As a former director of Public Health, Ildefonso Hernández knows well the seams of Spanish healthcare, its strengths and weaknesses. He believes that there is a lack of political will and real commitment to assume that the National Health System (SNS) must be redesigned, because until now “it has been ‘pulling away’, because it seemed that ‘nothing was happening’ and no decisions have been made time”. The pandemic has highlighted the needs and the underlying problems have worsened.
reventiva y Salud Pública from the Miguel Hernández University and a member of the Spanish Society of Public Health and Sanitary Administration (Sespas) emphasizes socio-sanitary policies, “in order to achieve healthy aging, it is not good for people over 60 years of age to all they have is three or five or more drugs. There are no benefits to keep people healthy.”
They say that the primary care crisis is just the tip of the iceberg of the health situation in Spain…
It is a topic that has been dragging on for a long time. There has been no political will at any time to change things. To sum it up: it has happened to public health, as the effects are not seen a priori, they are not quickly quantified and it seems that they are not noticed. But now we are seeing the magnitude of the problem.
The reality is that the problem is entrenched and the damage to the system has been accumulating year after year. How is it corrected?
It’s complicated. It has been ‘pulling’, because it seemed that ‘nothing was happening’ and no decisions have been made on time. You have to redesign the model and change some fundamental things. The same Spanish Public Health Society (SESPAS), in its day, and the Health Economics Association have made several reports to change and promote modifications of the model.
The changes that are needed, are they so profound?
A lot of time has gone by without adjusting the architecture of a model that was fine. Obviously, Spain has good figures for health and the operation of the health service, but in order to maintain it, important changes must be made. What the pandemic has done is highlight many of the underlying problems, as has happened in all countries of the world.
What will be those changes that will have to be made?
There are several issues that are key. The problem is not just a system that has to be more focused on chronic patients. You have to change a system. that it has losses of resources and it has governance problems that mean that some of the fundamental issues are not taken into account. They are not easy or simple changes, it is not focusing on one type of patient. It is about a transformation from an exclusive biomedical care model to another in which the solutions are not drugs or surgeries or super-expensive devices, but rather are benefits of a social nature.
An example?
To get an idea: the lack of response to mental health problems is now more evident. This has to do with the fact that there have been too many responses of a biomedical type, of drugs that do not alleviate the origin of the disease. In other words, the problem of the increase in suicides in young people cannot be answered with drugs. Spain is one of the countries, along with Portugal, that consumes the most anxiolytics and antidepressants. This is serious because the underlying problems are not corrected in this way. There are problems of discomfort below that have to do with social policies, with responses from the system in the field of primary and community care.
Does the medicalization of the patient leave out other types of necessary approaches?
Clear. Many simplify in the famous medicalization and we stay there. But you have to see the set of needs. As regards benefits, in mental health and other illnesses we only medicalize, but we would have to carry out other types of aid through rehabilitation and physiotherapy. It is a different type of assistance. It is easier to give a pill than to try to correct a habit.
Or is it thought that they are not equally effective?
Indeed, these alternatives are also considered to be soft from the point of view of scientific evidence, when it is not true. It has been shown that many of these interventions, in the field of physiotherapy and in others, have very high gains in terms of years and quality of life per euro invested. These benefits are practically non-existent. And the system has to be transformed towards this because otherwise we are not going to respond to the health needs of the population, especially because to achieve healthy aging it is not good for people over 60 to have to take 12 or 15 drugs. There are no benefits to keep people healthy.
But, will there be a way to measure the impact, the cost-effectiveness of these non-pharmacological therapies?
Perhaps it has not been known how to measure them, but it has not been known how to expose that cost-effectiveness that often has to be demonstrated, even with drugs. In this case, it must be possible to demonstrate that this investment is also real in this type of intervention. There are huge investments in biomedicine and there is utter disregard and delay in investing in the alternatives. There are research policies that are systematically forgotten, only looking at productivity. It is not clear that part of the economic profitability has to do precisely with ensuring that people do not spend, that they do not have problems that involve spending. They have forgotten about social benefits. An example is children in vulnerable families who need assistance because by not receiving it they accumulate problems throughout their lives, they and their environment.
So, are social and health policies the ones that have lost that prominence?
Situations in vulnerable families, in childhood and adolescence must be prevented through investments that have not only human but economic profitability, very high, of course. This has been demonstrated in Sweden. From the point of view of public health, we continue to think about changing the system to make it sustainable, but we do not think about the package of legal and fiscal regulations in health. It took a lot to move forward with the gambling law and develop a regulation for the protection of minors. Because we all know the impact of addictions, including those of gambling, which create social situations. But we must go further: regulate food labels, condition access to processed products… We have and want a high life expectancy and this is the answer. Because there is nothing worse for the health system than an 80-year-old person dying in an ambulance leaving for another extremely expensive dose of chemotherapy without having received good end-of-life care.
Along with all this are the problems suffered by health professionals who are the key figure that has held the seams of this cracking system.
Fair. The labor relations of the health systems create disease in the health workers themselves, instead of taking care of them, of valuing them. And it would not only have to be changed with better conditions and contracts, but also by providing them with professional development. And this has to do with what we were saying before medicalization. It is that primary school personnel are not trained or offered training within their working hours. And if they are formed, it is thanks to the congresses organized by the industry, in which pharmaceutical innovations are exposed. It’s not that I criminalize the industry, which is brilliant, but I miss a training agenda designed to respond to the health needs of the population.
One issue that concerns him is the new public health law and the future agency. Will this project that has been stuck since 2011 be completed this year?
Things just haven’t worked out. The draft that they have made is not complete, especially in the part of independence of appointments. We need an agency that is independent, that does not depend on the ministry, that recruits people based on merit, capacity… We also request this for the Agency for the Evaluation of Health Technologies and Interventions. Because then it sounds strange that the Ministry itself has appealed the request for transparency about the way things have been arranged with some drugs. That cannot be so. The public health law must have compliance guarantees, and it does not. Nor has a section on conflicts of interest been developed. And that has nothing to do with political color, but with the will to do things well.
In the end, in this legislature there are many pending issues?
The problem is that it is not prioritized, but nobody wants to do it, there is no explicit policy. Government programs are quite unfortunate because they do not have a real analysis of the problems. All the electoral measures are neither specified nor adjusted or simply remain populist measures at the time of announcement. They do not become tangible. Having a Minister of Finance who knows Health well, why has nothing been done with the taxation of tobacco and alcohol, with the impact that these addictions have on public health.
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