at V.Bettella, F.Gentile, F.Anaya Cintas
03 DEC – Dear Director,
we read the letter from dr. Cossutta, a family doctor in Portugal, and others published by her and we think it will be useful to contribute our direct professional experience to the public debate on Italy’s health reform project. In Spain, all professionals who work in local and hospital health services, subject to public competition, are hired as employees of the NHS.
The various activities relating to primary care take place mainly in the “Centros de Salud” or “Consultorios locales” (as the health centers located in towns with less than 15,000 inhabitants are called here). A recent census (2020) has a total of about 28 per 100,000 inhabitants for a total of just over 13,000 structures including “central”, “peripheral” or “rural” that cover the entire national territory in a very widespread manner (wider than the Italian one), including “disadvantaged” areas, in which about 30,000 family doctors, 6,500 pediatricians and 30,000 nurses work. The centers, especially the larger ones, are managed by a Medical Coordinator and a Nursing Coordinator. In health centers the activity of the individual doctor is integrated with that of other colleagues and professionalism in team work; in the same center, many family doctors can also coexist who alternate in morning and afternoon shifts together with nurses and collaborators with administrative or secretarial duties, and with minimal variability between the different centers also with obstetricians, social workers, psychologists , physiotherapists, OSS, etc….
The doctor’s work is always carried out in close collaboration with a nursing figure. A very important combination is therefore formed for the complete management of the patient because, among other things, particular importance is given to prevention for which both doctor and nurse play a key role in promoting health through the correction of risk factors. implementing initiative medicine. Each doctor has from 1,400 to 1,600 patients and each pediatrician from 800 to 1,200 children (up to 15 years) who refer only and exclusively to them.
Thus a fundamental relationship of trust and confidence is established with the patient, and therefore it is not at all true that addiction involves the loss of this relationship as we have read in various Italian articles. In the “Centros de Salud” the bureaucratic part strictly related to the diagnosis (prescriptions, sickness certificates, etc …) belongs to the doctor; of all the rest, thanks to the shared electronic file, the team takes care of it, which considerably lightens its work, consequently leaving more space for the clinical part but above all for home care which is also always carried out usually together with a nurse, who still maintains his autonomy for certain home visits.
Most of the centers are equipped with a small operating room where minor surgery can be performed, thus reducing access to hospital services and waiting lists, as well as having various 1st level diagnostic instruments available for perform electrocardiograms, fundoscopies, pap tests, spirometries, etc. and possibly also x-rays. There are often dental units for children, units for sexual health, mental health and drug addiction. The obstetrics clinic is also generally present; the midwife follows non-risk pregnancies, the puerperium, breastfeeding and coordinates with the family doctor, facilitating the task.
Most health centers have a room equipped for resuscitation with life-saving drugs and basic equipment for possible first aid in an emergency, and a day-hospital room for brief observation of the most problematic patients. The medical staff who work there can be made up of the same family doctors if they give their availability (therefore it is not mandatory) or by external personnel who are dedicated exclusively to urgent activity in day and night shifts.
An interesting aspect is represented by the requests for consultancy, called in Spanish “interconsultas”, which can be carried out easily and quickly through the shared computer system and which initiate direct communication with the hospital specialists to whom a particular case is to be addressed. . It should not be forgotten that health centers also play an important role in the training of family medicine specialists during their four years of specialization in “Medicina de Familia y Comunitaria” because here the family doctors (and also the nurses since 2010) they are all specialists!
One of the positive aspects of this system is undoubtedly the wide organizational autonomy of the center on the one hand and professional autonomy of the doctor on the other, so the doctor does not have to worry about organizing practically anything and can therefore devote himself almost exclusively to the practical clinical aspect. of the profession in which no one, not even the Coordinator, ever enters into the merits having rather managerial duties.
As civil servants you are entitled to 22 working days of vacation per year and to a salary (almost equivalent to that of hospital colleagues) in which there is a capital share in the order of only 15-20%. In case of absence due to illness, vacation or other, the General Management of the Health Centers will take care of finding a replacement by drawing from a special list or rearranging the agenda of the doctors of the center to make up for the absence. In general, the shifts are in the morning or in the afternoon from Monday to Friday (… and they are always the same) and there is no on-call or imposed guards, even if in some Regions, for example. that of Valencia, we also work on Saturday mornings.
As for free choice, a hot topic we have seen in the Italian debate, citizens are free to choose the medical professional they like best. Based on the domicile, the patient is assigned to a specific health center where he can freely choose his “trusted” doctor / pediatrician. In general, we always try to accommodate the preferences of patients when the doctor in question has not reached the maximum number of patients. In this case, however, exceptions are often made if the doctor agrees. In addition to the pre-established daily schedule, the doctor always has extra time to possibly see patients who have not been able to book and need urgent consultations.
The reality of the smaller and more peripheral health centers, on the other hand, is much more similar to that of the family doctor’s surgeries we are used to in Italy, unfortunately even in large cities. In these centers, which represent the most basic form of health center in Spain, the family doctor may find himself working alone, with the difference that he is still provided with a well-structured and fully equipped clinic, and is always assisted by an administrative and a nurse.
In conclusion Director, here in Spain, as in Portugal (see article by Dr. Cossutta), all health workers are state employees and this does not conflict at all with the capillarity of assistance, the free choice of the patient, the relationship of trust. doctor-patient or professional autonomy, indeed! All this is guaranteed and, in addition, compared to the Italian scenario that we know well, in a context of greater organization that offers citizens better assistance and better working conditions for doctors.
These aspects should be told with intellectual honesty, the one with which, although necessarily in a synthetic form, we hope to have contributed to providing correct and disinterested information and to chase away the “ghosts of addiction” foreshadowed in too many articles we have read.
D.ssa Valentina Bettella
Family doctor, Fuerteventura
Dr. Federico Gentile
Pediatrician, Tenerife
D.ssa Francisca Anaya Cintas
Family nurse, Valencia
03 December 2021
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