure is the number of beds.

Table 2: Available beds in Spanish hospitals sorted by functional control type For-profit Total Year Public Not-for-profit private available hospitals private hospitals hospitals hospital beds 2004 105 052 21 799 31 075 157 926 2005 105 998 22 148 31 413 159 559 2006 105 289 21 997 32 385 159 671 2007 105 062 21 608 33 627 160 297 2008 106 500 21 393 33 088 160 981 2009 108 469 20 043 32 767 161 279 2010 108 191 20 858 31 973 161 022 2011 109 554 20 672 32 312 162 538 2012 109 211 20 595 32 235 162 041 Source: Personal compilation based on data from the National Hospital Catalogue (2005-2013)

The proportion between public and private hospitals and their capacity is the following:

Figure 2: Hospital distribution in 2012

Public hospitals 41% 41% Not-for-profit private hospitals For-profit private hospitals

18%

Source: Personal compilation based on the National Hospital Catalogue, 2013

Figure 3: Distribution of hospital beds in 2012

20% Public hospitals

Not-for-profit private 13% hospitals For-profit private 67% hospitals

Source: Personal compilation based on the National Hospital Catalogue, 2013

There are numerous private hospitals and specialised care centres in Spain but they have a much smaller capacity than the public hospitals.

Hospital personnel

There are two types of personnel in the Spanish Healthcare System:

 Signed employees have a contract with a given hospital for full-time or part- time work.  Contributing personnel undertake activities in the hospitals but have no contract with these centres and do not receive payment from them.

Table 3: Distribution of healthcare personnel in Spanish hospitals, evolution over time Signed Doctors Non- Total Signed Contributing Other Year nursing in healthcare Population Personnel Doctors Doctors personnel personnel Training personnel 1997 390 285 53 766 17 437 183 064 13 642 112 141 10 235 39 583 381 1998 395 022 54 690 17 117 186 505 13 590 112 390 10 730 39 722 075 1999 403 200 56 811 16 887 190 995 13 632 112 901 11 974 39 927 224 2000 409 341 57 899 17 087 194 279 13 220 113 783 13 073 40 264 162 2001 417 050 59 377 18 150 198 057 12 674 114 058 14 734 40 721 447 2002 430 066 61 993 17 752 204 304 13 877 117 006 15 134 41 314 019 2003 441 422 64 519 18 150 209 336 14 001 118 733 16 683 42 004 575 2004 459 788 67 804 20 015 217 221 14 824 122 184 17 740 42 691 751 2005 471 264 69 263 20 240 222 712 15 218 124 517 19 314 43 398 190 2006 490 157 72 186 20 555 232 059 16 126 127 900 21 331 44 068 244 2007 513 662 76 362 21 604 242 349 16 555 133 389 23 403 44 873 567 2008 530 505 80 414 21 344 251 453 17 525 135 597 24 172 45 593 385 2009 541 069 83 177 21 451 256 650 18 217 135 832 25 742 45 929 432 Increase 38.63% 54.70% 23.02% 40.20% 33.54% 21.13% 151.51% 16.03% Source: Personal compilation based on the ESCRI database, 2013 18

Comparing the variation in personnel and overall population from 1997 to 2009 we can conclude that health coverage has been improving continuously with more doctors and nursing personnel per inhabitant.

As for the internal composition of hospital personnel, very little has changed over the years. A small decrease in the percentage of non-healthcare personnel favoured a small increase in the percentage of doctors and nurses. The proportion of contributing doctors also diminished although private centres still rely heavily on them. Of all their healthcare personnel in 2009, 23.3% were contributing doctors and nurses (mainly doctors) compared to less than 1% for public hospitals.

Figure 4 illustrates the weight of the different members of hospital staff. “Other personnel” refers to healthcare staff not assigned to another category.

Figure 4: Distribution of hospital personnel in 2009

5% Signed Doctors 15% Contributing Doctors 4% (chiefly in private centres) 25% Signed nursing personnel

Doctors in Training

Non-healthcare personnel 3% Other personnel 48%

Source: Personal compilation based on the ESCRI database, 2013

High-technology medical equipment

There has been a steady increase in the number of advanced technology devices over the last eight years as shown in Table 4 below. But as for the private hospitals that have no contract with the NHS, this increase is lower than the average for all medical equipment except the Linear Particle Accelerators. In some cases the increase is negative because of the closure of various hospitals in the crisis years to date.

We can conclude then that the public NHS financed proportionally more new high- technology acquisitions than the private hospitals over the last 8 years, increasing its coverage of the population.

Table 4: High-technology medical devices in Spanish hospitals, evolution over time Year CT MRI DSA ESWL LINAC HEM 2005 587 350 182 83 135 197 2006 611 386 188 93 146 214 2007 654 417 194 91 160 220 2008 677 438 190 92 179 218 2009 693 459 192 93 183 227 2010 690 492 195 93 192 233 2011 699 510 206 94 199 242 2012 716 533 216 96 203 243 % increase 22% 52% 19% 16% 50% 23%

CT: Computerised axial tomography; MRI: Magnetic Resonance Imaging; DSA: Digital subtraction

angiography; ESWL: Extracorporeal shock wave lithotripsy; LINAC: Linear particle accelerator; HEM:

Hemodynamics chamber

Source: Personal compilation based on data from the National Hospital Catalogue (2006-2013)

3.2. Rates of usage for specialised care Data on the use of resources is also interesting to have in order to identify trends and prioritise the needs in the System.

Table 5: Healthcare usage indicators, evolution over time Registered Average Surgery Haemodialysis hospital CT usage MRI usage length interventions usage per Year admittances per 1 000 per 1 000 of stay per 1 000 1 000 per 1 000 population population adjusted population population population by cause 2000 119.20 90.97 51.86 15.13 39.73 6.55 2001 119.34 92.43 56.34 17.77 35.62 6.51 2002 118.36 93.09 60.90 22.63 35.53 6.48 2003 118.52 95.21 62.40 25.5 37.41 6.41 2004 118.76 96.34 65.16 28.21 37.34 6.37 2005 117.50 97.28 66.81 30.61 31.47 6.34 2006 117.71 97.95 70.26 32.86 31.03 6.23 2007 117.11 99.16 73.19 35.42 32.38 6.24 2008 116.14 100.18 76.77 38.92 31.92 6.17 2009 114.69 101.54 80.08 43.06 33.09 6.04 2010 113.78 101.27 83.13 47.58 39.57 6.01 2011 114.25 107.67 85.74 49.57 39.15 5.89 Increase -4.15% 18.36% 65.33% 227.6% -1.46% -10.08% Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

From this information it can be assessed that MRI and CT are preferred diagnostic procedures with an ever-increasing demand. This is not so for haemodialysis.

The average length of stay and the number of admittances and operations offer a clue on the demand for medical personnel and hospital beds. Increased high-technology availability could be at the root of the achieved improvements. However, maintaining technology levels high is expensive and a cost-benefit assessment would be helpful in an eventual restructuring of medical technology and personnel.

3.3. Primary Healthcare resources

Aside from centres for specialised attention, on the primary healthcare level we find:

 Health Centres: places where various doctors and nurses attend the population either on prior arrangement or walk-in basis. The most frequent consultation is by arrangement with the family doctor.  Local Offices: smaller offices, dependent on a Health Centre and located in more remote areas with a smaller number of professionals offering their services.

Table 6: Primary Healthcare centres in Spain 2004-2011 Year Health Centres Local Offices Total 2004 2756 10145 12901 2005 2833 10148 12981 2006 2840 10216 13056 2007 2913 10178 13091 2008 2914 10202 13116 2009 2954 10207 13161 2010 2979 10154 13133 2011 3006 10116 13122 Source: Personal compilation based on SIAP reports for the years 2004-2011

Table 6 is a summary of the evolution of the number of primary healthcare centres in Spain. Almost all these centres are publicly owned and managed by the regional Health Services. There are two particular cases that deserve to be mentioned: Catalonia and the Comunidad Valenciana. In Catalonia some primary healthcare centres are in the hands of public entities other than the Health Service, others are managed by private charities and a third set by mutual funds. In the Comunidad Valenciana there are some 150 primary healthcare centres under private management but publicly funded by virtue of a contract with the Department for Health.

The figures in Table 6 show an increasing trend at first but after 2009 there are some closures. Even so, they only affect the Local Offices while the number of Health Centres never goes down. This suggests the conversion of some Local Offices into Health Centres and an effort to bring more quality to primary healthcare.

In 2011 the primary healthcare facilities were staffed by more than 35 000 physicians, mostly family doctors with a specific list of patients assigned to each. They also employed more than 29 000 nurses and the non-healthcare staff consisted of more than 21 000 workers.

Reflections

As the crisis progresses the limitations it imposes on the country are reaching the NHS. With centres closing both at the primary and the specialised level, some questions are in order:

 Are the hospital closures only an investment gone wrong or do they have a significant impact in the fundamental rights of Spanish citizens to receive universal quality healthcare?  Should the private hospitals that no longer return profit to their owners be bought by the Administration, burdening its budget even more, in order to maintain the current Healthcare standards?  Was there a real need for such expansion? If there wasn’t, isn’t it possible that medical centres could be closed without jeopardising the quality of the NHS and without hindering its compromises with access and equity?

4. Comparison of resources across OECD countries In order to evaluate the performance of the Spanish Healthcare System a comparison is helpful. The assessment will be made based on the OECD Health Data report from 29 Oct 2012, which provides important figures for resource inventories and other health-related statistics4.

Since some countries (for example the US) have a very different way of managing healthcare this section will use the OECD average as base and comment on trends occurring in states that have systems similar to the Spanish NHS (e.g. Australia, Canada, Italy).

Number of physicians per 1 000 population

The number of practicing physicians per capita in Spain has increased steadily over time. The density per 1 000 population was 3.8 in 2010, growing to 4.1 in 2011. This data places Spain above the OECD average for 2010 in line with Italy and Australia and much above Canada. The United Kingdom shows a value of 2.8 physicians per 1 000 population.

Nursing staff per 1 000 population

As with physicians, there has been an upward trend in the proportion of practicing nurses to total population. But even though the indicator rose sharply in 2011 it is far below the OECD average. Only countries that can still be considered as developing have lower nursing staff numbers. Italy is the closest of the states established for comparison but Australia, Canada and the UK almost double Spain’s value of 4.9 nurses per 1 000 population in 2010.

Medical and Nursing Graduates

The students graduating each year from Spanish universities deserve a passing mention. Both indicators are smaller than the respective OECD averages.

In Spain the central government decides how many university vacancies to open for a given year depending on the situation of the NHS and future projections. Taking this fact into consideration, the number of graduating nurses has been stable over the years while the figure for medical graduates has diminished. This decrease reflects, at least in part, the Government policy although the challenge of the university studies probably also plays a role in the final outcome.

4 See Annex II for the relevant OECD averages compared in this section. 23

Number of beds per 1 000 population

In this case all trends are downward sloping, thus revealing that with effective healthcare the need for hospital space is reduced. Spain’s 3.2 beds per 1 000 population place it below the 4.9 OECD average and in line with all other countries with similarly structured systems. Around 2 out of 10 beds are reserved for psychiatric, geriatric and other care requiring long hospital stay. The remaining 80% are destined to what is called “acute” care: general hospitals, surgery, maternal and infant care, etc.

High-technology devices per 1 000 000 population: MRI units

For this set of values observations deviate strongly from the average of 12.5 MRI units per million inhabitants. In 2010 this value for Spain was 10.7, higher than the numbers for Australia, Canada and the UK. Italy shows a very steep increase since 1997 which results in 22.7 MRI units per million inhabitants in 2010. In Japan the quantity is twice Italy’s. Substitutes for the technology, such as the CT scan, could be part of the explanation and the needs of the population constitute another important element. Even so, with the limited information it’s very difficult to give a reference for a desired value.

High-technology devices per 1 000 000 population: CT scanners

Similar to the data for the MRI units, Spain’s number of CT scanners per million inhabitants, 15 in 2010, is below average and close to Canada’s. Australia triples this number and Italy doubles it. The United Kingdom is the contrast with 8.2 CT scanners per 1 000 000 population. Again, it is difficult to judge, but a reasonable guess could be that other, older or newer forms of diagnosis, substitute CT scanners to a degree.

If the estimates for the United Kingdom are correct, their usage of both CT and MRI is very similar to Spain’s but the number of devices they have is much smaller. This could mean that an optimisation of resources is possible so it is an option that should be looked into.

5. Performance of the Spanish NHS: 2000-2011 comparison In this section we assess the performance of the NHS with a three-branch analysis.

 Public satisfaction indicators show the perception of the patients that use the NHS. They are subjective but their evolution over time should shed some light on its relative performance since the year 2000.  Objective performance indicators are meant to show some real quality improvements in the NHS over time.  Health indicators provide insight into the life-expectancy improvements.

5.1. Public satisfaction indicators5 General satisfaction indicators

Based on information from the Healthcare Barometer 1995-2011 published by the Ministry for Health, Social Services and Equality, the general degree of satisfaction with the NHS has increased over the decade between 2000 and 2011. When asked to grade the NHS’s services, people rated it at 5.94 in a scale of 1 to 10 in the year 2002 and at 6.59 out of 10 in 2011, a significant increase in satisfaction. The second most cited indicator also experienced an improvement: a greater percentage of users valued the functioning of the system as good or very good (from 66.80% in 2000 to 73.12% in 2011).

However, these results fluctuate across Autonomous Regions and, although there has been convergence over the years, it would seem that some regional Health Services are not up to standard. Others, by contrast, turned around completely the previous opinions of their users. Since these general indicators are not too helpful, an analysis of more specific indicators might be more useful.

Specific activity indicators

Specific activity indicators are also satisfaction indicators and also use the scale of 1 to 10. However, because the questions relate to one specific area of primary or specialised care, the impressions that the user has are better formed than when asked about the NHS as a whole. The questions relate to topics such as the attitude of healthcare personnel, the availability of medical technology and equipment, the waiting times, the consultation times, etc. The questions are similar for primary and specialised healthcare.

When analysing these indicators it is hard to tell if the services are valued better or worse than in the year 2000. For example, when asked about the particular aspects of primary healthcare, the users surveyed reported a degree of satisfaction which was

5 See Annex III for the detailed breakdown of all public satisfaction indicators considered in this section. 25 almost equal to the one recorded in 2000. There is no clear increasing trend; in fact there is a steep decrease right after 2000. Thus, the following small improvements only contribute towards a return to previous levels, finally achieved in 2011. Only one aspect experienced continuous important growth: family doctors now refer patients to specialists much oftener. But whether this is positive or not depends on the point of view, since one interpretation could be that family doctors now are not qualified to advise on issues that used to be treated in primary healthcare ten years ago.

A similar pattern applies for hospital care although in this case not all activity indicators have returned to 2000 levels. Patients consider that medical equipment now is worse than it was ten years ago. In 2011, compared to 2000, a bigger percentage of users believed that Health Services are not working towards shortening waiting lists and more people thought that this problem was worsening with time instead of improving.

There is a particular question about perceived improvements over the last 5-year period, which is of great importance since public opinion of healthcare is a great influence on resource investment. But the data shows that a smaller percentage of users notice an improvement in healthcare nowadays compared to 2000. The rest, an increasing proportion, think that the features of the system are at the same level or worsening.

What this data shows is that the question of service levels needs to be reconsidered. With higher standards of living and a society that is more and more demanding the subjective rating of public healthcare dropped so low that it took a decade to recover. The probable cause was the devolvement of the Healthcare competences to the Autonomous Regions. While I do believe that it had an impact I cannot concede that it was of such abysmal proportions. Public opinion is easily swayed and it would seem that as the crisis sets in healthcare users have lowered their expectations and their evaluation of the features of the NHS is improving even after some of the dreaded spending cuts and reforms have been implemented. If patients have biased perceptions of the healthcare system then part of the expansion that took place within the NHS might have been unnecessary and based mostly on an eagerness to improve the popular perceptions of the system. That is not to say that improvements shouldn’t be made, but they should probably rely more on objective observations – from the inside.

5.2. Objective performance indicators Data is available on some indicators that can be used to assess improvements in hospital care. Their evolution between the years 2000-2011 is shown in Tables 7 and 8.

Table 7: Quality indicators for specialised care in Spain, 2000-2011 Rate of Acute Number of Rate of hospital- In-hospital Global % adverse transfusion pressure acquired mortality of reactions to reactions ulcers per Year infection per 100 readmitted drugs notified per 1 000 1 000 per 100 hospital patients per 1 000 hospital hospital hospital discharges population discharges discharges discharges 2000 6.38 0.04 0.77 0.20 5.14 3.80 2001 6.73 0.06 0.79 0.20 5.83 3.83 2002 6.78 0.06 0.81 0.17 5.99 3.91 2003 6.79 0.07 0.85 0.17 6.64 4.04 2004 6.86 0.07 0.84 0.18 6.92 3.92 2005 7.01 0.08 0.86 0.18 7.93 4.12 2006 7.05 0.08 0.86 0.18 8.23 3.93 2007 7.14 0.09 0.86 0.17 8.57 4.10 2008 7.08 0.12 0.9 0.16 10.5 4.05 2009 7.16 0.15 0.91 0.16 11.4 4.07 2010 7.08 0.15 0.85 0.17 12.88 4.13 2011 7.31 0.16 0.82 0.17 13.96 4.29 Increase 14.6% 300% 6.5% -15% 172% 12.9% Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

Table 8: Waiting times (days) for specialised interventions and consultations Waiting time for non- Waiting time for Year urgent surgery specialised

interventions consultations 2003 81 2004 78 2005 83.42 2006 70 54.37 2007 74 57.98 2008 71 59 2009 69.73 58.99 2010 64.97 53.17 2011 73 57.72 Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

It would seem that the reduction of waiting lists has progressed in an erratic fashion. A steep reduction in 2010 was followed by an even steeper worsening in 2011. It is hard to tell if consistent efforts for the reduction of waiting times exist.

The hospital performance indicators suggest a similar conclusion. While the data can’t prove a systematic worsening of the system since 2000 – more variables would have to be factored in for that – it proves that improvements haven’t been targeted. A clear

27 example is the case of pressure ulcers: notice should have been taken of the growing rate at which they appear and an effort to reduce them should have been undertaken.

5.3. Health indicators Finally, classic indicators such as life expectancy and mortality are shown in Table 9.

Table 9: Life expectancy at birth and mortality rate per 100 000 population, 2000-2011 Adjusted mortality rate Year Life expectancy at birth per 100 000 population 2000 79.05 611.45 2001 79.44 595.77 2002 79.67 592.73 2003 79.67 600.06 2004 79.95 565.23 2005 80.23 568.46 2006 80.95 532.35 2007 81.08 533.99 2008 81.24 519.73 2009 81.80 503.70 2010 82.22 487.02 Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

Spain has one of the best life expectancy figures for Europe and it has been increasing steadily over time. However, it is a broad indicator that is heavily influenced by the environment and climate, by the food and habits and by the economic level of the country. The elements that are responsibility of the Healthcare system and influence these indicators are disease prevention and drug prescription. However, they are only a small part of what is meant when evaluating the system as a whole. For this reason life expectancy figures can hardly be used to prove or disprove an argument about the healthcare improvements in Spain.

6. The financing of Spanish Healthcare The funds for healthcare in Spain come from the general public in the form of taxes and private insurance payments and from the patients themselves when they pay for private services or buy medicines (with the current co-payment they contribute less than 50% of the price). The following flowchart shows the structure of the funding:

The mutual funds and the Social Marine Institute are financed directly by the State and Social Security. Their beneficiaries are civil servants and their dependants, except for people working in the NHS. These mutual funds contract the services that they require to private providers and their affiliates in 2010 represented 5% of the population.

Figures 5 and 6 show a breakdown of the contributions for the years 2003 and 2010 in order to compare the changes over time. Public financing is shown in blue and private financing is in red:

Figure 5: Healthcare financing breakdown by financing agent, year 2003

1,23% 0,72% Central administration

Regional and local 22,87% administrations Social Security Administrations 5,51% Private insurance institutions 64,46% 5,21% Direct payments

Other

Source: Personal compilation based on A System of Health Accounts (SCS) 2003-2010 data

Figure 6: Healthcare financing breakdown by financing agent, year 2010

0,62% 0,57% Central administration

19,67% Regional and local administrations Social Security 5,52% Administrations 4,63% Private insurance institutions 68,98% Direct payments

Other

Source: Personal compilation based on A System of Health Accounts (SCS) 2003-2010 data

Public financing gained importance over time, especially healthcare financed by the Autonomous Regions and local entities. The Central Administration and Social Security reduced their percentage contributions. The private sector lost importance overall but its total expenditure increased over the years.

6.1. Healthcare expenditure in absolute values In order to gauge the strain that healthcare expenditure puts on the Spanish economy as a whole, an analysis over time is appropriate. Figure 7 shows the evolution of healthcare expenditure per capita over the years 2003-2010. There was a substantial increase of 42% per capita over the time period which supposed a 57% increase of expenditure in absolute terms.

Figure 7: Healthcare expenditure evolution over the period 2003-2010

2.500

2.000 Total 1.500 expenditure per capita 1.000 Public expenditure 500 per capita

0 2003 2004 2005 2006 2007 2008 2009 2010 Source: Personal compilation based on A System of Health Accounts (SCS) 2003-2010 data

Figure 8: Healthcare as percentage of GDP, evolution over the period 2003-2010

10,00% 5% 4% 9,50% 3% Total 9,00% 2% 1% expenditur e as % of 8,50% 0% GDP -1% GDP 8,00% -2% growth rate 7,50% -3% -4% 7,00% -5% 2003 2004 2005 2006 2007 2008 2009 2010 Source: Personal compilation based on data from the National Statistics Institute (INE) and A System of Health Accounts (SCS) 2003-2010 31

Figure 8 is concerned with healthcare expenditure as percentage of GDP. It plots healthcare expenditure on the primary axis and GDP growth on the secondary axis.

Up until 2007, before the crisis, healthcare spending as % of GDP increased slowly and it was not felt excessively because GDP was also growing. Since the SCS data includes expenditure on the elderly and disabled which is not strictly healthcare spending, it is only logical that the financial strain would increase in time. But when the crisis hit healthcare expenditure couldn’t be reduced immediately while GDP plummeted (especially in the year 2009). Now GDP growth figures show a less dramatic reduction but still remain negative and the debate over healthcare spending is a hot topic.

What needs to be clear before embarking in long justifications of the healthcare system is that the expenditure was already increasing at a very fast rate and was becoming a problem before the crisis struck. Even if it represented a smaller percentage of GDP then, efforts should have been made in order to rein in the spending. After all, why spend 42% more than in 2000 on a healthcare system that the users perceive to be much the same as it was back then?

By observing the data it can be seen that the strain on public finances became larger over time because of the general increase in healthcare expenditure but also because of a shift from private contributions (patient payments) to public spending (see figures 5 and 6). This shift is probably a consequence of the difficulties brought by the crisis. On one hand, patients can choose to endure a longer waiting time for a service that they could have either through the NHS or by paying to a private provider. This substitution effect means less business for the private hospitals and professionals and a bigger strain on the public system. Another possibility is that patients are delaying treatment of some minor issues as much as possible in order to save on the medical expenses. Both effects are logical consequences of income loss. For the NHS the existence of a substitution effect means that restructuring would be even harder since now more people rely on public healthcare.

An implication of the financing breakdown shown in figures 5 and 6 is that any reforms will have to be implemented by the Autonomous Regions, since they finance the biggest portion of Spanish healthcare. But what scope do they have for reform? What are their limits and compromises? The healthcare services rating varies from region to region and complaints have been voiced over the differences in per capita expenditure across the country. Circumstances vary between the Autonomous Regions and they will need to be explained before undertaking an analysis that has to be as general as possible.

6.2. Financial circumstances of the Autonomous Regions In the year 2010 the per capita budget in the Autonomous Regions was as follows:

Figure 9: Per capita budget in Spain’s Autonomous Regions, 2010

Source: http://www.dondevanmisimpuestos.es/ccaa/

The variance observed between Autonomous Region budgets is roughly € 1 000 per capita but when Navarra enters the calculations it soars to € 3 000. The difference can be considered significant.

Healthcare expenditure budget data (which does not take into account extra expenditure on care for the disabled and the elderly) for 2010 is shown in Figure 10:

Figure 10: Healthcare Budget per capita in Spain’s Autonomous Regions, 2010

Source: http://www.dondevanmisimpuestos.es/ccaa/ 33

When considering the healthcare budget the variation between the average and the lower limit is much smaller, because healthcare is a basic service, essential for upholding the welfare state and fulfilling the equity principle that forms the base for Spanish democracy. For this reason there is a common lower bound for healthcare expenditure per capita that differs between Autonomous Regions but must be respected by all of them.

Since healthcare is the most important part of any Autonomous Region’s budget and income varies significantly between them, the financial effort for supporting the NHS differs greatly in the different regions. Comunidad Valenciana spends 38.35% of its budget on healthcare while Navarra assigns 22.06% to it. Thus, C. Valenciana has smaller room for manoeuvre than other regions and the sustainability of healthcare is a more pressing issue there. This is not to say that richer regions should not think of healthcare reform, quite the contrary, but they can allow themselves to do it over time and without causing big disturbances to the system in its current form.

6.3. Breakdown of public healthcare expenditure The last year for which real expenditure data is available is 2008, and the dataset does not include the extra spending on care for the elderly and disabled.

Figure 11: Public healthcare expenditure classified by expenditure item, 2008

2% Hospitals and specialized 4% services Primary health care services

19% Prevention and public health

Health services to collectives 3% 55% 1% Pharmacy

16% Patients transport & medical products other than drugs Capital expenditure

Source: Personal compilation based on the Statistic on Public Health Expenditure (EGSP), 2002- 2011 series

According to the breakdown in Figure 11, primary healthcare services represent only 16% of spending even though their number is considerable since the condition for their location is that users of the system must be able to arrive after a 15-minute walk from any place. 34

Pharmacy spending is a big percentage considering that co-payment for the acquisition of drugs is implemented.

The biggest expenditure item is the one that covers the hospitals and other specialised services, because of their personnel needs and also owing to infrastructure and technology necessities.

To touch briefly on another possible classification, it must be mentioned that for the year 2008:

 Personnel wages represented 42.2% of the total budget.  Contractual payments to private hospitals accounted for 11.1% of the budget.

Wages are by far the most important expenditure item and also the easiest way to save a large amount of money. This justifies, in part, the salary cuts implemented during the last two years.

Payments for the provision of services made to private hospitals could be renegotiated depending on the conditions stipulated in the contracts, in order to extract some savings for the NHS.

6.4. Financial trouble in the NHS As seen above, the budgets for the NHS are developed at the regional level, except for some 6% of total expenditure that stems from the State and Social Security budgets.

In 2009 a reform to give more tax autonomy to the different Autonomous Regions was approved. By virtue of it, starting in 2011, a bigger percentage of the tax merited at the regional level would stay in the Autonomous Regions and so the State transfers would diminish.

Ever since the crisis begun, tax revenues have been falling so what this move accomplishes is, essentially, to shift some deficit from the State to the Autonomous Regions. The need for the reduction of expenditure remained the same as it would have been before the reform.

With decreasing regional revenues and costs that are difficult to handle, the NHS has struggled in the crisis years. An added problem was the existence of accumulated debt with private providers, essentially for medicines and medical devices. The debt levels haven’t changed greatly since the crisis begun but the average time elapsed until the providers receive payment has almost doubled. The obvious result is a hindrance for the activity of the providers and a worsening of their economic position.

Debt in the NHS at the end of 2011

Based on a report published in February 2012 by the private foundation IDIS (Institute for Development and Integration in Healthcare), NHS debt with its private providers amounted to approximately 15 700 million euro at the end of the year 2011. The detailed breakdown is as follows:

 Debt with the providers of drugs to hospitals: € 6 369 million  Debt with medical technology providers: € 5 230 million  Debt with private service providers6: € 4 100 million

So far the Autonomous Regions with the biggest debt, far above the rest, are Andalucía and Comunidad Valenciana. Their combined debt is in excess of € 5 000 million.

These debt levels are one of the chief reasons to undertake reforms as soon as possible.

6 Private service providers include hospitals and laboratories but also non-healthcare services contracted by the public hospitals

7. Sustainability Analysis of the Spanish NHS So far it has been argued that:

 Over the last 10-15 years healthcare resources have increased greatly, especially in the publicly funded NHS. Be it hospitals, Primary Healthcare attending points or personnel, there was a strong upward trend in all of them, over and above the increase of the covered population.  The NHS doesn’t have the freedom to regulate its resources in the same way that private hospitals do. This is evident by the evolution of the number of public hospitals and healthcare personnel.  The comparison to OECD countries is favourable when considering the availability of hospital beds and physicians. However, there is room for improvement, for example by purchasing more high-technology devices. Since there are different types of healthcare systems operating around the world, an in-depth analysis of some of their characteristics could provide insight into possible efficiency improvements. The OECD comparison is a first step towards this goal because it provides the necessary benchmarks.  Improvements have been made in the sense that more resources are now devoted to healthcare, but specific efficiency improvements have not been shown.  The public’s perception of healthcare is influenced by their circumstances and expectations. When the economy was buoyant expectations were high and public opinion of healthcare services deteriorated with time. Now that the public NHS is under threat they value it more. Both points of view contain a degree of bias that must be taken into account.  Healthcare expenditure has increased steadily over the last 8-10 years, an effort that went almost unnoticed while the economy was growing but that is now becoming a problem.  The NHS has great financial trouble that requires action. The final responsibility is for the Autonomous Regions and each of them faces a different situation depending on its budget and circumstances.

After considering the resources, financing and organisation of healthcare in Spain it becomes clear that the current system is not sustainable and it hasn’t been sustainable for some time according to our definition. The expenditure increase was much too great to be able to endure for a long time, and the definition of sustainability requires that it should be able to maintain itself in similar shape indefinitely. The public system is the one most at risk.

The context of the crisis has only shown this fact in a clearer light and made its resolution a pressing matter. The level of debt that has accrued in the NHS is a sign of

37 the limited flexibility in regards to expenditure present in the system. Reforms are needed and are being undertaken but the haste for their implementation only makes the matter more delicate. If changes are not made with the long-term survival of the system as the first priority, Spain will carry most of its current drawbacks into the future and face the same trouble when another crisis strikes. In order to avoid such a situation a priority analysis is necessary. Priorities are two-fold: short-term obligations and foreseeable long-term issues.

7.1. Priority analysis

Short-term obligations

 Reaching the EU deficit objective: less than 3% of GDP by 2016.  Reducing debt within the NHS.  Promoting growth: shift of priorities from healthcare to other sectors until the crisis abates.

Long-term issues (implementation horizon – 10 years)

 Stabilizing healthcare expenditure per capita within preset limits.  Ensuring that the NHS will be able to provide a similar level of service in the future, when the effects of the demographic shift become more important.  Making sure that the chosen providers are the most efficient and economical.  Ensuring more equality between Autonomous Regions both in spending and in the functioning of the Health Services.  Restructuring of Health Departments and Health Services to make their composition simpler to understand and operate.  Cooperation between Autonomous Regions in order to improve efficiency across the country.  Shift towards new technologies to lighten administrative costs and ensure a better accountability and comparability.  Use of new technologies to improve treatment and diagnosis costs (eHealth).  Keeping up with scientific and technologic advance to improve the quality of healthcare in Spain.

It’s easy to see that long-term concerns can be considered expensive and even the measures to reduce costs usually require a big initial investment. It is for this reason that they must be undertaken slowly and after careful planning. However difficult it might prove, I believe that unless long-term issues are addressed in the next 10 years it will be too late for action. This time limit must also be kept in mind when planning short-term measures because they could influence negatively a future, more important reform.

7.2. Current measures taken to address short and long-term problems

Since it became patent that Spain’s deficit and debt was unsustainable measures to reduce them have been implemented.

Regarding healthcare, a reform was promulgated in 2012 with the aim of ensuring its sustainability and reducing the NHS’s financial obligations. It introduced some changes to the functioning of the system:

 The beneficiaries of free healthcare were reduced, by basically excluding part of the foreign population residing in Spain. While previously proof of residence was enough to have the right to receive free healthcare now a residence permit is required (except for persons aged 18 and under). The measure does not apply to the treatment of pregnancies and serious illnesses or accidents.  “Healthcare tourism” measures. Foreign nationals coming to Spain benefitted from the free healthcare service and an overlooked clause in the law meant that Spain didn’t claim back the expenses from their country of origin. After the reform healthcare tourism will diminish because of the rules for residence permits.  State Fund that will finance any cross-region medical attention, in order to solve the problems arising from concerns in the Autonomous Regions about who should pay for the treatments.  Introduction of co-payment for non-urgent medical transport.  Modifications to the rules of drug pricing and establishment of a detailed database that will allow physicians to prescribe the cheapest from all the adequate medicines.  Introducing a common register containing the details of the professionals working in the NHS. Harmonisation of their qualifications in order to ensure mobility within the country. Since few new professionals will have access to work in the NHS it is expected that in this way resources can be organised more efficiently.  Ending the different service contracts that link professionals with the NHS, leaving only two categories: personnel working for the NHS and personnel working for other institutions (and therefore not recorded in NHS statistics).  Making use of economies of scale by purchasing products at the national level and sharing one service provider between various centres.  Energy Saving Plans to be produced by the regional Healthcare authorities and approved before year end 2013.

Apart from the above measures, depending on the Autonomous Region different spending reduction schemes have been adopted. Some restrict the opening hours of Primary Healthcare and Emergency services and others have tried to introduce a

39 payment for each drug prescription. Freezing wages has been a common occurrence. In some cases the Courts of Justice have deemed the measures too extreme and they have had to be revised.

Some of the measures implemented with the reform can be criticized because of their impact on the principles of universality and equity. Denying free healthcare to illegal immigrants residing in the country and establishing co-payment for non-urgent transport fall into that category. But going further, other points of view suggest that depriving a percentage (albeit small) of the population of healthcare is a threat to public health. Judging by the financial data analysed previously, patient transport is a very small percentage of total expenditure so it is highly probable that the measure creates more trouble than positive results. I tend to agree with these criticisms and I believe that it would be better to backtrack on these particular measures of the reform.

Other changes are founded in the right idea but their wording means a patchwork answer where a permanent solid solution could be reached. For example, the residence permit clause is meant to deter healthcare tourism but there is no reason for such “tourism” to disappear if a working compensation system is established. This also applies to regional accounting problems which could be solved with a compensation system between the Autonomous Regions.

In general all the measures that target harmonisation and rational decrease of expenditure are welcome and the only concern would be with their correct implementation. Still, it is striking to see that, even though it is well known that centralised management is cheaper in some regards the competences on those particular items were transferred to the Autonomous Regions along with other management features. What the current reform aims to implement is a partial return to the previous model.

I believe that complete re-centralisation of healthcare would be a very drastic measure since decentralisation was implemented with the belief that it would bring quality improvements to the NHS. However, other quality (and quantity) improvements can be achieved by harmonising some aspects of public healthcare and this opportunity should not be overlooked. The NHS could become better and stronger after some well aimed reforms, looking forward without going back.

8. Outlook to the future When defining sustainability it was stated that the system had to be environmentally, economically and socially viable. In this case social viability is defined by the upholding of the basic principles: universality, equity, free access at the point of use, public funding. But there is another limiting aspect of social viability: the resistance to change. The NHS is the best valued public service in Spain and the citizens would not want drastic changes to the model. This is why privatisation is out of the question, and even re-centralisation is quite drastic. This is why the reforms proposed below are aimed mainly at achieving economic viability, since environmental viability is beyond of the scope of this work.

8.1. Reforms for the NHS To guarantee the financial sustainability of the NHS the current budget should be reduced without detracting from the basic rights associated with healthcare. There are two ways to achieve this: reducing the demand for healthcare and making the supply of healthcare more efficient.

To regulate the costs of supplying the service, there should be a maximum limit to total public expenditure on healthcare. This “roof” may increase with GDP growth. However, it should have a moderate growth trend, lower than the growth trend of GDP. In this way a boom in the economy will not cause excessive spending.

Another idea would be to establish healthcare spending as a percentage of GDP but to have a different % measure for contraction and expansion periods and to keep the percentage for crisis years low. The reason is that if healthcare expenditure is optimised it will afterwards be impossible to decrease it without great disturbances to the level of care. To keep it safe from spending cuts it should have its own efficiency mechanism – the GDP percentage limit. In this way the sustainability of the NHS would be guaranteed when other parts of the system falter.

After establishing the limit an effort must be made in order to reduce demand to within-budget limits. The service provided must evolve in line with the shift in medical requirements. For example, as the population ages it is possible that there will be a bigger need for Health Centres, to keep track of certain health conditions on a walk-in basis. Prevention should also be given a more important role since the modern society’s problems frequently originate from avoidable abuses. This would possibly reduce the need for hospitals which are much more expensive than prevention and education campaigns or new Health Centres. It would also cause a personnel shift. Predicting and managing healthcare demand can help in keeping healthcare expenditure relatively stable and the only modifications required would be the relative weights of the different spending items.

The “roof” can be established by going back to previous spending levels (since the expansion has been too large). For example we could take the analysed increase (from 2003 to 2009) and reduce it by half. That would mean public spending of € 1 335 per capita instead of the current € 1 589. The total reduction would be 12 000 million euro.

As it stands at the moment, even if the saving could be implemented over a single year it still wouldn’t be able to cover the debt that the NHS has accrued. All the more reason to make sure that the goal is achieved. The best course of action would be to reach this savings objective by increasing resource efficiency and implementing better practices.

If current public expenditure levels were decreased by 12 000 million euro it would represent less than 6% of GDP, a value not seen since 2005. In this case 5% should be set as the limit for expansion periods.

8.2. Key points for the reform  Solidarity  Co-operation  Efficiency  Harmonisation  Reduction of resources  Renegotiating contracts  Pricing system  Transparency

Solidarity: Because of the differing economic situations between Autonomous Regions a system for the allocation of extra funding that favours those with bigger financial trouble must be established. Part of it should be earmarked for the NHS and it should be managed by the State in a transparent and justified manner.

Co-operation: The regional Health Services should establish a way of sharing operational experience so that best practices are implemented throughout the country. They should also improve their financial management by establishing a transfer system for treatments outside the Autonomous Region of residence.

Efficiency: Taking advantage of the information sharing channel in order to improve by comparison with each other. Designing new, more resource-efficient methods to maintain the current quality levels. Reduction of administrative costs by implementing harmonised digital forms, by restructuring the health departments, by placing functional control in the hands of a single public body7, etc.

7 See Annex I 42

Harmonisation: Sharing providers as much as possible, implementing the same accounting and information system and the same personnel classification system. This should favour mobility (redistribution of resources) and reduce management costs in the medium and long term.

Reducing resources: In the short term spending cuts will have to be enacted. Hospitals with little demand should be closed and their resources transferred to other places within the Network. Since personnel numbers cannot be reduced by laying people off, their salary will have to experience a cut. However, their job circumstances should be taken into account in order to avoid exacerbating the financial trouble of particular collectives.

Renegotiating contracts: Contracts with providers should be renegotiated as they expire in order to leave breathing room for the NHS. Long-term contracts should be avoided as much as possible and when signing new agreements they should incorporate clauses for similar contingencies.

Introducing a pricing system: One of the problems of the NHS is that it is not clear how much a given treatment or diagnosis costs. If it were known, the public-private healthcare debate would stand on a more solid ground. As it is, inefficiencies are overlooked because of this ignorance of individual costs. Once it is introduced a fairer pricing for the services contracted with the public hospitals could be established. It would also provide a ground for competition and make it easier to settle financial issues between different Health Services.

Transparency: Currently there is a lack of meaningful, comparable information on the National Health System, especially when trying to compare across the different Autonomous Regions. This problem needs to be solved by implementing a harmonised information system with standard criteria for all Autonomous Regions. The data obtained from this system should be made publicly available to third parties in order to facilitate policy analysis and allow for quality and efficiency proposals.

8.3. The case for public-private agreements As has been mentioned before, different kinds of contracts between the NHS and private hospitals operate in Spain. There is a long ongoing debate about which form of healthcare provision is more efficient and economical.

Although the different management systems have been operating for a considerable amount of time, almost no studies are publicly available right now that could allow for a meaningful comparison. This is a weakness of the healthcare system that mostly reaps the bad consequences of this collaboration – the costs of managing multiple organising models. It is not clear whether any cost reductions take place thanks to these contracts.

Thus, yet another objective for the NHS appears: after establishing the quantitative data for the public provision of the service it must be matched to all the different management models operating in the country. The debate should finally be illustrated by the real data in order to devise a more meaningful and sustainable future model for the system as a whole.

9. Conclusion Right now the Spanish National Health System is not economically sustainable. What this means is that current spending trends cannot be allowed to continue into the future because they would lead to healthcare becoming an expenditure item for the country that is too big a percentage of State income. The bigger the spending becomes, the more flexibility it takes away from the public budget. The State’s ability to face economic and financial trouble is lessened when its flexibility is limited and its long-term continuity becomes endangered. That’s why basic social services such as healthcare must always operate at their most efficient, something that has not been happening during the last expansionist decade.

Now comes the time for reform, for the best possible use of healthcare resources. Priorities will become very important in the future management of the NHS because sacrifices must not be made heedlessly, they must have a purpose. The people most at risk must be considered at all times when enacting spending cuts and emergency measures. The long-term survival of the NHS must also be factored into the equation.

A deep analysis of the NHS at the functional level is required in order to enact rational spending reductions. Future reforms must be based on the following key-points:

 Solidarity  Co-operation  Efficiency  Harmonisation  Reduction of resources  Renegotiating contracts  Establishing prices for the public services  Transparency  Assessment of the benefits of public-private agreements

The Spanish NHS might not be sustainable at the moment but it can definitely achieve this goal in the near future.

Annexes

Annex I – Detailed breakdown of hospitals in Spain, sorted by functional control type

Public Entities Private Organisations Prison Ministry Autonomous County/Town Public Charity Charity Other Non- Year NHS Administra- Municipalities of MATEP TOTAL Regions Councils Entities (Red Cross) (Church) charities charity tion Defence 2004 208 2 12 22 5 44 8 24 8 57 56 333 779 2005 210 2 10 20 5 45 8 24 8 58 58 335 783 2006 210 2 10 19 6 46 8 23 8 58 58 340 788 2007 217 2 9 16 3 54 8 22 8 56 56 349 800 2008 248 2 9 13 3 40 4 20 6 55 59 345 804 2009 254 2 11 13 5 41 4 21 6 53 57 336 803 2010 259 2 8 11 3 41 4 21 5 54 62 324 794 2011 254 2 13 10 3 42 3 21 5 53 59 325 790 2012 255 2 12 10 3 42 3 21 5 54 59 323 789

The above table illustrates the organisational complexities that Health Services have to manage on an ongoing basis.

“Public Entities” is the denomination associated to mixed management, when more than one public administration or service shares the responsibility for a given hospital or medical complex.

The table has been compiled with data from the National Hospital Catalogue publications for the years 2005 through 2013.

Annex II – OECD data for selected healthcare indicators

Nursing personnel Physicians per 1 000 2010 (or nearest year) per 2010 (or nearest year) population 1 000 population Australia 1 3,08 Australia 1 10,06 Austria 1 4,78 Austria 1 7,67 Belgium 1 2,92 Belgium 3 15,06 Canada 2 2,37 Canada 1 9,34 Chile 3 1,43 Chile 3 1,51 Czech Republic 1 3,58 Czech Republic 1 8,06 Denmark 1 3,48 Denmark 1 15,44 Estonia 1 3,24 Estonia 1 6,13 Finland 2 3,27 Finland 1 9,58 France 2 3,27 France 2 8,45 Germany 1 3,73 Germany 1 11,27 Greece 2 6,13 Greece 2 3,31 Hungary 1 2,87 Hungary 1 6,22 Iceland 1 3,6 Iceland 1 14,54 Ireland 2 3,13 Ireland 2 13,07 1 1 Israel 3,5 Israel 4,76 Italy 1 3,68 Italy 3 6,3 Japan 1 2,23 Japan 1 10,11 Korea 1 1,99 Korea 1 4,63 Luxembourg 1 2,77 Luxembourg 1 11,1 Mexico 1 2,03 Mexico 1 2,48 Netherlands 2 2,92 Netherlands 1 8,4 New Zealand 1 2,61 New Zealand 1 10,03 Norway 1 4,07 Norway 1 14,39 Poland 1 2,18 Poland 1 5,26 Portugal 3 3,82 Portugal 2 5,65 Slovak Republic 2 3,34 Slovak Republic 2 6,03 Slovenia 1 2,43 Slovenia 1 8,19 Spain 1 3,78 Spain 1 4,88 Sweden 1 3,8 Sweden 1 11 Switzerland 1 3,81 Switzerland 1 16,03 Turkey 2 1,69 Turkey 2 1,6 United Kingdom 1 2,71 United Kingdom 1 9,6 United States 1 2,44 United States 2 10,95 OECD AVERAGE 3,14 OECD AVERAGE 8,56 1. Data refer to practising physicians. Practising 1. Data refer to practising nurses. Practising physicians are defined as those providing care directly nurses are defined as those providing care directly to patients. to patients. 2. Data refer to professionally active physicians. 2. Data refer to professionally active nurses. They They include practising physicians plus other include practising nurses plus other nurses working physicians working in the health sector as managers, in the health sector as managers, educators, educators, researchers, etc. (adding another 5-10% researchers, etc. (adding another 5-10% of nurses). of doctors). 3. Data refer to all physicians who are licensed to 3. Data refer to all nurses who are licensed to practice. practice.

Nursing graduates Medical graduates per 2010 (or nearest year) per 100 000 2010 (or nearest year) 100 000 population population Australia 12,01 Australia 67,15 Austria 22,78 Austria 47,89 Belgium 8,99 Belgium 41,69 Canada 7,18 Canada 1 29,53 Chile 5,48 Chile 36,67 Czech Republic 13,86 Czech Republic 12,2 Denmark 16,35 Denmark 78,2 Estonia 11,12 Estonia 31,19 Finland 10,61 Finland 58,73 France 6,02 France 34,39 Germany 12,3 Germany 28,17 Greece 14,29 Greece 1 13,8 Hungary 10,4 Hungary 28,63 Iceland 13,84 Iceland 77,99 Ireland 17,54 Ireland 36,67

Israel 4,12 Israel 10,95 Italy 11,13 Italy 16,16 Japan 6 Japan 38,35 Korea 7,06 Korea 94,71 Luxembourg .. Luxembourg 19,92 Mexico 11,55 Mexico 9,81 Netherlands 8,2 Netherlands 40,05 New Zealand 7,26 New Zealand 30,62 Norway 11,27 Norway 65,45 Poland 8,07 Poland 25,28 Portugal 11,86 Portugal 34,84 Slovak Republic 8,49 Slovak Republic 69,22 Slovenia 11,18 Slovenia 66,83 Spain 8,41 Spain 20,89 Sweden 10,66 Sweden 1 42,52 Switzerland 10,39 Switzerland 67,13 Turkey 7,02 Turkey 5,96 United Kingdom 9,25 United Kingdom 33,21 United States 6,62 United States .. OECD AVERAGE 10,34 OECD AVERAGE 39,84

1. Data refer to professional nursing graduates only, excluding graduates from lower level nursing programmes.

MRI units per million MRI exams per 1 000 2010 (or nearest year) 2010 (or nearest year) population population Australia 5,64 Australia 23

Austria 18,59 Austria 1 47,6

Belgium 1 10,65 Belgium 52,8

Canada 8,24 Canada 46,7

Chile 4,12 Chile 7,4

Czech Republic 6,27 Czech Republic 33,5

Denmark 15,39 Denmark 57,5

Estonia 8,21 Estonia 48,1

Finland 18,65 Finland ..

France 6,95 France 60,2

Germany 1 10,3 Germany 95,2

Greece 22,55 Greece 97,9

Hungary 3 Hungary 2 31,7

Iceland 22,01 Iceland 74,2

Ireland 12,51 Ireland 1 17,3

Israel 1,97 Israel 18,1

Italy 22,35 Italy ..

Japan 43,1 Japan ..

Korea 19,94 Korea 14,7

Luxembourg 13,81 Luxembourg 79,6

Mexico 1,96 Mexico ..

Netherlands 12,22 Netherlands 49,1

New Zealand 10,54 New Zealand 1 3,6

Norway .. Norway ..

Poland 4,69 Poland ..

Portugal 9,23 Portugal ..

Slovak Republic 6,81 Slovak Republic 33,2

Slovenia 4,41 Slovenia 1 2

Spain 1 10,66 Spain 1 45,6

Sweden .. Sweden ..

Switzerland 1 17,77 Switzerland ..

Turkey 9,52 Turkey 79,5

United Kingdom 5,87 United Kingdom 1 40,8

United States 31,55 United States 97,7

OECD AVERAGE 12,48 OECD AVERAGE 46,28

1. Data include equipment in hospital only. 1. Data refer to exams in hospital only. 2. Data refer to exams outside hospital only.

CT scanners per CT exams per 1 000 2010 (or nearest year) 2010 (or nearest year) million population population Australia 42,81 Australia 93 Austria 29,8 Austria 1 145,5 Belgium 1 13,22 Belgium 179,3 Canada 14,19 Canada 126,9 Chile 10,2 Chile 50,2 Czech Republic 14,45 Czech Republic 86,5 Denmark 27,58 Denmark 105,2 Estonia 15,67 Estonia 275,4 Finland 21,07 Finland .. France 11,81 France 145,4 Germany 1 17,73 Germany 117,1 Greece 34,31 Greece 320,4 Hungary 7,3 Hungary 2 76,2 Iceland 37,74 Iceland 159,8 Ireland 15,64 Ireland 1 75,4

Israel 9,18 Israel 127,2 Italy 31,58 Italy .. Japan 97,27 Japan .. Korea 35,28 Korea 106,2 Luxembourg 25,64 Luxembourg 188 Mexico 4,83 Mexico .. Netherlands 12,34 Netherlands 66 New Zealand 15,57 New Zealand 1 22,4 Norway .. Norway .. Poland 14,33 Poland .. Portugal 27,39 Portugal .. Slovak Republic 13,81 Slovak Republic 89,2 Slovenia 12,69 Slovenia 1 12,8 Spain 1 14,96 Spain 1 82,8 Sweden .. Sweden .. Switzerland 32,6 Switzerland .. Turkey 12,41 Turkey 103,5 United Kingdom 8,2 United Kingdom 1 76,4 United States 40,67 United States 265 OECD AVERAGE 22,57 OECD AVERAGE 123,83

1. Data include equipment in hospital only. 1. Data refer to exams in hospital only. 2. Data refer to exams outside hospital only.

Hospital beds per 2010 (or nearest year) 1 000 population Australia 3,73 Austria 7,63 Belgium 6,44 Canada 3,19 Chile 2,04 Czech Republic 7,01 Denmark 3,5 Estonia 5,33 Finland 5,85 France 6,42 Germany 8,25 Greece 4,85 Hungary 7,18 Iceland 5,79 Ireland 3,14

Israel 3,31 Italy 3,52 Japan 13,62 Korea 8,76 Luxembourg 5,37 Mexico 1,64 Netherlands 4,66 New Zealand 2,74 Norway 3,3 Poland 6,59 Portugal 3,35 Slovak Republic 6,42 Slovenia 4,57 Spain 3,16 Sweden 2,73 Switzerland 4,97 Turkey 2,52 United Kingdom 2,96 United States 3,08 OECD AVERAGE 4,93

The figures represent a small part of the OECD Health Data 2012 statistics, available at: http://www.oecd.org/els/health-systems/oecdhealthdata2012- frequentlyrequesteddata.htm

Annex III – Selected questions from the “Healthcare Barometer”

Q. 2 Which of the following statements expresses your opinion on the functioning of the Healthcare System in our country more accurately?

It works quite well in general 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 21,34 18,41 18,58 19,80 19,40 19,16 20,05 19,23 21,20 23,86 24,24

It works well but some changes are necessary 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 45,46 47,67 47,61 47,10 48,30 50,53 47,35 48,86 48,00 50,02 48,88

It needs fundamental changes although some things work well 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 25,51 27,31 26,96 27,10 26,00 24,97 26,85 26,17 25,30 21,60 21,91

It works so bad that it needs to be completely redone 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 6,38 5,51 5,60 5,00 5,10 4,42 4,69 4,88 4,70 3,51 4,20

Q. 3 In general, are you happy or unhappy with the way the public healthcare system works in Spain? Use a scale of 1 to 10 to answer, where 1 means you are "very unhappy" and 10 means you are "very happy".

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 5,94 6,05 6,12 6,14 6,23 6,27 6,29 6,35 6,57 6,59

Q. 8

Based on your personal experience or your understanding of them, I would like you to assess the following aspects of public healthcare which refer to the assistance provided by family doctors and pediatricians (primary healthcare). The scale goes from 1 "completely insatisfactory" to 10 “completely satisfactory”.

The proximity of the centres 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 8,00 7,39 7,36 7,80 7,62 7,68 7,64 7,53 7,74 7,85 8,06

How easy it is to get an appointment 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,17 6,61 6,51 6,70 6,59 6,63 6,45 6,54 6,51 6,89 7,06

The opening hours 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,44 6,82 6,78 7,20 7,10 7,10 7,05 7,14 7,18 7,35 7,57

The treatment that healthcare personnel dispense 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,82 7,22 7,23 7,40 7,38 7,36 7,33 7,35 7,42 7,50 7,75

The care provided by medical and nursing personnel during home visits 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,41 6,77 6,82 7,00 6,93 6,94 6,87 6,91 6,96 7,13 7,29

The time the doctor spends with each patient 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,07 6,40 6,38 6,50 6,49 6,49 6,32 6,40 6,58 6,76 6,98

Q. 8 Continued

Based on your personal experience or your understanding of them, I would like you to assess the following aspects of public health care which refer to the assistance provided by family doctors and pediatricians (primary healthcare). The scale goes from 1 "completely insatisfactory" to 10 “completely satisfactory”.

The doctor's knowledge of patient medical history and the follow-up provided on each patient's particular health problems 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,40 6,77 6,83 7,00 6,97 6,97 6,89 6,95 7,05 7,26 7,52

The confidence and assurance transmitted by the doctor 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,74 7,10 7,15 7,40 7,40 7,38 7,27 7,35 7,40 7,54 7,77

The waiting time for consultation 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 6,00 5,42 5,31 5,60 5,59 5,58 5,48 5,52 5,56 5,79 5,93

The existing equipment and technological resources in the centres 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,08 6,27 6,42 6,70 6,48 6,71 6,55 6,49 6,66 6,87 6,92

The information received about your health problem 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,41 6,72 6,83 7,20 7,16 7,11 7,06 7,06 7,20 7,34 7,50

When you need it the family doctor refers you to a specialist 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 4,56 5,71 5,76 7,20 7,10 7,20 7,09 7,17 7,19 7,26 7,39

Q. 8 Continued

Based on your personal experience or your understanding of them, I would like you to assess the following aspects of public health care which refer to the assistance provided by family doctors and pediatricians (primary healthcare). The scale goes from 1 "completely insatisfactory" to 10 “completely satisfactory”.

The waiting time for diagnostic tests 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value ------5,26 5,22 5,24 5,45 5,66

Q. 13

I would like you to assess, based on your experience or the notion you have of them, the following aspects of the care provided in public hospitals. Please use a scale of 1 to 10, where 1 means "completely unsatisfactory" and 10 means you value it as “completely satisfactory”.

The number of people sharing a room 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 5,64 5,24 5,29 5,40 5,50 5,38 5,44 5,32 5,47 5,65 5,84

Accommodation aspects (meals, toilets and general comforts in the rooms) 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 6,71 6,11 6,14 6,40 6,39 6,34 6,40 6,25 6,27 6,47 6,56

The administrative requirements for hospital admission 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 6,27 5,70 5,76 6,40 6,05 6,09 6,12 6,11 6,19 6,33 6,47

Waiting time for non-urgent admissions 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 4,26 4,11 3,97 4,30 4,18 4,45 4,53 4,46 4,54 4,74 4,84

Q. 13 Continued I would like you to assess, based on your experience or the notion you have of them, the following aspects of the care provided in public hospitals. Please use a scale of 1 to 10, where 1 means "completely unsatisfactory" and 10 means you value it as “completely satisfactory”.

The care and attention provided by the medical personnel 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,47 6,75 6,97 7,10 7,20 7,21 7,12 7,08 7,19 7,24 7,35

The care and attention provided by the nursing personnel 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,61 6,87 7,04 7,20 7,30 7,29 7,21 7,14 7,25 7,26 7,44

The treatment received from non-healthcare personnel 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,41 6,71 6,90 6,90 6,99 6,99 6,89 6,87 6,89 6,83 6,97

The existing equipment and technological resources in the hospitals 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 8,23 7,46 7,53 7,70 7,61 7,68 7,58 7,61 7,72 7,76 7,91

The information received from the hospital personnel about the evolution of your health problem 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Value 7,34 6,67 6,92 7,10 7,11 7,12 7,02 7,05 7,15 7,22 7,38

Q. 15

Do you thing that the health authorities are acting to reduce waiting lists?

Percentage of the survey respondents who believe that YES, they are 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 40,49 41,62 42,99 46,40 45,70 48,53 47,27 42,32 41,30 36,92 33,19

Percentage of the survey respondents who believe that NO, they aren't 2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 15,06 22,25 29,62 30,10 32,20 30,13 31,94 34,05 35,40 33,53 36,34

Q. 18

In your opinion, has each of the following healthcare services improved, worsened or remained at the same level in the last 5 years?

Percentage of the survey respondents who believe that Primary healthcare has improved 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 51,65 50,67 51,70 47,60 48,28 47,44 41,79 42,30 42,73 41,14

Percentage of the survey respondents who believe that Primary healthcare has worsened 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 4,73 5,21 4,50 5,00 5,18 5,86 8,79 8,30 7,87 10,71

Percentage of the survey respondents who believe that Primary healthcare has remained at the same level 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 36,97 37,64 36,40 40,20 39,70 40,27 41,43 41,80 42,32 41,52

Q. 18 Continued

In your opinion, has each of the following healthcare services improved, worsened or remained at the same level in the last 5 years?

Percentage of the survey respondents who believe that Specialised consultations have improved 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 44,80 40,65 44,40 38,80 40,55 40,50 35,90 35,80 36,31 34,72

Percentage of the survey respondents who believe that Specialised consultations have worsened 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 6,50 6,53 5,70 7,20 6,49 6,92 9,50 9,70 8,88 11,83

Percentage of the survey respondents who believe that Specialised consultations have remained at the same level 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 38,87 42,30 38,20 42,00 41,39 41,11 42,26 42,70 43,53 42,18

Percentage of the survey respondents who believe that Hospital care has improved 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 48,02 44,05 47,00 41,60 43,18 42,30 37,78 37,60 39,35 37,72

Percentage of the survey respondents who believe that Hospital care has worsened 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 5,56 5,70 4,80 6,00 5,25 6,43 8,60 8,90 7,47 10,52

Percentage of the survey respondents who believe that Hospital care has remained at the same level 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 36,59 39,25 36,40 39,40 39,12 39,80 40,57 40,80 40,61 40,21

Q. 21

Now that all Autonomous Regions are responsible for their own healthcare provision, do you think that they should all reach an agreement when considering the provision of new services to the citizens?

Percentage of the survey respondents who believe that Autonomous Regions SHOULD reach an agreement 2003 2004 2005 2006 2007 2008 2009 2010 2011 Percentage 75,33 80,10 82,90 83,97 85,83 86,21 84,90 83,62 84,68

Source: Barómetro Sanitario, historical series 1995-2011

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