Emergency services

About 15 years ago, I was in Pontevedra, Galicia, Spain, and had to go to the emergency room at the local hospital, which serves about 400,000 inhabitants. I had a physical problem, which could have been cardiac. It was a Saturday, and, familiar with Portuguese emergency services, I was worried about the care I would receive. When I arrived, there were about six people in the waiting room, and there was a desk where two nurses were sitting. I approached them and explained my situation. They told me to wait in the waiting room, and after about five minutes, they told me I could come in. Inside, it was a calm environment with very few people. I was initially examined by a nurse who took my blood pressure and performed an ECG. She called the doctor who examined me and ordered tests to check for signs of a possible heart attack. They placed me in an observation room, where two other people were. Shortly after, a cardiologist, who must have been in the ward, arrived and examined me. It was all very calm and pleasant. In that room, where a nurse occasionally passed by, forcing me to uncross my feet, I stayed for about two hours. The cardiologist who had examined me and brought the tests with him appeared. He performed a new ECG and told me there was nothing cardiac-related, discharging me.

Compared to our shameful emergency rooms, this was heaven. I didn't pay anything because I had a European Health Insurance Card.

About two years ago, I was at the marina again in Grove, Galicia, Spain. While undoing a rope from the boat, I felt intense lower back pain, radiating to my right thigh, which immobilized me. I was taken to the hotel, where I asked for someone to administer an injection. Shortly after, I received a call from the health center in Grove, a small coastal town, asking what my problem was. After explaining, the woman on the phone said she would put me through to the doctor on duty, known there as a "guardia" doctor. I spoke to him, and after listening to me, he said he would send an outpatient medical team to the hotel. They arrived at the hotel about 20 minutes later. The team consisted of a doctor and a nurse, and after examining me, the doctor told the nurse to administer an injection she had brought. I asked about payment, and the doctor replied that it was free, as it was part of the Galicia Outpatient Medical Service. I was already aware of this service, but not with that efficiency.

Unlike Portugal, a third-world country, these services and efficiency have existed for decades in most European countries, where no one goes to the emergency room, except in exceptional cases, without seeing a general practitioner. This means that a hospital emergency service is only efficient if primary care is also efficient.

For about 40 years (though they weren't like this before), emergency services in Portugal have been third-world, chaotic, and dangerous, with patients left unattended in corridors on stretchers, or sitting waiting, and professionals completely unmotivated. Because of all this, there's a risk that true emergencies will go unnoticed. They are, above all, breeding grounds for contamination. The vast majority of these patients aren't hospital emergencies, but rather sufferers of pathologies that could and should be treated in primary care, in health centers, or at home, through home-based outpatient medical services.

But the problem is that these services no longer exist!!

I'll try to explain how we got here. Until around 1980/1982 (I can't pinpoint the exact dates), the well-known "Caixa doctors" system operated. Almost all doctors, including hospital doctors, worked double jobs at the Caixas because the salaries were low. Consultation hours were two hours each, and there was no waiting list (wasn't that great?!), but there was one good thing: daily home medical and nursing services. All district capitals had doctors who only made home visits, which was a basic requirement for becoming a permanent staff member. In other peripheral or rural centers, the doctor (after consultations if someone on their list had requested one or more home visits) was required to perform them under penalty of serious disciplinary action for medical negligence. I confess I never enjoyed doing home visits, but the truth is, it's part of the profession.

It wasn't a perfect system, but it had one advantage: it diverted outpatients from hospital emergency rooms. Until the 1980s, while this system was in operation, working 24-hour hospital emergency services (as I did at Santo António Porto Hospital) wasn't a sacrifice, but rather a pleasure, as we only handled hospital emergencies, with exceptions. We were cohesive teams, where, beyond work, we shared experiences and forged lifelong friendships.

Around that time, Dr. Paulo Mendo, who was for me the best and most knowledgeable Secretary of State for Health, did a magnificent thing: he established the so-called medical careers, like a building:

• Family Doctors — THE BASIS
• Hospital Doctors — Intermediaries
• Public Health Physicians

He regulated hospital medical careers, with medical staff at various levels, and anyone seeking advancement had to pass rigorous jury exams, essentially based on meritocracy. For him (and for me), the career of Family Doctor, general practitioner, was the most important and would be the pillar of the building, on which the others would rest. That is, if the foundation didn't work, the entire edifice would be at risk of crumbling. Patient management would fall to the family doctor, who had the closest contact with the patient and, if they agreed, would resort to hospital specialties, which were secondary. The idea was, as the name suggests, a good doctor-patient relationship that could even lead to permanent availability. Outpatient emergencies and home health services would be guaranteed, and patients could only use the ER at their own recommendation and responsibility, except in exceptional cases. Unfortunately, the government fell, elections were held, and these family doctor careers, although decreed, were never fully regulated. The family doctor career remained limited to training, access, and a 35-hour workweek, without defining how these hours would be applied or the family doctor's rights and responsibilities. I know that 20 hours were dedicated to consultations, and the remaining 15 hours were, I was told, for filing? To this day, I never knew what these filings were (in my ignorance, I assumed they were some kind of carpentry or metalwork). The truth is, a void remained that has never been filled in 40 years. This led to a steady increase in the number of people forced to resort to hospital emergency services, which were unprepared for this problem. This increase wasn't sudden; it was insidious, like a malignant disease, growing year after year until it reached its current strangulation.

Faced with this constant increase in the number of people visiting the ER, which in some cases exceeded 300%, hospital administrations were forced to hire so-called "staff doctors" who, generally speaking, worked at the health centers where these patients should be treated. Companies were also created to "rent" doctors to hospitals, at rates that currently, in some cases, reach the exorbitant price of €150/hour, with spending on staff doctors exceeding €200 million by 2024. I consider these figures obscene! "Standard doctors," and there are already those who dedicate themselves exclusively to this, are a terrible solution for the ER, as they are disconnected from the emergency teams, perform temporary work in shifts, and do not provide continuity of patient care. They request additional tests, and by the time these are performed, the doctor is often no longer on duty.

Now the Minister of Health, while acknowledging that task workers are a "factor in the NHS's malignity and the major problems it faces," has come out to say that she will regulate task work within the NHS, taking several measures. However, the truth is that the underlying problem remains. She also says that emergency services feel hostage to the work of task workers, because without them, emergency services could be paralyzed!

But I say it's also true that if primary care operated as it should, removing patients from emergency rooms, and if hospital doctors were motivated with decent salaries, these companies would disappear, as they would have no reason to exist (they're another Portuguese invention). If they exist, it's because official services, due to their poor functioning, allow them to. These companies, too, are hostage to this. I personally dislike them. Their dismantling is in the hands of all parties, as they thrive on "the worse, the better." Madam Minister, incidentally, is currently in the eye of the storm, but the reality is that the problem has been going on for 40 years, and in that time, dozens of ministers from various parties have served in the Ministry of Health, but they have achieved nothing. You are not alone, as all the others have experienced the same negative situation.

What Hospitals want is to get rid of day laborers, a figure that institutionally does not exist and only serves exceptional and temporary periods.

Forty years is a long time! During this time, vested interests and organized lobbies have developed that thrive on this vacuum. Family doctors have become accustomed to not making home visits and will try to keep it that way. It's not pleasant, but they have to do it because it's part of their professional duties, and if they exert pressure, it's better to change professions! Even the population itself (in the Portuguese style) reacts badly to changes, even if they're for their own good.

The Minister and all those who preceded her should leave their Lisbon offices and try to see what's happening outside this sad country and copy, not invent, what has been resolved for decades in European countries. I recommend a trip to Galicia and consult the autonomous government to understand how they solved the problem, at much lower cost, or if you prefer, go to France.

Meanwhile, hospital medical careers, which were regulated and had adequate medical staff, experienced their golden years in the 1990s. There were structures, modern medical equipment, motivated professionals with professional achievement (albeit poorly paid), career progression dependent on jury selection processes, specialty interns, and hospital management teams comprised of elected Hospital Directors, Hospital Career Administrators, and Nurse Directors. In the North, there was an Association of Hospital Directors, chaired by Dr. Paulo Mendo, which met once a month, where ideas were exchanged and problems discussed.

At that time, I felt for the first time that we were just a small step away from advanced Europe, as nothing embarrassed us when we visited foreign hospitals. Then… and there's always an unfortunate aftermath in Portugal's history, there was the election of Prime Minister António Guterres, who, for me, was the weakest Prime Minister and the one who facilitated democracy. In fact, he himself acknowledged this, to his credit, when he resigned. He couldn't say no to the party machine, and everything changed, and party politics entered the hospitals in full force, where the managerial position was considered a good place to accommodate party clientele, ending meritocracy. The competitive examinations were regulated and reduced to a farce. This led to the famous remark by a jury president: "Everyone's approved. Does anyone want to take the exam?" Then, to avoid having to witness what would inevitably happen in person , I abandoned my hospital career at 58. Building is difficult and time-consuming; destroying is easy and quick!

An NHS can't be built in a single term. It requires competence, political courage, forgetting partisan rivalries, forgetting votes, and thinking only of the interests of the people and the country.

In the Netherlands, political parties made a so-called “20-year health pact” years ago, where any specific changes had to have majority consent.

Would that be or will that be possible here in Portugal? Health policy can't be constantly changing when a new minister takes office, even if they're from the same party, as is often the case.

Personally, I, having been involved in the health of this country for years, would like this to happen, but hope is low.