Portugal’s health service crisis: “questions/ answers”

State news agency tackles what other media sources dub “nation’s shame”

Emergency Gynecology, Obstetrics and Childbirth services at various hospitals are closed for another weekend as the crisis in Portugal’s State health service intensifies.

Lusa, the country’s State news agency has published what it calls ‘questions, answers’ in an attempt to explain the situation.

“Constraints” (the word used to describe serious failings) are “also expected through the weekend in hospitals of Santarém and Lisbon”.

The lack of doctors – particularly in the speciality of obstetrics –  is  happening all over the country.

“In addition to the situation in these emergency services, there are also some problems in general emergency services in hospitals across the country”.

Just as the director of the country’s DGS  health department warned earlier this summer, “the worst thing that can happen” to anyone in Portugal is to get sick or have an accident in August.

Crisis in hospital emergency services: why now?

Lusa’s explanation to this question is that “the greatest difficulties in emergency services have usually arisen during holiday periods (summer or festive seasons) or during peaks in demand for services (flu season, for example), covering general emergency services across the board.

Problems in emergency services have been getting worse over the years, especially in some specialties, as is now the case with gynaecology and obstetrics, due to the increasing difficulty in ensuring 24-hour emergency services, 365 days a year, due to a lack of doctors, thus forcing the closure of some services”.

The ‘questions, answers’ text does not completely explain the reasons for the problems – which healthcare syndicates (and political parties) will say are years of disinvestment and poor management.

Lusa does not interpret it quite this way, admitting nonetheless that “the main cause of difficulties in completing emergency room schedules has been the departure of many health professionals from the national health service and the retirement of many others, whose jobs have not been filled over the years with the same number of new hires.

The news agency does acknowledge that “both the Portuguese Medical Association and the unions have insisted that the lack of attractiveness of the medical career in the national health service (SNS) has caused a “flight” of doctors – from all specialties – to more attractive job markets, in the private sector or abroad.

“The aging of the medical staff” is another issue. Older doctors (those aged 55 and over) can be exempt from doing emergency work. Even at 50 they can refuse night shifts.

“The need for more predictable recruitment tenders that are less out of touch with reality has also been raised”, says Lusa.

How can the crisis in obstetric emergency services be explained? 

“In the gynaecology/obstetrics emergency services the reasons are identical (lack of specialists), and here the average age of these specialists makes it even more difficult to draw up work schedules, a problem that is even more acute during holiday periods.

“According to calculations made by the specialty college of the Portuguese Medical Association released in June, around half of the gynecologists and obstetricians registered in the Medical Association who are still working (12% are over 75 years old) are outside the SNS, in private hospitals.

“The figures also indicate that between 2023 and 2035 more than 350 specialists in gynecology and obstetrics will retire, but at the same time 540 will be trained. It would be necessary for most of them to stay in the SNS in order to bring the average age structure back down.

“According to a portrait of existing resources and needs in this area, summarised in an article published in Acta Médica Portuguesa, the aging of this group of professionals is growing – in 2020, 46% of the more than 860 specialists working in the SNS were aged 55 or over and could therefore refuse to work in emergency services.

Regional imbalances: Where are the most problematic areas in obstetric emergencies?

“The areas with the greatest need in this area are Lisbon and Vale do Tejo and the Algarve, but there are also occasional problems in Braga and the Alentejo.

What has the government done to try and solve the problem of emergency services? 

“In order to immediately solve the problem of emergency services, the government decided, without the agreement of the medical unions, to establish a transitory regime for the payment of overtime to emergency doctors, with amounts varying between €50 and €70. In some cases, payments can go as high as €90.

“This system has been in force since July 26and will continue for six months (until the end of January 2023).

“The (government) diploma defines that expenses on service provision and medical overtime to be carried out until January 31, 2023 cannot exceed amounts paid in the second half of 2019.

“The document also intends to limit the use of service providers, so that only in cases where the closing of emergency services is in question will hospitals be able to reach the amounts paid to permanent staff doctors.

What has the government done in the specific case of obstetric emergency services? 

“This year, in an attempt to respond to the difficulties in maintaining functioning emergency services in gynecology/obstetrics, the government set up a monitoring commission to accompany the response in gynecology/obstetrics and childbirth departments.

“The first measure taken was to create a space on the health portal with information about the opening hours of each obstetrics service, allowing pregnant women to see which services are closed.

“The commission is also part of the technical group preparing a proposal for the creation of a hospital referral network in maternal and child health”.

Looking closely at these three ‘actions’, one can see that very little has actually been done; certainly nothing has been done to reverse the problems.

What are hospital referral networks? 

“The Hospital Referral Networks aim to regulate relations of complementary and technical support between hospitals, in order to guarantee access of all patients to health care services and units” (This too is a sweeping statement in as much as ‘guaranteeing access’ can mean people having to travel huge distances to receive healthcare that ‘normally’ would be offered much closer to home).

What is the government negotiating now with doctors?

“The government’s negotiations with medical unions involve structural issues such as full dedication to the SNS (ie no part time work in private hospitals), the valorisation of work in emergency services and the regulation of organisation of medical work. In addition, at the end of July, the government and unions agreed to include salary scales for SNS doctors in negotiations.

Is the problem only about money?

No.

“In their negotiations with the government and medical unions have always emphasized the need to review salary scales, but  stress that it is not only the difference in salaries offered by the SNS and the private sector that make doctors leave the public services.

“They have also emphasized inequalities in payments offered service providers for work in emergency departments, which are always a great deal more than what is paid to permanent staff/ professionals.

“Another problem is “conditions in the public health service (obsolete facilities and equipment)”.

What do the Portuguese Medical Association and the trade unions say? 

Both recognise that “none of these problems are new“, but they have been getting progressively worse, admits Lusa – until the country arrived at this point: August, with heavily pregnant women everywhere wondering whether they will be lucky when the big day comes – and find a local maternity unit open – or will they face travelling kms away from home, trying to find a safe place to deliver their babies?