DOCTOR RUI Lourenço is a general practitioner working in Loulé and also teaches at the Escola Superior de Saúde in Faro. He took office as president of the Administração Regional de Saúde do Algarve (ARS Algarve), the Algarve regional health authority, in April 2005 and, one year on, The Resident’s Caroline Cunha met with him to discuss the latest health issues affecting the region.
The Resident: Why was the decision recently taken to increase patients’ fees from two to 3.30 euros at Centros de Saúde (health centres) and 6.90 to 8.50 euros in hospital emergency departments, which come into force this month? Why weren’t these increased gradually and what difference, if any, will this make to the health service?
Rui Lourenço: It is necessary to increase the fee paid by patients in order to meet the health authority’s costs, plus increases have only been made in line with inflation. There was no increase made in 2005 and, although I do not know the exact reason behind this, I can assume it was due to the change in government.
I believe the present system is fair. You may not know this, but nearly half the population is exempt from paying anything at health centres and hospitals. Those exempt include children under 12, pregnant women, the unemployed, the poor, those surviving on less than the minimum wage, OAPs living on pensions below the national minimum wage, alcohol and drug addicts, and those suffering from chronic illnesses such as diabetes, Parkinson’s, tuberculosis, Aids and cancer, among others.
We need to add a greater perceived value to the service and a co-payment such as this (consultations are, of course, still heavily subsidised by the state) helps to moderate demand. As many as 40 per cent of the people arriving at hospital casualty departments in Portugal cannot be classed as urgent cases. These are what we call ‘false emergencies’. The current government is working on improving access to primary care.
T.R: What is the latest situation with regard to the Hospital Central planned for construction at Parque das Cidades (in the same complex as the Algarve football stadium, built for the Euro 2004 Championship)? After all the controversy, is it still going ahead and, if so, when will construction begin and what is the expected opening date?
R.L: Six new hospitals are needed in Portugal (Lisbon, Algarve, Évora, Gaia, Vila do Conde/Póvoa de Varzim and another south of the Tejo, at a location yet to be defined) and are planned for construction over the coming years. In order to decide which hospitals get priority, Porto University was commissioned to carry out a study. The ranking, which was published in February of this year, placed the Hospital Central for the Algarve in second position (behind Hospital de Todos os Santos for Lisbon).
The project for the 550 bed Hospital Central is currently in the public discussion phase, due to end this month. Following this, the government must launch a public tender for the construction work. However, before this can be done, it must decide on the operation model for the Public Private Partnership (PPP). This means it must decide if the partnership relates to the construction of the hospital and its day-to-day running or just to its construction, for example. Only once this is decided can the tender go ahead. The tendering process will take 20 months to complete. It might sound long, but this is because of European Union rules that oblige the tender to be open to construction firms throughout Europe, not only those here in Portugal.
We estimate that the hospital will open in six years time, in 2012.
T.R: There seems to be a large proportion of Spanish doctors and nurses working at public hospitals and health centres in the Algarve, what is the reason for this?
R.L: I would say that around 20 per cent of the doctors in the Algarve are Spanish. In the 90s, Spain found itself with a surplus of doctors, but, nowadays, they are starting to experience a shortage. For this reason, some are returning and maybe you will notice a difference already. Another point worth mentioning is that it is more common these days for workers to seek jobs abroad and we are seeing European citizens following this trend more and more, seeking work in other Member States, which affects all countries and all professions.
The Algarve has around 500,000 residents, Alentejo 700,000 and the interior area to the right hand side of the country has around one million. You will find that the Portuguese doctors are more heavily concentrated in the Lisbon, Coimbra and Porto areas, which together host around 60 per cent of the national population or, in other words, roughly six million people. It’s a matter of spread and not a lack of doctors.
The number of practising doctors in Portugal, according to the Organisation for Economic Co-operation and Development (OECD), is 3.2 doctors per 1,000 members of the population, while in UK this number is 2.2. The difference may be with regard to the number of nurses – 4.2 per 1,000 in Portugal, while the UK has 9.1 per 1,000. What I want to say is that, in the UK, a lot of medical work is carried out by nurses.
T.R: Are the Algarve’s blood banks self-sufficient or do they rely on support from other regions?
R.L: Yes, they are self-sufficient. We have an ongoing blood donor campaign that is very successful, meaning that our stocks are at 100 per cent. For this reason, we do not need to buy in blood from abroad. The way Portugal’s blood banks work is that the blood is used everywhere throughout the country, wherever it is needed. Therefore, blood stored in the Algarve is used elsewhere in Portugal when required.
T.R: Why is the Ministry of Health threatening to close down the night service at Silves SAP and what is the reason for creating more basic emergency units?
R.L: Currently, there are three main services to deal with emergencies: INEM, Faro Hospital and Barlavento Hospital. They are not sufficient to cope with the region’s needs and, therefore, we have to have basic emergency units created outside of hospitals. For this reason, we plan to transform some of the 24-hour Serviços de Atendimento Permanente (SAPs), which are located at Centros de Saúde, into basic emergency units. These must be used if the victim lives more than an hour from Faro or Barlavento Hospital. The proposal of the Direcção Geral de Saúde is to create a basic emergency unit in Vila Real de Santo António. Albufeira, Vilamoura, Quarteira and Loulé are the areas with the most tourists in the summer and, therefore, it has been proposed to create a further two to be located in Loulé and Albufeira. It is not necessary to keep Silves SAP open during the night or transform it into a basic emergency unit because patients in that area are within an hour’s travelling distance from Barlavento Hospital or Albufeira’s basic emergency unit. Our research has shown that, of the seven cases seen at Silves SAP on average per night, the majority are false emergencies that can wait until 8am the following day. Only 1.2 cases are real emergencies.
It must be pointed out that the SAP service in Silves will still operate between 8am and midnight, only ceasing to operate between midnight and 8am.
It is the aim to ensure that real emergencies are dealt with at facilities properly equipped to respond to the patients’ needs, rather than time being wasted at a SAP that may then have to send the patient on to the hospital afterwards.
T.R: Do you believe that progress in terms of health services in the Algarve is hampered by bureaucracy? What is being done to fight the bureaucracy and waiting lists?
R.L: In the past, much of the bureaucracy and delays existed due to a basic lack of planning. The current government is working hard to re-organise the system and to provide better access to primary care, while ensuring more efficient use of resources.
Among the measures currently being implemented are paperless Centros de Saúde and hospital emergency departments. Instead of paper records, all patient information and observations will be stored on computer. First, this will be done in both hospitals and then at the Centros de Saúde. The first two health centres to use the new procedure will be Castro Marim and Monchique.
In order to give more people a family doctor and reduce waiting times for consultations, Unidades de Saúde Familiar are being created based at existing Centros de Saúde. This will mean that instead of many health centres in the region closing at 4pm, they will stay open until 8pm. They will be open from 8am until 8pm. Due to the increase in the working timetable for medical staff, doctors and nurses are currently being given a choice if they wish to apply for these positions with extended hours. However, over the next five years, the new timetable will become obligatory and Serviços de Atendimento Permanente (SAPs), currently operating at Centros de Saúde, will be phased out. The long-term aim is for care to be provided by the family health units, basic emergency units and district hospitals.
In addition to these measures, the ARS Algarve has just announced a new project entitled Telemedicine, funded by the INTERREG programme (EU funding), which aims to make the consultation process quicker and more efficient through the use of information technology (read related article on p.3).
R.L: There are currently around 5,000 Britons who hold the Cartão de Utente (Portuguese national health card). However, we believe there to be nearly 30,000 British people resident in the Algarve and as many as 60,000 here during the summer.
According to the 2005 figures supplied by the Serviço de Estrangeiros e Fronteiras, the office for foreigners and border control, a total of 10,807 Britons in the Algarve hold a Portuguese residency card.
With regard to usage of Portugal’s health services, British visitors who are in the Algarve for up to 90 days are considered as holidaymakers and, as Portugal enjoys an agreement with the UK, they have free access to the national health system here on presentation of their passport.
However, after 90 days, under this arrangement, they are considered as being resident and, therefore, should be applying for a Cartão de Utente. There is a large proportion that is not doing this and, although this does not present a serious problem at present, in the future, this could become an issue to be discussed with the British authorities. In order to plan resources and obtain adequate funding, there needs to be accurate statistics. It is my view that citizens must have access to one country’s health system as resident, or another – not both at the same time. Holidays abroad are an exception.
T.R: Much funds have been raised for the Associação Oncológica do Algarve (AOA) thanks to the support of the foreign community (i.e. the Mamamaratona events), but the association seems to face many barriers in trying to get its projects off the ground (the breast screening service and the new radiotherapy unit in Faro, for example). Why is good work being rewarded in this negative way?
R.L: I believe there may have been some problems in the past, prior to my time, but I sincerely believe there was fault on both sides – however, on a positive note, I believe everything is going well now.
The breast screening service is working efficiently. Women between the ages of 50 and 65 are being called up throughout the Algarve. In April, it is the turn of women in Olhão and afterwards, the mobile unit will be making its way to Loulé and Faro. Activity in these areas will no doubt raise the profile of the screening programme.
In order for it to be worthwhile, 60 per cent of women falling in this age group must take part in the programme, and this is being achieved. With regard to the radiotherapy unit, I believe the equipment is being installed and the unit is currently in the licensing phase – a stage it must complete to comply with the law.
T.R: Legislation was brought in last year, making it mandatory to obtain a health declaration from your doctor before you will be given access to public municipal swimming pools. Why was this done? Some people are waiting up to two months or more to get an appointment to have a check-up to obtain this declaration. Does this system work?
R.L: All those who intend to take moderate exercise must undergo a check-up by a doctor to see if everything is OK. This is the reason to place a health declaration doctor alongside the family doctor.
This declaration of health must be the result of a routine medical consultation. A new consultation is not necessary if the last consultation was carried out recently. There is no reason to wait two months, but if this situation persists, an explanation must be given by the director of the health centre.
T.R: What preparations have been made by ARS Algarve for the possible threat of a bird flu pandemic in humans reaching the region?
R.L: Avian influenza, or bird flu, is a contagious disease of animals caused by viruses that normally infect only birds and, less commonly, pigs. The widespread persistence of H5N1 in poultry populations poses two main risks for human health. The first is the risk of direct infection when the virus passes from poultry to humans, resulting in very severe disease. A second risk, of even greater concern, is that the virus – if given enough opportunities – will change into a form that is highly infectious for humans and spreads easily from person to person.
Such a change could mark the start of a global outbreak (a pandemic). Portugal and ARS Algarve took all the measures recommended by the WHO, by improving an early warning system and acquiring adequate supplies of Oseltamivir (commercially known as Tamiflu), a drug that can reduce the severity and duration of illness.
At the moment, bird flu is a veterinarian issue. We must be vigilant and report sick or dead birds to the local veterinarian authorities by calling the veterinarian advice line, 800 207 275.