Juan Abarca Cidón is one of the most key voices in understanding Spanish healthcare. He is a doctor and chairs one of the large hospital groups, HM Hospitales. Before reflecting on how we face Covid in his LinkedIn posts, he reflected on the national health system through The Spanish health system. From its origins to the present day (The Sphere of Books).
When everything shakes (Deusto) reaches the second edition. "It is a crisis management manual, of how the management of the hospital and the group tried to confront and manage that avalanche that we had," says its author, adding that "we must clearly record what we did, what the private sector did." The book also highlights common management points, such as "being late for everything" and "trying to prioritize the economy over health." Beyond its pages, Abarca reflects on the current moment of our health.
He started with his social media posts in 2020 and 2021, which he says have been the foundation for the book. What was done well, what was not and what could have been done in managing the pandemic?
The book is developed following the structure of three seasons of publications: Parts of War, Diary of the Resistance and Stories for Hope. Three questions run through it: what we did well, what we didn't do and what we could have done; I didn't want to say what we did wrong.
With the passage of time, there is talk of the resilience capacity of the health system, in the face of slower management by administrations. Do you share that reading?
We must differentiate the first wave in Madrid from the rest of the pandemic: there we did what we could and the virus passed over us. What the system demonstrated was not resilience, but the endurance of the professionals in the face of the onslaught. Resilience would have been adapting without stopping the scheduled activity. At a micro and mesomanagement level, the system worked because the professionals took the reins and the public and private hospitals worked as a network: in Madrid, we functioned as a single hospital. What failed miserably was the political-administrative management, not because of anyone, but because the system was not prepared. The State and Ingesa lacked resources, the state of alarm was not declared in time and there was a lack of coordination to bring reinforcements to Madrid while patients were dying in the hundreds in other communities. We had to bring resources from other hospitals almost in contraband.
Six years later, the Public Health Agency will be located in Zaragoza, but there is still no decree. What lessons are left for us?
We have learned a lot, but we have done nothing. The first lesson is that "the bandage must be put before the wound": if the economy confronts health, health wins, because without it people do not go out or consume. The nursing homes still have to resolve their chronic lack of care resources and medium and long-term hospitals - during the pandemic they depended on primary care doctors who became infected en masse - and the system needs strategic reserves of material and a ministry with more coordination capacity. The reconstruction document of July 2020 was done very well, but it has not been applied, and the parties allege that it is due to political tension.
"We have learned a lot from the pandemic, but we have done nothing"
What role do the parties play in this scenario, where healthcare is a weapon?
People are tired of waiting lists and individual abandonment in mental health, ALS or dependency. The party that reaches the government must think about well-being in a comprehensive way, and that will involve "stepping on a lot of calluses." Those who say they defend public healthcare actually defend the statutory model, and their best way to maintain it is to criticize private healthcare. Simply adding more money is not enough: the increase in public health spending in recent years has not been accompanied by an equivalent increase in activity, and processes must be changed and work differently. Politicians do not want to implement the necessary reforms for fear of social noise.
There are regulations in Congress that seek to update healthcare based on 20th century bases, such as the Framework Statute or the Medicines Law. Should we rethink the model of the General Health Law of 1986?
In these 40 years, a good part of its articles (75%) are no longer applicable or are outdated. We must rethink the model, maintaining universality and equity, but taking the formula of "contribute according to ability, receive according to need" towards a personalization that goes beyond the level of income. I propose co-payments in stages for innovation: who can pay 50, who can pay 40, who can pay 20 and who can't pay anything. And resort to the private one with concerts where the public one cannot cope.
Why is the private sector demonized?
The public often sees the sector as a threat, instead of as a strategic sector that contributes almost 2.5% of the GDP and hundreds of thousands of jobs: if we are not able to defend it inside, how are we going to defend it outside? People also do not see public health as an expense, but as an obligation.
What should be the bases of this new health model for the 21st century without settling into the dichotomy between public and private?
First, we must change the SNS management model, going against the frameworks established by the Framework Statute, which only adds bureaucracy, prevents measuring results and does not allow for rewarding professionals who work harder. Second, conceive the citizen in a holistic and fair way in coverage. Third, normalize the private sector as a necessary complement to reduce waiting lists.
Regarding the concertation models, what differences exist?
The Catalan model is very particular and is much better prepared for the future. It only has eight hospitals under the statutory model; The rest are public or private non-profit companies that are governed by the labor regime, which makes them much more efficient, although their budget is closed and, when it is exhausted, they must slow down their activity. In addition, Catalonia has the largest network of medium and long-term hospitals. In Madrid, the concession model only covers five hospitals, and in Valencia there is only one left. The rest of the CCAA resort to specific concerts from waiting lists.
