¿Se pueden garantizar por ley los límites temporales en las listas de espera de la sanidad pública?

Recently (04/11/23) an article was published in El País, by Pablo Linde, with the title, “Reduce health waiting lists by law: is the commitment of PSOE and Sumar viable?” in which the authorship team of this proposal for the AES Economy and Health Blog, modestly had the opportunity to participate.

As a result of this, a digital debate was generated that has allowed the preparation of this document that we hope will continue to contribute to improve, once and for all? (let us continue with optimism, please, avoiding it being a nightmare) both the correct expectation of each and every one of the users of this our “National Health System” (SNS) and its management within public health organizations and at all its levels, macro, meso, micro and nano.

A couple of questions as premises. The first: we reflect as a citizen, what do we want when we go to a professional or health center? Understanding of our problem, correct treatment that is personal and warm, flexible, accessible, close, useful, without delays or major administrative work, continuous over time and equitable, providing each person with what they need. Later the “problems” appear and we reflect again, is that right? Violinists or pianists or throwing flower petals at our path are not requested, from the entrance to the exit of each process, but those characteristics that may not be met and where finally faced with a pathological issue (even if it is suspicious) are requested. we are concerned, the wait. The second: if we have had the number of vaccines administered updated daily in the unfortunate “COVID era” (see here and here) with data on doses delivered and administered of vaccines and people with a complete schedule, with less than a day of margin, why can’t we assess this very agile update with the results of health activity in public organizations, including this point ? that now occupies and worries us not only as researchers or academics or… but as users at the time of our healthcare, the “waiting”?

The waiting list is a dynamic system of repositories where patients waiting for consultation, tests or interventions are «packed», which is expressed in waiting times to access services, times that are the result of the processing-production capacity. that public health services have.

There are vectors that increase the embalming of patients: morbidity; referrals, reviews, prescription of diagnostic tests and indication of interventions. Other vectors drain: production of consultations, tests and interventions.

For technical reasons there must always be repositories. Patient entries and exits have a complex dynamic in health services: when the balance is defeated towards longer waits, part of the demand is inhibited or seeks alternatives (private sector, alternative networks, or other care procedures); When accessibility is increased (special programs to reduce waiting lists), part of the inhibited demand emerges again and neutralizes part of the effect of the greater production of services.

From the allocative point of view, the virtue would be in the combination of actions on the demand side (appropriate indications and greater role of primary care), on the supply side (improvement of the organization and productivity of efficiency services), and in the balance itself, which should be set at acceptable and adequate waiting times, supported by mechanisms to discriminate situations in which waiting aggravates the prognosis, or produces greater damage.

Due to the complexity of these actions, the development of a program to improve the waiting list must be considered systemic, and involves articulated actions of demand, supply and their balance.

Treating the symptom is a very common mistake: removing pressure from waiting with programs to increase supply may be necessary at certain times, but it is inconvenient when done by avoiding the necessary reformist and systemic actions.

Another mistake is to decree the end of waiting through regulation: setting legal limits can be politically attractive due to its finality and immediacy. But rather than forcing itself, what the health authority has to do is manage the changes and reforms necessary to achieve a socially efficient and acceptable balance with waits.

If on this path you set deadlines as control objectives for your aircraft, then it may be interesting to do so; But if it is formulated as a law of guarantees, and allows some patients to go with public financing to be treated in the private sector, then a new and important problem of weakening the scarce resources necessary to support the public health network is created. Health services; It could be considered as a means of privatization on the side of waiting time guarantees.

Therefore, in order to continue being positive and constructive in the face of this controversy, why not plan correctly? What are, in short, the details of the hidden agendas of the participating agents, politicians, unions, professional associations, scientific associations, the professionals themselves, suppliers of all kinds… that prevent the definitive solution waiting in the public health organization? ? ? The various plans and autonomous regulations already in place in the line of limiting the wait (surgical, above all), reinforced in the programs of the past regional elections (see “(some) references” at the end of the text) and in the daily action of these thirty years? (and even more years) based on the classic “star” measures, of “referral to private healthcare” and, secondly, on the so-called “self-concerts” conceived as an extraordinary professional activity, remunerated in the evening hours. What have they achieved beyond evaluations for research and scientific publications on the matter? (a sample selected here, based on the free search in “Pubmed«: 1, 2, 3, 4 and 5).

How is it going to be guaranteed if the provision is not provided by the central administration? subsidies and penalties can be imposed for the degree of compliance; or establish that, once the guarantee period has passed, patients can go to the private sector and request reimbursement (if they do this, a new front of leakage of public funds to finance the private sector will continue to be promoted, currently under controversy due to the pressure of his own waiting despite the updates on previous exercises).

The evidence (see here and here) in other countries tells us that improving the management of waiting lists (through, for example, explicit rationing or clinical priority) can reduce waiting times, while guaranteeing a maximum time for all patients only achieves that waiting times pass from one to another.

Under the modest vision of this team of authority and responding to the question of the initial title, “Can temporary limits on public health waiting lists be guaranteed by law?”, the legislative basis is established (from the General Law of Health 1986) although it is always updatable and improvable.

With a future projection, the criteria for managing waiting within the health organization and from the Interterritorial Council of the SNS (CI-SNS) must be agreed upon, made transparent, evaluated (at least from an “Airef Sanitary” agency or also called “HispaNICE” that evaluates the incorporation and status of both health technologies and SNS benefits) and continually improved.

These actions would contribute to improving both equity for all citizens under the scope of the SNS and the measures to be taken in this line of ostensible improvement of “waiting lists”, based on real social and individual participation, for example, empowering each citizen to lead the witness of their wait by entering their inclusion date themselves and analyzing it periodically directly from the administrative “feedback”, without having to go to complain to the user/patient service of each center.

Finding the perfect renovation plan is also a priority in the highly technological healthcare, because after years of disinvestment (since the “Great Recession”) there is a significant decapitalization with obsolescence of buildings, facilities and technologies. Innovation, which is more striking due to its technological fascination, must be appropriate, and its introduction is required accompanied by an evaluation of effectiveness, efficiency and planning of its dissemination.

However, the objective is to defend, on the one hand, efficient governance and, at the same time, transparency, absolute as such, real, which serves to compare centers and services and thereby defend and correctly manage the equity of any citizen before . “waiting”, both diagnostic and therapeutic and in direct care (consultations in primary care and hospital care).

Unfortunately there are no shortcuts to solving this problem; Good governance and professional management are the means to advance and achieve more virtuous balances.

Reference:

Peiró S (2000). Waiting lists: a lot of noise, little information, opportunistic policies and minimal management. No. 6 Clinical and Health Management, Health Services Research Foundation (http://www.iiss.es/gcs/gestion%20clinica%206.pdfaccessible on November 19, 2023).