When a body bleeds to death, a tourniquet can be the emergency solution to stop the bleeding. But then the wound will have to be healed. The agreements that the regional governments are reaching with the primary doctors of half of Spain to end their strikes (the last one in Madrid) may be the tourniquet that a system in crisis needed, but to heal the collapse it is suffering, structural reforms will be necessary , according to all the family medicine societies and unions consulted by EL PAÍS.
The prolonged strike in Madrid (almost four months) has managed to start a more generous economic agreement than in other communities where there has been a strike, with a fixed bonus of 450 euros per month, which can reach 1,150 depending on the afternoon shifts and the volunteer hours you do. But, as explained by Lorenzo Armenteros, spokesman for the Spanish Society of General and Family Physicians (SEMG), the fundamental lines of the pacts —which he describes as “minimum”— are very similar in all territories: a limit of daily patients in the agendas (which is usually between 30 and 35), better economic conditions to attend to those who do not give time in overtime in the afternoon, less bureaucracy and incentives for places that are difficult to cover (such as some rural ones).
With some variations, this is what unions and governments have agreed to in Andalusia, Cantabria, Extremadura, Catalonia, Castilla y León, Castilla-La Mancha and Navarra (whose doctors have preventively called a strike in case the agreement is not met). There are still strikes in the Valencian Community, Galicia, Ceuta and Melilla, which ask to move forward on this same path.
The three large family medicine societies in Spain celebrate the agreements, but they are far from enthusiastic. They want to verify that what is signed in the papers is fulfilled in the day to day of the doctors. And they emphasize that the solution of overtime to care for patients must be temporary, while they demand a great state pact for health to provide the primary care system with the doctors it needs (which number around 5,000) to to be able to attend to citizens with the time they require without having to use the afternoons.
“Overflow schedules (overtime coverage in the afternoon for patients who do not meet the agreed quota) can be a temporary solution, but what we need are sized templates so as not to lose longitudinality (that the patient is always attended by the same doctor), to be able to train new professionals and practicing doctors, in addition to attending to organizational tasks”, claims Remedios Martín, president of the Spanish Society of Family and Community Medicine (semFYC). “These organizational changes are urgent proposals to lower the pressure of care, but once the agendas are limited, we must go further and transform the primary,” she continues.
José Polo, president of the Spanish Society of Primary Care Physicians (Semergen), believes that the professionals’ claim is “fair”, although he believes that the agreements come to “put out bonfires” and that “the embers remain”. “There is still a lot to build, to move forward. We will see how the MIR election turns out this year and if there is a disappointment as big as the past ”, he reflects, referring to the 200 vacant positions that remained in Family and Community Medicine.
The Ministry of Health has been increasing the offer of these places in recent years to try to alleviate the deficit reported by doctors, but this will mean long-term relief, since it takes four years to train professionals. Those unfilled positions from 2022 that Polo mentions were the symptom of the lack of prestige and attractiveness that the specialty suffers.
Compliance with agreements
With regional and municipal elections just around the corner, both the scientific societies and the unions fear that the commitments will fall into oblivion when they are held. Beyond the economic ones, which are difficult to reverse, promising a number of patients per day or cutting red tape (which consumes doctors up to 40% of their time) is easier said than accomplished. Armenteros fears that the agreements are a mere ruse to avoid electoral punishment and denounces that “they do not get to the bottom of the issue.” Because not only are there fewer doctors, but since the pandemic, the demand for care “has grown” enormously.
In Cantabria, the first autonomous community to go on strike and the first to reach an agreement, they came to call a new strike when they saw that what was signed was not being complied with. They finished it and now they observe how “compliance is irregular”, in the words of Vicente Alonso, general secretary of the Cantabria Medical Union. The Ministry of Health ensures that the average number of patients per doctor is 30, below the 36 committed. But there are places that exceed this figure and where the possibility of overtime in the afternoon has not been opened, according to Alonso. Unions and Government will meet on the 27th of this month to follow up on the agreement.
Another community that agreed to a maximum of 36 daily patients is Extremadura. María José Rodríguez, general secretary of the medical union in this community (Simex), acknowledges that it is difficult to reach this figure in all consultations. “In January we gave ourselves three months to achieve it and taking into account that it is the first time that something like this has been launched, it is difficult to apply. It is a process that involves the management of appointments, the administrative ones, the assistance ones. Compliance is so far spotty. There are colleagues who tell us that their agendas remain the same. What we ask is that consultations be made easier in the afternoon,” she points out.
In any case, all these solutions —the doctors insist— “are a band-aid”. They will not avoid problems like the one denounced this month by the Spanish Association of Primary Care Pediatrics (AEPap): more than 523,000 children under 16 years of age in Spain (more than 7%) do not have an assigned primary care pediatrician. “Hundreds of studies tell us that mortality is not necessarily reduced with the best doctors, but with continuity, that yours always take care of you, that promotes healthy habits and can attend to emotional problems that are so frequent now. And for that you need time”, concludes Lorenzo Armenteros.
Politicians from both parties justify that there is a structural problem of lack of doctors, due to the few who joined the system in the years after the financial crisis. This is partly true, but unions and companies assure that with better conditions and greater incentives in positions that are difficult to fill, many physicians who choose to work in the emergency room or go abroad would join the vacant positions.
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