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Lisbon 2019

PORTUGAL

João de Deus

President

Lisbon 2019

Director of

International

Department

PMA

History

• Mainly of private nature

• Minimal health care in “Mercies Hospitals” – poor

people

• Religious charities

• 1971

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History

• 1974

• Constitution of 1976:

• Principle of health citizen’s, with the creation of a

“national universal health care, general and free”

• 1979 - NHS

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NHS

• Primary care – Health units

• Hospital network

• Did it work?

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1960 1970 1980 1990 2000 2005 2010 2013 2015

2017 2018

Infant

mortality

77,5 55,5 24,2 12,2 5,8 3,8 3,3 3,1 2,9 2,7 3,3

Life

expectancy

63,9 66,7 71,4 74,1 76,7 78,3 79,1 80,8 81,2 81,6

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Mortality rates from ischemic heart disease

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Why did it work ?

• Organization (?)

• Medical careers

– Backbone

• Clinical leadership

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• Training programs (PMA)

• Length of training

• Evaluation

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• Medical careers

• Collective agreements in the framework of a medical

career

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• Defined as a sequence of ascending

grades / steps of different knowledge and

scientific & technical skills, on the basis of

training, courses, and competency public

evaluations (CPD).

Medical Careers Reflect Different

Professional Skills And Competencies

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Continuous Professional Development

Medical

Student Medical Doctor

Pre-graduation

6 years

Formal

Education

5/7 years

Trainee /

Junior

Doctor

Assistant

(Specialist)

Consultant

(Graduate

Specialist)

Senior

Physician Student

Head of Department

Remuneration increases accordingly

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• Self regulation

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Leadership is essential

• 1. must have infectious optimism;

• 2. determination to persevere in the face of

difficulties;

• 3. and radiate confidence even when he himself is

not too certain of the outcome

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Clinical Leadership is essential

A physician can be taught:

• - to see the big picture,

• - the needs of a hospital as a whole,

• - the budgetary constraints

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Clinical Leadership is essential

A physician is already a professional with rigorous

training and can be taught on:

• - leadership skills

• - strategic planning;

• - setting goals for a hospital;

• - consider different organizational models as the

best way to deliver programs;

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Clinical Leadership is essential

A physician is already a professional with rigorous

training and can be taught on:

• - team building and communication;

• - management personel (hiring, union

agreements, disciplining, performance

evaluation, how to budget)

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Physician-Leaders and Hospital

Performance: Is There an Association?

• The Institute for the Study of Labor (IZA) in Bonn

• Amanda H. Goodall

• July 2011

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Physician-Leaders and Hospital

Performance: Is There an Association?

• top-100 U.S. hospitals in 2009

• widely-used media-generated ranking of quality

• The personal histories of the 300 chief executive

officers of these hospitals are then traced

• The CEOs are classified into physicians and non-

physician managers

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Physician-Leaders and Hospital

Performance: Is There an Association?

• Each chief executive officer was classified into

one of two categories ― physician-leaders, and

leaders who are non-physician managers

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Physician-Leaders and Hospital

Performance: Is There an Association?

• It finds ― in each of three disciplinary

fields ― that hospitals positioned

higher in the US News and World

Report‘s “Best Hospitals” ranking are

led disproportionately by physicians

• The study shows that hospital quality

scores are approximately 25% higher in

physician-run hospitals than in the

average hospital.

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Portugal today (10 million)

• Hospitals – 212

– Public – 121

– Private – 91

• Primary care health centers - 363

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Portugal today

• Financing

– Constitution of 2005: “Through a

national universal health care and

general and, given the economic and

social conditions of citizens,

tendentially free”

– Co-payment (exceptions)

– Subsystems (Army, Civil servants,

bank employees,..)

– Private health insurances

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Portugal today

• Financing

– Access to NHS

– Public insurance

• Equitable

• State budget

• Taxes

• Co-payment

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• The best of the worlds ?

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Portugal today

• Grouping

• 23 groups of Hospitals

• 54 groups of health centers in primary care

(ACES)

• 8 local health units

• 20 Hospitals

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Crisis

• Medical career is partially frozen

• Very low payment for extra hours

• Understaffed teams

• Inequalities between regions

• Shortage of doctors (FD, Hospital)

• Early retirement

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CHALLENGES

• PRIVATIZATION OF HOSPITALS AND CHANGES

IN MANAGEMENT MODELS ARE THREATENING

THE MEDICAL CAREERS

• INDIVIDUAL EMPLOYMENT CONTRACTS

(HOURLY WAGE EARNERS OR BY MEDICAL ACT)

• COMPANIES

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PUBLIC TENDER FOR THE

PROCUREMENT OF SUPPLIES FOR

HEALTH, FOR THE PROVISION OF

SERVICES TO MEDICAL INSTITUTIONS OF

NATIONAL HEALTH SERVICE

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1. The award criterion is the lowest price per hour.

2. The award will be made separately for each

batch.

3. For each batch will be selected the maximum of

five (5) service providers, which are ordered by

lower prices, increasingly.

4. In case of equality in price between proposals it

will be given priority to the one presented first .

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• Labour conditions of hospital doctors play a crucial

role in patients’ safety.

• Poorly paid work, non-specialized doctors doing

specialized tasks, cheap manpower in health

services, quantity instead of quality indicators only

leads to an increasing risk for patients’ safety.

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CONSEQUENCES

• Desorganization of health departments

• Hierarchical disruption

• Loss of interest in training junior doctors

• End of team work

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CONSEQUENCES

• Less quality in health care

• Risk for patients safety

• Destruction of National Health Service

• Shortage of doctors

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• It’s all bad ?

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CHALLENGES

• Waiting time for surgery

• Integration between Primary and Secondary care

• e-records, e-prescription

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Waiting time for surgery

• SIGIC

• Reasonable waiting time

• Surgery check

• Choose an Institution

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Integration between Primary and

Secondary care

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Health Center Hospital

Back to back

GP / Hospital Doctor

GP FAMILY DOCTOR

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Primary care HC Family Health Units

Family Doctor

Hospital

Continuing

Care

Social

Tertiary Care

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Integration between Primary and

Secondary care

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GP Patient Hospital

Half day work

No priorities

Waiting time

Integration between Primary and

Secondary care

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IT

ALER

T

Syste

m

Family

Doctor Hospital

No working hours lost

Priorities

Balanced waiting time

e-records, e-prescription

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The Portuguese Health Record (PHR) constitutes the

national health record data sharing facility.

This data can be shared between citizens, healthcare

professionals and healthcare entities.

While some data can be registered on PHR other is

accessed via web service technology that links old

and new existing applications.

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PDS/PHR Portuguese Health Record

This project is supported by the Portuguese Ministry of Health and the Comissão de Acompanhamento para a

Informatização Clínica (CAIC), the comission that supports the computerization of clinical records (Dispatch 9725/2013).

As well as it is developed by Serviços Partilhados do Ministério da Saúde, EPE (SPMS).

MoU – Health Sector

Citizen Portal (Portal do Utente)

Official launch: May 2012

Scope: Personal Health Record area that offers online informative

and electronic services to the patient. It aims to strengthen the

relationship between citizens and the NHS.

Professional Portal (Portal do Profissional)

Official launch: June 2012

Scope: Provide professionals with access to patient clinical data

stored in servers and records from different institutions and central

repositories.

Institutional Portal (Portal Institucional)

Testing

Scope: Provide statistics from anonymised clinical data to central

institutions.

International Portal (Portal Internacional)

Official launch: June 2013 (pilot)

Scope: Enable the epSOS pilot to serve as electronic patient’s

summary review for professionals.

PDS/PHR - Plataforma de Dados de Saúde /

Portuguese Health Record

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Portuguese

Patient Summary

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New ePrescription (PEM@med ) integrated in reall time with the EU

guideline based Patient Summary

Prescription

alerts

Alert to Clinical

recomendation

s

Drug

Information

Historical

Prescriptions

(with dispense

information)

Patient

Summary

• Allergies and

adverse reactions

• Chronical

medication

Update chronical

medication

Prescription

Local System: Health Patient Record

Update Health Patient

Record

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“Pros”

• NHS based on medical careers

• E-health (centralized)

• Doctors in the center of changes

• Organization (primary care, hospitals)

• Medical associations together

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“Cons”

• External enterprises

• Underfunding (4,8%)

• Absence of strategic plan.

• Doctors leaving NHS

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Total Public Health Expenditures

€ 356,54 Billion

Source: German Federal Statistical Office (DESTATIS) 2018

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“Cons”

• External enterprises

• Underfunding (4,8%)

• Absence of strategic plan.

• Doctors leaving NHS

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“Cons”

• Frozen of medical careers

• Delay to fill the medical posts (private)

• Excessive working time

• Working conditions

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Different

countries

Different

health

systems

Different

models

Different

problems

Expensive

treatments

Health always

good target for

cost saving

measures

High

technology

Privatization

of hospitals Financial

problems

crisis

Patients

safety and

quality of

care

EUROPE TODAY

GENERAL SPECIFIC

Lisbon 2019

Lisbon 2019

THANK YOU