Tiago Villanueva: How does the financial crisis affect demand for health services?

Tiago_VillanuevaThe unemployment rate in Portugal is at an all time high of 16,3%, and 2013 is looking even bleaker, due to announced tax hikes that will see people’s net income squeezed even further.

As a locum doctor, my hourly rates have dropped by about 20% compared to one year ago, and sadly, I am expecting them to drop further in January. Considering tax and social security rates will go up significantly in 2013, I fear my disposable income will probably end up as about half of what it was compared to one year ago, and may end up at the level of a trainee doctor, or even lower. In Ireland, a country that has also been bailed out, locum rates are still currently about three to four times higher than those in Portugal, which makes me wonder how they do it.

With less disposable income available due to unemployment and decreasing wages, I have noticed shifts in patterns of demand for health services. Many patients who used to use private healthcare rather than the national healthcare system, are now starting to go to the GP regularly for the first time. In the private sector patients can self-refer themselves to specialists, and in the public system, GP’s act as gate-keepers to secondary care. As a GP, I feel as frustrated as patients at the long waiting times for appointments to see a specialist at the hospital, which in some specialties can be over a year. At the same time, the national health system has also become less accessible than it used to be, as co-payments for consultations in primary care and in the hospital have also gone up significantly this year. Patients now pay 20 euros to access an emergency department, up from 9,60 euros, and they pay 5 euros to see the GP, up from 2,25 euros.

While this may not seem like much compared to the very high fees that are charged here in private practice, it has made a huge difference to some people, particularly the elderly with multiple co-morbidities who have low pensions, and who need to pay hefty amounts of money every month in co-payments for appointments and for drugs. They are the ones who are most affected by all this austerity, as a few euros can make the difference between attending and not attending appointments, or in purchasing or not purchasing needed drugs. It would make sense to lower attendance rates in emergency departments in exchange for greater accessibility and the ability to solve problems in primary care (attendance rates in emergency departments are about 50% higher than in the United Kingdom), but I am not so sure that is the case.

With thousands of qualified professionals leaving Portugal for greener pastures, I have slowly seen the rise of a new type of patient, the FIFO—Fly In Fly Out. These are patients who have been relocated by their company or forced to find work overseas, particularly in Brazil or in the former Portuguese colonies in Africa, which are now emerging economies (such as Angola) with a high demand for qualified professionals. These patients often leave their families behind, and return home every few months to Portugal. Many FIFO patients I’ve seen don’t miss the opportunity to come for a medical check-up every time they come home, and I’ve even had a patient who changed the date of a hospital appointment after I made my referral in order to coincide with a trip home. These new emigration patterns are also creating opportunities for Portugese doctors in the emerging world, for example working as a doctor in an offshore oil rig in Angola.

Due to the relentless and increasingly suffocating austerity environment, it’s looking like in 2013 it will be even more difficult to access good healthcare services, and for professionals to provide good care.

Tiago Villanueva is a locum GP based in Portugal, and a former BMJ Clegg Scholar and editor, studentBMJ