Tiago Villanueva: Is there an end in sight for austerity?

Tiago_VillanuevaI’ve blogged before about the impact of austerity on healthcare, mainly on the hard hit Portuguese healthcare system. And just when I thought things have already gone too far, new developments over the last few days have cast even more dark clouds over the healthcare system, and have spread additional apprehension and outrage in the population.

The International Monetary Fund has released a report consisting of “technical advice provided by the staff of the IMF to the authorities of Portugal (the “TA recipient”) in response to their request for technical assistance.” The report proposes a number of measures aimed at cutting 4000 million euros of government spending starting in 2014. This includes making about 20% of public sector workers redundant and decreasing salaries by up to 7%.

For the healthcare sector in particular, this means increasing proposed “user fees” to access health services and increasing co-payments for drugs. One Portuguese daily newspaper has suggested that fees to access emergency departments in hospitals could potentially go up from the current rate of 20 euros to around 40 euros. Even though there is excessive use of emergency departments, in part that has to do with the difficulty in accessing primary care services in some areas. I worked for some time in a practice located in one of the most deprived areas of the Greater Lisbon Area, where it was frequent to hear the administrative staff tell patients that they would have to wait two or three months for an appointment with their GP.

For a lot of people with private insurance, private healthcare is starting to compete with the public system in terms of costs, so some people prefer to resort to private medicine as the first point of contact. And many people in Portugal agree that making access to public healthcare increasingly difficult will pave the way for private health insurance to flourish, and lead to the “americanisation” of our healthcare system, which will leave the poorest and frailest of our society extremely vulnerable (even if many benefit from exemption from co-payments). Moreover, it will weaken the gatekeeper and coordination role of primary care even more, as patients will increasingly tend to be seen initially by specialists rather than GP’s.

The report also added that Portuguese doctors benefit from a high income and other perks (like well paid overtime), and that there was room to cut more spending there. That was especially shocking to read, and particularly to see that the report estimates Portuguese doctor’s purchasing power to be equivalent to that of doctors in Finland and Ireland, and even superior to that of doctors in wealthier nations like Germany and Norway. According to a recent document by the European Federation of Salaried Doctors, the income of Portuguese doctors falls in the bottom half of European countries. In order to make up for such low salaries in the national health service, in reality what happens is that Portuguese doctors often juggle a mix of public and private work. If doctors end up earning a reasonable income it is the result of very long hours of work and a significant impact on their own health, on their personal life, and on their family life. Even then, it’s peanuts when compared to the six and seven figure incomes of executives, managers, bankers, etc. Cutting down on doctor’s incomes even more will only exacerbate the need and motivation to carry out more private work.

There’s nothing wrong with trying to make a healthcare system more efficient or more cost effective (and some measures may make some sense), but there is an acceptable limit to what can be cut and how much can be cut without jeopardizing the provision of quality healthcare. The healthcare system’s problems are too complex to be dealt simply with relentless austerity.

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