Author: Tanita Rósenova Sábeva

Tutor: Xavier Martínez-Giralt Dept of Economics and Economic History

Universitat Autònoma de Barcelona

Presented: Bellaterra, May 2013

Sustainability and Future of the Spanish Healthcare System

3

Introduction

Spain has recently seen major social protest defending public healthcare in the

country. The reasons for it are the direct result of the global economic crisis which

plunged Spain into a recession. The country is hard-pressed to save money and the

budgets for basic services such as healthcare and education have been reduced in the

last 2 years. To obtain more financing some of the regions implemented unpopular

measures. The spending cuts and prescription co-payment which affected healthcare

in Catalonia as well as the privatisation of 6 hospitals in Madrid are good examples as

they caused a considerable public uproar and mass demonstrations on the streets.

Efficiency gains and the need to save are the main reasons given by the incumbent

authorities for all the recent modifications affecting healthcare but this explanation

does not seem to be enough.

Looking deeper into the issue, two very important concerns arise. The first of them is

the direct problem of the restructuring of healthcare personnel caused by the

privatisations and budget constraints. Many people in weak positions are likely to find

themselves in very precarious work conditions. The second concern has to do with the

erosion of trust in politicians which is widespread around the country. The part

politicians played in causing some of the past excesses in Spain is hard to overlook.

Now that savings must be mustered at all costs to pay off those excesses the mistrust

focuses on the people connected to the reforms. Rumours are hard to ignore,

especially when some of the managers-to-be in the private hospitals have links to the

governing political party.

With this in mind, the reason for expenditure cuts and sacrifices becomes more

interesting. Going through the official documents, the sustainability of the healthcare

system is mentioned repeatedly as the cause for the various reforms limiting coverage

and changing the functioning of the service. Allegedly, unless public spending on

healthcare decreases notably, the stability of the system will be in jeopardy. This work

aims to discover if the public healthcare system in Spain is indeed unsustainable or

whether there are other interests at play fuelling the debate.

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Index

Introduction 3

1. Background 7

1.1. Historical perspective 7

1.2. Defining Sustainability 8

2. Organisational structure of healthcare in Spain 11

2.1. Guiding principles of the Spanish National Health System 11

2.2. Organisation of the Spanish National Health System 11

2.3. Functional Organisation of the NHS 14

3. Resources of the Spanish Healthcare System 16

3.1. Hospital resources 16

3.2. Rates of usage for specialised care 20

3.3. Primary Healthcare resources 21

4. Comparison of resources across OECD countries 23

5. Performance of the Spanish NHS: 2000-2011 comparison 25

5.1. Public satisfaction indicators 25

5.2. Objective performance indicators 26

5.3. Health indicators 28

6. The financing of Spanish Healthcare 29

6.1. Healthcare expenditure in absolute values 31

6.2. Financial circumstances of the Autonomous Regions 32

6.3. Breakdown of public healthcare expenditure 34

6.4. Financial trouble in the NHS 35

7. Sustainability Analysis of the Spanish NHS 37

7.1. Priority analysis 38

7.2. Current measures taken to address short and long-term problems 39

8. Outlook to the future 41

8.1. Reforms for the NHS 41

8.2. Key points for the reform 42

8.3. The case for public-private agreements 43

9. Conclusion 45

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Annexes 46

Annex I – Detailed breakdown of hospitals in Spain, sorted by functional control

type 47

Annex II – OECD data for selected healthcare indicators 48

Annex III – Selected questions from the “Healthcare Barometer” 53

References 61

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Figures and Tables

Figure 1: Broad classification of responsibilities in the Spanish NHS 12

Figure 2: Hospital distribution in 2012 17

Figure 3: Distribution of hospital beds in 2012 18

Figure 4: Distribution of hospital personnel in 2009 19

Figure 5: Healthcare financing breakdown by financing agent, year 2003 30

Figure 6: Healthcare financing breakdown by financing agent, year 2010 30

Figure 7: Healthcare expenditure evolution over the period 2003-2010 31

Figure 8: Healthcare as percentage of GDP, evolution over the period 2003-2010 31

Figure 9: Per capita budget in Spain’s Autonomous Regions, 2010 33

Figure 10: Healthcare Budget per capita in Spain’s Autonomous Regions, 2010 33

Figure 11: Public healthcare expenditure classified by expenditure item, 2008 34

Table 1: Hospitals sorted by functional control type 16

Table 2: Available beds in Spanish hospitals sorted by functional control type 17

Table 3: Distribution of healthcare personnel in Spanish hospitals, evolution over time

18

Table 4: High-technology medical devices in Spanish hospitals, evolution over time 20

Table 5: Healthcare usage indicators, evolution over time 20

Table 6: Primary Healthcare centres in Spain 2004-2011 21

Table 7: Quality indicators for specialised care in Spain, 2000-2011 27

Table 8: Waiting times (days) for specialised interventions and consultations 27

Table 9: Life expectancy at birth and mortality rate per 100 000 population, 2000-2011

28

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1. Background

1.1. Historical perspective

When does the issue of healthcare sustainability arise? Since most of the healthcare

spending in Spain comes from the public budget the first thing to consider would be

fiscal sustainability.

The first formal attempt to regulate fiscal policy in Spain took place in 1992 with the

signing of the Maastricht Treaty. Within the European Union framework all countries

were to adopt economic measures in order to converge to a similar level and make the

Union more stable as a whole. Reference values were established for deficit (3% of

GDP) and debt (no more than 60% of GDP). The European Commission was appointed

as supervisor, reporting progress and breaches to the European Council which, in turn,

could impose fines or implement supporting programmes to deviating Member

States.

For 10 years the economic situation progressed smoothly. Spain managed to reduce

its debt level and deficit was well under the 3% threshold. The prize for this solid

economic behaviour was to be included in the Monetary Union, the next step towards

economic integration in the EU.

After the adoption of the Euro the Spanish economy was buoyant and further

improvements were reached regarding debt and deficit. For the years 2005-2007 there

was a current account surplus and debt was reduced to 36.3% in 2007.

When the financial crisis reached Spain in late 2008 it collapsed the construction and

financial sectors and by 2010 their growing trouble had caused unemployment to soar

to 20%. The Government tried to boost growth by increasing its own spending and

creating temporary jobs, mainly on infrastructure building and renovation. This was

done under the name “Plan E” and lasted through 2009 and 2010.

The final result was a great increase in debt levels (from 40% of GDP in 2008 to 61% in

2010) with almost nothing to show for it. The situation was worsened by the monetary

constraints inherent to Spain’s membership of the Eurozone. The economy was

almost free falling and debt levels reached 69% of GDP by the end of 2011. Ultimately

this put Spain at the centre of the recent sovereign debt crisis, eroding confidence in

its leaders and causing interest rates on sovereign bonds to soar.

It was in this turbulent environment that the European Union decided to act, setting a

course for the recovery of its Member States. The emergency policies at the national

level were deemed unsuccessful and contrary to the European goal of working

towards European economic integration. In order to return to the integration path a

strategy called “Europe 2020” was approved in 2010. It built on the Lisbon Strategy

approved in 2000, meant to improve competitiveness across the EU, and defined new

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objectives: growth and jobs created in a stable economic environment. Within the

context of Europe 2020 all member states have to work with the best possible

coordination to ensure a speedy recovery from the crisis.

Sustainability of public finances is a very important part of Europe 2020. All EU

countries, but especially the ones most affected by the sovereign debt crisis, have to

take drastic measures to reduce deficit and debt. A benchmark of 2.6% of GDP was

set for annual deficit reduction in the case of Spain (for the period 2011-2013). This

measure is considered essential but not superior to all other concerns. Social

discontent, unemployment, education levels and research stagnation also have to be

addressed. Thus, the additional detail on the guideline specifies that taxes should not

harm growth, age-related spending (including healthcare) should be reformed and

expenditure should be focused on the aforementioned areas of economic and social

interest.

The reports and articles concerning the recent healthcare reforms don’t talk about

fiscal sustainability but rather about the sustainability of the public healthcare system.

The policy-makers of the European Union also seem convinced that age-related public

spending must undergo a reform. Following a logical reasoning, since healthcare

represents a big share of the State budget any small modification multiplied by the

sheer volume of the service could mean a big saving. However, healthcare is a

complex public service and sustainability has different implications depending on the

definition we associate with it.

1.2. Defining Sustainability

When first conceived, sustainability was a term associated with the environmental

problems that the Earth is facing, used to explain the depletion of resources.

Whenever a given resource is being exploited at a rate faster than its recovery rate we

refer to this exploitation as “unsustainable”.

Nowadays the concern about resources is present everywhere. No matter what, when

considering a long-term strategy, resource sustainability must be an integral part of it.

For this reason the definition can be considered too general. The economic point of

view is necessary for a better analysis.

Definitions of economic sustainability vary despite the wide usage of the term. It

would seem that the common notion of it is considered sufficient for discussion. Thus,

I will try to describe my own understanding of economic sustainability as best as

possible. Simply put, economic sustainability consists in the efficient and

environmentally responsible use of available resources to maximise the long-term

objectives of an organisation or State. It is usually associated with financial gains (or

growth of the economy) but complications arise with some activities – like the

provision of healthcare.

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Publicly provided healthcare is a loss-making service by definition. Resources are

pumped into it but results are almost impossible to quantify since they mostly

translate into a general state of well-being. The long-term objectives of a healthcare

system are different from those of a private company or even a government and the

economic point of view falls short – it doesn’t take into account the social factors

involved.

A comprehensive definition of a sustainable healthcare system, provided by the

Alliance for Natural Health (2008), is the following:

“A complex system of interacting approaches to the restoration, management and

optimisation of human health that has an ecological base, that is environmentally,

economically and socially viable indefinitely, that functions harmoniously both with the

human body and the non-human environment, and which does not result in unfair or

disproportionate impacts on any significant contributory element of the healthcare

system.”

This description encompasses three types of sustainability: environmental, social and

economic. It also voices a concern for all the people involved in the healthcare system,

including the contributors who fund it. For all its detail though, this description is

vague in the sense that it doesn’t give any clues as to what is considered unfair or

disproportionate.

What would happen if society was willing to sacrifice more to enjoy the current level

of healthcare provision or to improve it? Their willingness would make the economic

impact acceptable and the system viable. It serves to illustrate a less orthodox point of

view. Reinhardt (2001) considers that, for the issue of healthcare and benefits,

sustainability is all about the distribution of money. Depending on the morals of a

society a level of sacrifice will be considered viable or non-viable. Sustainability, he

argues, is an issue of what the members of society owe to each other.

So far the definitions seem out of reach for a practical work such as this one. Defining

fiscal sustainability might be of help since it provides a possible benchmark for the

economic sustainability of State-financed services such as healthcare. Dr. Anne-marie

Boxall (2011) states the following in a research paper concerned with the sustainability

of healthcare in Australia:

“[F]iscal sustainability in public finances means that governments must be able to pay

for all their financial obligations without making radical adjustments to taxes or shifting

the burden of debt onto future generations.”

Therefore, if there was a growing trend in healthcare spending over and above GDP

growth its fiscal sustainability could be questioned. If healthcare expenditure

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constituted a contributing factor to a mounting debt (with no perspective of recovery

since the service makes a loss) then future generations would be worse-off for it.

As has been argued, it is easier to talk about sustainability than to fully understand its

meaning and content. Going from the moral to the purely economical, the concept is

elusive. For the purpose of this work, I propose working definition for a sustainable

healthcare system resulting from a blend of the definition used by Dr. Boxall (2011) to

explain fiscal sustainability and the one provided by the Alliance for Natural Health

(2008). Thus, we refer to a sustainable healthcare system as:

“A complex system of interacting approaches to the restoration, management and

optimisation of human health that is environmentally, economically and socially viable

indefinitely and which does not result in unfair or disproportionate impacts on any

significant contributory element of the healthcare system. Economic viability must be

achieved without the Government making radical adjustments to taxes or shifting the

burden of debt onto future generations.”

The key words are “socially viable” and “indefinitely”. It is easy to see that in the short

term the Spanish Government will have to abide by the European directives and

strategies, and the deficit and healthcare objectives will be synchronised with those of

other Member States. However, the essence of the concept is the long-term and the

objectives of the healthcare system. This means that reforms must look to the future

after the current crisis and find a strategy which allows them to achieve a more

efficient healthcare provision without detracting from social well-being. The

foreseeable future should substitute for “indefinitely”, suggesting a period of at least

10 years when considering the sustainability of the healthcare system.

The present work will look at the immediate causes for concern and analyse the

sustainability of the National Health System within the pre-defined framework. It will

also evaluate some of the short-term measures taken to deal with the problems.

Finally, it will recommend a course of action based on the analysis undertaken

previously.

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2. Organisational structure of healthcare in Spain

Healthcare provision in Spain is organised following the NHS-Beveridge model,

integrating private and public entities. The main healthcare providers are:

The National Health System

Private insurers and mutual funds

Private professionals (dentists, etc.)

Charities and other not-for-profit entities

The National Health System is by far the most complex organisation and the only one

that strives to cover the entire population. It is the only public provider of healthcare.1

To gain some insight into its functional model an organisational analysis is necessary.

2.1. Guiding principles of the Spanish National Health System

Article 43 of the Spanish Constitution of 1978 establishes the right to health

protection and healthcare for all citizens. The principles and criteria enabling the

exercise of this right are materialised as follows:

Public funding, universal coverage and free healthcare services at the time of

use.

Defined rights and duties for citizens and public authorities.

Political decentralisation of healthcare devolved to the autonomous regions.

Provision of comprehensive healthcare, striving to attain high levels of quality

duly evaluated and controlled.

Integration of different public structures and health services under the

National Health System.

2.2. Organisation of the Spanish National Health System

Over time healthcare competences in Spain have changed hands: at first the State

managed the whole system but this responsibility was gradually transferred to the 17

Autonomous Regions the country is split into. The process ended in 2001 when the

last 10 regions accepted competences from the State.

The objective of this structural change was to bring healthcare closer to the citizens.

Seeking their participation ensures that quality changes take the users’ expectations

and needs into account first and foremost.

Clearly a reform of this magnitude brought about its own complications. The chief

concern was to maintain standards across the country and to ensure constant

communication between the Central Administration and the regional bodies

1 The National Health System draws on the resources of the private sector at need, in order to reduce

waiting lists and to have extra capacity in reserve.

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responsible for healthcare management. These tasks fall onto the Inter-territorial

Board of the NHS.

The NHS Inter-territorial Board

The Inter-territorial Board of the National Health System is the body responsible for

the coordination, cooperation and liaison among the Central and Autonomous Region

public health administrations. Its responsibility is to guarantee that all Spanish citizens

receive the level of health services that they are entitled to without discrepancies

throughout the territory.

Its main organs are Board itself and its Delegate Commission, integrated by high

representatives of the Ministry of Health, Social Services and Equality and the regional

Departments for Health. Many sub-committees work closely with the Board in order

to provide it with relevant information and working groups can be created at its

discretion to investigate matters of interest.

A third important organ is the Consultative Committee which provides a link to the

people most involved in the NHS – employers and employees. It has representatives

of both trade unions and employer’s organisations and has an advisory role.

Figure 1: Broad classification of responsibilities in the Spanish NHS

Source: National Health System of Spain, 2010

Central Government

It is represented by the Ministry of Health, Social Services and Equality in all matters

regarding health. Thus, the Ministry is the ultimate coordinator for the dependent

bodies concerned with the individual regulatory, management and control objectives.

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These are:

Healthcare Regulation and Coordination:

General Directorate for Public Health, Quality and Innovation: its functions

include detailing the regulation framework on epidemiological

information, health promotion, disease prevention, occupational health

and environmental health and ensuring its effective implementation. This

General Directorate also holds responsibility for the inspection of the NHS

and the local Health Services and for the provision of relevant information

on the NHS.

General Directorate for Professional Planning: responsible for the

coordination and planning of the human resource requirements of the

NHS. Its duties are to study the current organisation and its future needs

and emit proposals for the management of specialised health education

and the planning of the active human resources.

General Directorate for Basic NHS Services and Pharmaceutics: establishes

the services that the NHS will provide to the public.

o National Transplant Organisation: coordinates the assignment of

organs, tissue and cells throughout the territory ensuring that the

basic principle of equality is fulfilled.

Spanish Food Safety and Nutrition Agency: responsible for ensuring the

highest possible safety degree for food and for promoting healthy

nutrition.

Foreign Health:

General Directorate on Public Health, Quality and Innovation: regulates the

provision of epidemiological information and all foreign health issues in

accordance with EU treaties and agreements. Its responsibilities include

overseeing the implementation of the regulation.

Pharmaceutical Policy:

General Directorate for Basic NHS Services and Pharmaceutics: responsible

for pharmaceutics policy, it establishes the public prices for medicines and

other healthcare products and how they are to be dispensed. It is also

responsible for the public financing of medicines and medical products.

Spanish Agency for Medicines and Medicinal Products: responsible for the

evaluation and the authorisation of medicines and medical devices for use

in humans and animals. It also performs quality control on the medicines

and devices and has the obligation to inform the public of all relevant

issues.

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Management of INGESA:

General Directorate for Basic NHS Services and Pharmaceutics

o National Health Management Institute (INGESA): this entity

manages the healthcare services in the autonomous cities of Ceuta

and Melilla. This is the only direct managerial responsibility of the

Central Government.

Governments of the Autonomous Regions

They have the responsibility of organising healthcare within their jurisdiction. Each of

the seventeen Autonomous Regions has a Department for Health which regulates and

plans the provision of healthcare and its own Health Service which acts as provider or

purchaser of services. Other non-health administrations in the region which

collaborate with the Department for Health are under its guidance and responsibility.

Each autonomous Government is free to organize its Department for Health into as

many bodies as it deems necessary. The simplest is the Cantabrian Health

Department with three separate bodies: the Secretariat General, a General

Directorate for public health issues and a General Directorate for healthcare planning.

None of them manages resources directly, since that function is reserved for the

Health Service. The latter is organised into four branches, one manages primary

healthcare and the rest have part of the territory assigned to them.

By contrast, the most complicated organisational chart belongs to the Comunidad

Valenciana Health Department. It has an Autonomic Secretariat, a Sub-secretariat

which oversees the territorial divisions and also 6 General Directorates and 16 Sub-

directorates responsible for multiple areas covered by bodies called “Services”. The

regional Health Service is included in the count, so the difference is smaller than what

the first impression suggests, but it is nonetheless considerable. The regions of

Catalonia and Madrid present similarly complicated organisations. Catalonia in

particular is burdened by many territorial divisions and some public enterprises and

independently managed bodies which add to the complexity. This is due to the

historical evolution of the territory and of healthcare provision in the region.

2.3. Functional Organisation of the NHS

The Health Services are the bodies responsible for the management of the health

centres and facilities in their respective regions. These centres can be classified into:

Primary healthcare centres: they cover basic services and are available within

15 minutes of any place of residence. They provide home care when necessary.

The professionals in these centres have a close relationship with their patients.

They fulfil a gatekeeping role: only they can refer patients to specialist

treatment. It is also their responsibility to provide follow-up care after it has

15

been completed. Because of their proximity to the population, promoting

healthy habits and disease prevention is also a responsibility at the primary

healthcare level.

Specialist healthcare centres and hospitals: they provide specialist care in the

form of inpatient and outpatient care. They also provide complex diagnostic

tests following referral from primary healthcare centres.

These centres are organised in Health Areas, with at least one hospital per area, and

basic health zones where primary healthcare centres are based. The criteria for the

dimension of a health area or zone are mainly geographic, demographic and social.

The regional Departments for Health are free to establish different management

types for these centres but they have the ultimate responsibility on them. This has led

to multiple systems of public-private cooperation in the ownership and management

of the facilities. This is especially valid for Specialist Care centres which entail a much

bigger investment.

Public-private interaction models within the NHS

“British model” for hospital management: a private entity builds a hospital at

the commission of the public authorities and manages all of it except the

healthcare personnel. It receives annual payments from the public budget until

the investment is recovered.

“Alzira model” for hospital management: similar to the British model but

including the management of healthcare personnel. The public

administrations pay a stipulated amount per inhabitant of the Health Area

covered by the hospital until the investment is recovered.

Contracts with private hospitals for the provision of services: a privately owned

and managed hospital contracts part of its capacity to a Health Service. Then

the NHS can send patients there for diagnosis or inpatient care whenever the

public resources are insufficient. The private hospital receives the amount

stipulated in the contract (usually fees for the individual treatments and tests).

This is called “concierto” in Spain and many private hospitals have such

agreements, be they for-profit or not-for-profit centres.

When hospitals have 50% or more of their capacity contracted to the NHS they

are usually considered as part of the basic NHS network. Their management is

sometimes transferred to the Health Services. In all cases the NHS’s influence

on them is high.

There are other, less extended models. The reasons for their existence range from the

historical to the experimental. The organisational landscape in Spain means that

depending on the Autonomous Region the prevalent model for the provision of

healthcare services can vary greatly.

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3. Resources of the Spanish Healthcare System

3.1. Hospital resources

Number of Hospitals

Based on the National Hospital Catalogue, published annually by the Ministry of

Health, Social Services and Equality, the evolution of the number of hospitals in Spain

has been the following:

Table 1: Hospitals sorted by functional control type2

Year Public MATEP3 Charity

(Red Cross)

Charity (Church)

Other charities

Non-charity

TOTAL

2004 301 24 8 57 56 333 779

2005 300 24 8 58 58 335 783

2006 301 23 8 58 58 340 788

2007 309 22 8 56 56 349 800

2008 319 20 6 55 59 345 804

2009 330 21 6 53 57 336 803

2010 328 21 5 54 62 324 794

2011 327 21 5 53 59 325 790

2012 327 21 5 54 59 323 789

Source: Personal compilation based on data from the National Hospital Catalogue (2005-2013)

About half of the private hospitals have a contract with the NHS, be it for diagnosis or

for other services. When studying the performance of the NHS it is important to take

this fact into account in order to analyse the public coverage better.

7% of all the private hospitals classified above are integrated into the Hospital

Network for Public Use. They have a 100% contract with the NHS.

Around 40% of the remaining private hospitals have contracted some of their

services to the NHS.

An estimated 20% of all private hospital activity in 2010 was generated by NHS

patients.

2 Functional control: the entity exercising functional control is defined as the one which has the right

to determine the general hospital policy and nominate its administrators. It is usually the entity that

contributes the most to the financing of the hospital. This is not the same as ownership or management

type, because by virtue of given contracts a privately owned hospital could be financed in more than

50% by a public entity.

3 MATEP (Mutual Funds for the coverage of Workplace Accidents and Professional Illnesses):

considered not-for-profit private organisations since they cover civil servants and are financed with

Social Security contributions.

17

It is interesting to note that starting in 2008 the number of private hospitals has been

diminishing steadily while the number of public hospitals increased sharply in 2008

and 2009. The main consequence is that since 2008 the overall capacity of the system

remained fairly stable. The balance is of only 11 hospitals less even though the number

of for-profit private hospitals diminished to below 2004 levels.

Number of available hospital beds

The number of hospitals is not indicative of their size. The amount of resources that

they possess is a better indicator of levels of service provided. A widely cited figure is

the number of beds.

Table 2: Available beds in Spanish hospitals sorted by functional control type

Year

Public hospitals

Not-for-profit private hospitals

For-profit private

hospitals

Total available

hospital beds

2004 105 052 21 799 31 075 157 926

2005 105 998 22 148 31 413 159 559

2006 105 289 21 997 32 385 159 671

2007 105 062 21 608 33 627 160 297

2008 106 500 21 393 33 088 160 981

2009 108 469 20 043 32 767 161 279

2010 108 191 20 858 31 973 161 022

2011 109 554 20 672 32 312 162 538

2012 109 211 20 595 32 235 162 041

Source: Personal compilation based on data from the National Hospital Catalogue (2005-2013)

The proportion between public and private hospitals and their capacity is the

following:

Figure 2: Hospital distribution in 2012

Source: Personal compilation based on the National Hospital Catalogue, 2013

41%

18%

41%

Public hospitals

Not-for-profit private hospitals

For-profit private hospitals

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Figure 3: Distribution of hospital beds in 2012

Source: Personal compilation based on the National Hospital Catalogue, 2013

There are numerous private hospitals and specialised care centres in Spain but they

have a much smaller capacity than the public hospitals.

Hospital personnel

There are two types of personnel in the Spanish Healthcare System:

Signed employees have a contract with a given hospital for full-time or part-

time work.

Contributing personnel undertake activities in the hospitals but have no

contract with these centres and do not receive payment from them.

Table 3: Distribution of healthcare personnel in Spanish hospitals, evolution over time

Year Total

Personnel Signed

Doctors Contributing

Doctors

Signed nursing

personnel

Doctors in

Training

Non-healthcare personnel

Other personnel

Population

1997 390 285 53 766 17 437 183 064 13 642 112 141 10 235 39 583 381

1998 395 022 54 690 17 117 186 505 13 590 112 390 10 730 39 722 075

1999 403 200 56 811 16 887 190 995 13 632 112 901 11 974 39 927 224

2000 409 341 57 899 17 087 194 279 13 220 113 783 13 073 40 264 162

2001 417 050 59 377 18 150 198 057 12 674 114 058 14 734 40 721 447

2002 430 066 61 993 17 752 204 304 13 877 117 006 15 134 41 314 019

2003 441 422 64 519 18 150 209 336 14 001 118 733 16 683 42 004 575

2004 459 788 67 804 20 015 217 221 14 824 122 184 17 740 42 691 751

2005 471 264 69 263 20 240 222 712 15 218 124 517 19 314 43 398 190

2006 490 157 72 186 20 555 232 059 16 126 127 900 21 331 44 068 244

2007 513 662 76 362 21 604 242 349 16 555 133 389 23 403 44 873 567

2008 530 505 80 414 21 344 251 453 17 525 135 597 24 172 45 593 385

2009 541 069 83 177 21 451 256 650 18 217 135 832 25 742 45 929 432 Increase 38.63% 54.70% 23.02% 40.20% 33.54% 21.13% 151.51% 16.03%

67%

13%

20%

Public hospitals

Not-for-profit private hospitals

For-profit private hospitals

Source: Personal compilation based on the ESCRI database, 2013

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Comparing the variation in personnel and overall population from 1997 to 2009 we can

conclude that health coverage has been improving continuously with more doctors

and nursing personnel per inhabitant.

As for the internal composition of hospital personnel, very little has changed over the

years. A small decrease in the percentage of non-healthcare personnel favoured a

small increase in the percentage of doctors and nurses. The proportion of

contributing doctors also diminished although private centres still rely heavily on

them. Of all their healthcare personnel in 2009, 23.3% were contributing doctors and

nurses (mainly doctors) compared to less than 1% for public hospitals.

Figure 4 illustrates the weight of the different members of hospital staff. “Other

personnel” refers to healthcare staff not assigned to another category.

Figure 4: Distribution of hospital personnel in 2009

Source: Personal compilation based on the ESCRI database, 2013

High-technology medical equipment

There has been a steady increase in the number of advanced technology devices over

the last eight years as shown in Table 4 below. But as for the private hospitals that

have no contract with the NHS, this increase is lower than the average for all medical

equipment except the Linear Particle Accelerators. In some cases the increase is

negative because of the closure of various hospitals in the crisis years to date.

We can conclude then that the public NHS financed proportionally more new high-

technology acquisitions than the private hospitals over the last 8 years, increasing its

coverage of the population.

15%

4%

48%

3%

25%

5% Signed Doctors

Contributing Doctors (chiefly in private centres) Signed nursing personnel

Doctors in Training

Non-healthcare personnel

Other personnel

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Table 4: High-technology medical devices in Spanish hospitals, evolution over time

Year CT MRI DSA ESWL LINAC HEM

2005 587 350 182 83 135 197

2006 611 386 188 93 146 214

2007 654 417 194 91 160 220

2008 677 438 190 92 179 218

2009 693 459 192 93 183 227

2010 690 492 195 93 192 233

2011 699 510 206 94 199 242

2012 716 533 216 96 203 243

% increase 22% 52% 19% 16% 50% 23%

Source: Personal compilation based on data from the National Hospital Catalogue (2006-2013)

3.2. Rates of usage for specialised care

Data on the use of resources is also interesting to have in order to identify trends and

prioritise the needs in the System.

Table 5: Healthcare usage indicators, evolution over time

Year

Registered hospital

admittances per 1 000

population

Surgery interventions

per 1 000 population

CT usage per 1 000

population

MRI usage per 1 000

population

Haemodialysis usage per

1 000 population

Average length of stay

adjusted by cause

2000 119.20 90.97 51.86 15.13 39.73 6.55

2001 119.34 92.43 56.34 17.77 35.62 6.51

2002 118.36 93.09 60.90 22.63 35.53 6.48

2003 118.52 95.21 62.40 25.5 37.41 6.41

2004 118.76 96.34 65.16 28.21 37.34 6.37

2005 117.50 97.28 66.81 30.61 31.47 6.34

2006 117.71 97.95 70.26 32.86 31.03 6.23

2007 117.11 99.16 73.19 35.42 32.38 6.24

2008 116.14 100.18 76.77 38.92 31.92 6.17

2009 114.69 101.54 80.08 43.06 33.09 6.04

2010 113.78 101.27 83.13 47.58 39.57 6.01

2011 114.25 107.67 85.74 49.57 39.15 5.89

Increase -4.15% 18.36% 65.33% 227.6% -1.46% -10.08%

Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

From this information it can be assessed that MRI and CT are preferred diagnostic

procedures with an ever-increasing demand. This is not so for haemodialysis.

CT: Computerised axial tomography; MRI: Magnetic Resonance Imaging; DSA: Digital subtraction

angiography; ESWL: Extracorporeal shock wave lithotripsy; LINAC: Linear particle accelerator; HEM:

Hemodynamics chamber

21

The average length of stay and the number of admittances and operations offer a clue

on the demand for medical personnel and hospital beds. Increased high-technology

availability could be at the root of the achieved improvements. However, maintaining

technology levels high is expensive and a cost-benefit assessment would be helpful in

an eventual restructuring of medical technology and personnel.

3.3. Primary Healthcare resources

Aside from centres for specialised attention, on the primary healthcare level we find:

Health Centres: places where various doctors and nurses attend the population

either on prior arrangement or walk-in basis. The most frequent consultation is

by arrangement with the family doctor.

Local Offices: smaller offices, dependent on a Health Centre and located in

more remote areas with a smaller number of professionals offering their

services.

Table 6: Primary Healthcare centres in Spain 2004-2011

Year Health Centres Local Offices Total

2004 2756 10145 12901

2005 2833 10148 12981

2006 2840 10216 13056

2007 2913 10178 13091

2008 2914 10202 13116

2009 2954 10207 13161

2010 2979 10154 13133

2011 3006 10116 13122

Source: Personal compilation based on SIAP reports for the years 2004-2011

Table 6 is a summary of the evolution of the number of primary healthcare centres in

Spain. Almost all these centres are publicly owned and managed by the regional

Health Services. There are two particular cases that deserve to be mentioned:

Catalonia and the Comunidad Valenciana. In Catalonia some primary healthcare

centres are in the hands of public entities other than the Health Service, others are

managed by private charities and a third set by mutual funds. In the Comunidad

Valenciana there are some 150 primary healthcare centres under private management

but publicly funded by virtue of a contract with the Department for Health.

The figures in Table 6 show an increasing trend at first but after 2009 there are some

closures. Even so, they only affect the Local Offices while the number of Health

Centres never goes down. This suggests the conversion of some Local Offices into

Health Centres and an effort to bring more quality to primary healthcare.

22

In 2011 the primary healthcare facilities were staffed by more than 35 000 physicians,

mostly family doctors with a specific list of patients assigned to each. They also

employed more than 29 000 nurses and the non-healthcare staff consisted of more

than 21 000 workers.

Reflections

As the crisis progresses the limitations it imposes on the country are reaching the

NHS. With centres closing both at the primary and the specialised level, some

questions are in order:

Are the hospital closures only an investment gone wrong or do they have a

significant impact in the fundamental rights of Spanish citizens to receive

universal quality healthcare?

Should the private hospitals that no longer return profit to their owners be

bought by the Administration, burdening its budget even more, in order to

maintain the current Healthcare standards?

Was there a real need for such expansion? If there wasn’t, isn’t it possible that

medical centres could be closed without jeopardising the quality of the NHS

and without hindering its compromises with access and equity?

23

4. Comparison of resources across OECD countries

In order to evaluate the performance of the Spanish Healthcare System a comparison

is helpful. The assessment will be made based on the OECD Health Data report from

29 Oct 2012, which provides important figures for resource inventories and other

health-related statistics4.

Since some countries (for example the US) have a very different way of managing

healthcare this section will use the OECD average as base and comment on trends

occurring in states that have systems similar to the Spanish NHS (e.g. Australia,

Canada, Italy).

Number of physicians per 1 000 population

The number of practicing physicians per capita in Spain has increased steadily over

time. The density per 1 000 population was 3.8 in 2010, growing to 4.1 in 2011. This

data places Spain above the OECD average for 2010 in line with Italy and Australia and

much above Canada. The United Kingdom shows a value of 2.8 physicians per 1 000

population.

Nursing staff per 1 000 population

As with physicians, there has been an upward trend in the proportion of practicing

nurses to total population. But even though the indicator rose sharply in 2011 it is far

below the OECD average. Only countries that can still be considered as developing

have lower nursing staff numbers. Italy is the closest of the states established for

comparison but Australia, Canada and the UK almost double Spain’s value of 4.9

nurses per 1 000 population in 2010.

Medical and Nursing Graduates

The students graduating each year from Spanish universities deserve a passing

mention. Both indicators are smaller than the respective OECD averages.

In Spain the central government decides how many university vacancies to open for a

given year depending on the situation of the NHS and future projections. Taking this

fact into consideration, the number of graduating nurses has been stable over the

years while the figure for medical graduates has diminished. This decrease reflects, at

least in part, the Government policy although the challenge of the university studies

probably also plays a role in the final outcome.

4 See Annex II for the relevant OECD averages compared in this section.

24

Number of beds per 1 000 population

In this case all trends are downward sloping, thus revealing that with effective

healthcare the need for hospital space is reduced. Spain’s 3.2 beds per 1 000

population place it below the 4.9 OECD average and in line with all other countries

with similarly structured systems. Around 2 out of 10 beds are reserved for psychiatric,

geriatric and other care requiring long hospital stay. The remaining 80% are destined

to what is called “acute” care: general hospitals, surgery, maternal and infant care,

etc.

High-technology devices per 1 000 000 population: MRI units

For this set of values observations deviate strongly from the average of 12.5 MRI units

per million inhabitants. In 2010 this value for Spain was 10.7, higher than the numbers

for Australia, Canada and the UK. Italy shows a very steep increase since 1997 which

results in 22.7 MRI units per million inhabitants in 2010. In Japan the quantity is twice

Italy’s. Substitutes for the technology, such as the CT scan, could be part of the

explanation and the needs of the population constitute another important element.

Even so, with the limited information it’s very difficult to give a reference for a desired

value.

High-technology devices per 1 000 000 population: CT scanners

Similar to the data for the MRI units, Spain’s number of CT scanners per million

inhabitants, 15 in 2010, is below average and close to Canada’s. Australia triples this

number and Italy doubles it. The United Kingdom is the contrast with 8.2 CT scanners

per 1 000 000 population. Again, it is difficult to judge, but a reasonable guess could

be that other, older or newer forms of diagnosis, substitute CT scanners to a degree.

If the estimates for the United Kingdom are correct, their usage of both CT and MRI is

very similar to Spain’s but the number of devices they have is much smaller. This could

mean that an optimisation of resources is possible so it is an option that should be

looked into.

25

5. Performance of the Spanish NHS: 2000-2011 comparison

In this section we assess the performance of the NHS with a three-branch analysis.

Public satisfaction indicators show the perception of the patients that use the

NHS. They are subjective but their evolution over time should shed some light

on its relative performance since the year 2000.

Objective performance indicators are meant to show some real quality

improvements in the NHS over time.

Health indicators provide insight into the life-expectancy improvements.

5.1. Public satisfaction indicators5

General satisfaction indicators

Based on information from the Healthcare Barometer 1995-2011 published by the

Ministry for Health, Social Services and Equality, the general degree of satisfaction

with the NHS has increased over the decade between 2000 and 2011. When asked to

grade the NHS’s services, people rated it at 5.94 in a scale of 1 to 10 in the year 2002

and at 6.59 out of 10 in 2011, a significant increase in satisfaction. The second most

cited indicator also experienced an improvement: a greater percentage of users

valued the functioning of the system as good or very good (from 66.80% in 2000 to

73.12% in 2011).

However, these results fluctuate across Autonomous Regions and, although there has

been convergence over the years, it would seem that some regional Health Services

are not up to standard. Others, by contrast, turned around completely the previous

opinions of their users. Since these general indicators are not too helpful, an analysis

of more specific indicators might be more useful.

Specific activity indicators

Specific activity indicators are also satisfaction indicators and also use the scale of 1 to

10. However, because the questions relate to one specific area of primary or

specialised care, the impressions that the user has are better formed than when asked

about the NHS as a whole. The questions relate to topics such as the attitude of

healthcare personnel, the availability of medical technology and equipment, the

waiting times, the consultation times, etc. The questions are similar for primary and

specialised healthcare.

When analysing these indicators it is hard to tell if the services are valued better or

worse than in the year 2000. For example, when asked about the particular aspects of

primary healthcare, the users surveyed reported a degree of satisfaction which was

5 See Annex III for the detailed breakdown of all public satisfaction indicators considered in this section.

26

almost equal to the one recorded in 2000. There is no clear increasing trend; in fact

there is a steep decrease right after 2000. Thus, the following small improvements

only contribute towards a return to previous levels, finally achieved in 2011. Only one

aspect experienced continuous important growth: family doctors now refer patients

to specialists much oftener. But whether this is positive or not depends on the point of

view, since one interpretation could be that family doctors now are not qualified to

advise on issues that used to be treated in primary healthcare ten years ago.

A similar pattern applies for hospital care although in this case not all activity

indicators have returned to 2000 levels. Patients consider that medical equipment

now is worse than it was ten years ago. In 2011, compared to 2000, a bigger

percentage of users believed that Health Services are not working towards shortening

waiting lists and more people thought that this problem was worsening with time

instead of improving.

There is a particular question about perceived improvements over the last 5-year

period, which is of great importance since public opinion of healthcare is a great

influence on resource investment. But the data shows that a smaller percentage of

users notice an improvement in healthcare nowadays compared to 2000. The rest, an

increasing proportion, think that the features of the system are at the same level or

worsening.

What this data shows is that the question of service levels needs to be reconsidered.

With higher standards of living and a society that is more and more demanding the

subjective rating of public healthcare dropped so low that it took a decade to recover.

The probable cause was the devolvement of the Healthcare competences to the

Autonomous Regions. While I do believe that it had an impact I cannot concede that it

was of such abysmal proportions. Public opinion is easily swayed and it would seem

that as the crisis sets in healthcare users have lowered their expectations and their

evaluation of the features of the NHS is improving even after some of the dreaded

spending cuts and reforms have been implemented. If patients have biased

perceptions of the healthcare system then part of the expansion that took place

within the NHS might have been unnecessary and based mostly on an eagerness to

improve the popular perceptions of the system. That is not to say that improvements

shouldn’t be made, but they should probably rely more on objective observations –

from the inside.

5.2. Objective performance indicators

Data is available on some indicators that can be used to assess improvements in

hospital care. Their evolution between the years 2000-2011 is shown in Tables 7 and 8.

27

Table 7: Quality indicators for specialised care in Spain, 2000-2011

Year

Global % of

readmitted patients

Acute adverse

reactions to drugs notified

per 1 000 population

Rate of hospital-acquired infection per 100 hospital

discharges

Number of transfusion reactions per 1 000 hospital

discharges

Rate of pressure

ulcers per 1 000

hospital discharges

In-hospital mortality per 100 hospital

discharges

2000 6.38 0.04 0.77 0.20 5.14 3.80

2001 6.73 0.06 0.79 0.20 5.83 3.83

2002 6.78 0.06 0.81 0.17 5.99 3.91

2003 6.79 0.07 0.85 0.17 6.64 4.04

2004 6.86 0.07 0.84 0.18 6.92 3.92

2005 7.01 0.08 0.86 0.18 7.93 4.12

2006 7.05 0.08 0.86 0.18 8.23 3.93

2007 7.14 0.09 0.86 0.17 8.57 4.10

2008 7.08 0.12 0.9 0.16 10.5 4.05

2009 7.16 0.15 0.91 0.16 11.4 4.07

2010 7.08 0.15 0.85 0.17 12.88 4.13

2011 7.31 0.16 0.82 0.17 13.96 4.29

Increase 14.6% 300% 6.5% -15% 172% 12.9%

Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

Table 8: Waiting times (days) for specialised interventions and consultations

Year

Waiting time for non-urgent surgery interventions

Waiting time for specialised

consultations

2003 81

2004 78

2005 83.42

2006 70 54.37

2007 74 57.98

2008 71 59

2009 69.73 58.99

2010 64.97 53.17

2011 73 57.72

Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

It would seem that the reduction of waiting lists has progressed in an erratic fashion.

A steep reduction in 2010 was followed by an even steeper worsening in 2011. It is

hard to tell if consistent efforts for the reduction of waiting times exist.

The hospital performance indicators suggest a similar conclusion. While the data can’t

prove a systematic worsening of the system since 2000 – more variables would have

to be factored in for that – it proves that improvements haven’t been targeted. A clear

28

example is the case of pressure ulcers: notice should have been taken of the growing

rate at which they appear and an effort to reduce them should have been undertaken.

5.3. Health indicators

Finally, classic indicators such as life expectancy and mortality are shown in Table 9.

Table 9: Life expectancy at birth and mortality rate per 100 000 population, 2000-2011

Year Life expectancy at birth Adjusted mortality rate per 100 000 population

2000 79.05 611.45

2001 79.44 595.77

2002 79.67 592.73

2003 79.67 600.06

2004 79.95 565.23

2005 80.23 568.46

2006 80.95 532.35

2007 81.08 533.99

2008 81.24 519.73

2009 81.80 503.70

2010 82.22 487.02

Source: Ministry of Health, Social Services and Equality, Key Indicators of the NHS, 2012

Spain has one of the best life expectancy figures for Europe and it has been increasing

steadily over time. However, it is a broad indicator that is heavily influenced by the

environment and climate, by the food and habits and by the economic level of the

country. The elements that are responsibility of the Healthcare system and influence

these indicators are disease prevention and drug prescription. However, they are only

a small part of what is meant when evaluating the system as a whole. For this reason

life expectancy figures can hardly be used to prove or disprove an argument about the

healthcare improvements in Spain.

29

6. The financing of Spanish Healthcare

The funds for healthcare in Spain come from the general public in the form of taxes

and private insurance payments and from the patients themselves when they pay for

private services or buy medicines (with the current co-payment they contribute less

than 50% of the price). The following flowchart shows the structure of the funding:

30

The mutual funds and the Social Marine Institute are financed directly by the State

and Social Security. Their beneficiaries are civil servants and their dependants, except

for people working in the NHS. These mutual funds contract the services that they

require to private providers and their affiliates in 2010 represented 5% of the

population.

Figures 5 and 6 show a breakdown of the contributions for the years 2003 and 2010 in

order to compare the changes over time. Public financing is shown in blue and private

financing is in red:

Figure 5: Healthcare financing breakdown by financing agent, year 2003

Source: Personal compilation based on A System of Health Accounts (SCS) 2003-2010 data

Figure 6: Healthcare financing breakdown by financing agent, year 2010

Source: Personal compilation based on A System of Health Accounts (SCS) 2003-2010 data

0,72%

64,46%

5,21%

5,51%

22,87%

1,23%

Central administration

Regional and local administrations

Social Security Administrations

Private insurance institutions

Direct payments

Other

0,57%

68,98%

4,63%

5,52%

19,67%

0,62% Central administration

Regional and local administrations

Social Security Administrations

Private insurance institutions

Direct payments

Other

31

Public financing gained importance over time, especially healthcare financed by the

Autonomous Regions and local entities. The Central Administration and Social

Security reduced their percentage contributions. The private sector lost importance

overall but its total expenditure increased over the years.

6.1. Healthcare expenditure in absolute values

In order to gauge the strain that healthcare expenditure puts on the Spanish economy

as a whole, an analysis over time is appropriate. Figure 7 shows the evolution of

healthcare expenditure per capita over the years 2003-2010. There was a substantial

increase of 42% per capita over the time period which supposed a 57% increase of

expenditure in absolute terms.

Figure 7: Healthcare expenditure evolution over the period 2003-2010

Source: Personal compilation based on A System of Health Accounts (SCS) 2003-2010 data

Figure 8: Healthcare as percentage of GDP, evolution over the period 2003-2010

0

500

1.000

1.500

2.000

2.500

2003 2004 2005 2006 2007 2008 2009 2010

Total expenditure per capita

Public expenditure per capita

-5%

-4%

-3%

-2%

-1%

0%

1%

2%

3%

4%

5%

7,00%

7,50%

8,00%

8,50%

9,00%

9,50%

10,00%

2003 2004 2005 2006 2007 2008 2009 2010

Total expenditure as % of GDP

GDP growth rate

Source: Personal compilation based on data from the National Statistics Institute (INE) and A System of Health Accounts (SCS) 2003-2010

32

Figure 8 is concerned with healthcare expenditure as percentage of GDP. It plots

healthcare expenditure on the primary axis and GDP growth on the secondary axis.

Up until 2007, before the crisis, healthcare spending as % of GDP increased slowly and

it was not felt excessively because GDP was also growing. Since the SCS data includes

expenditure on the elderly and disabled which is not strictly healthcare spending, it is

only logical that the financial strain would increase in time. But when the crisis hit

healthcare expenditure couldn’t be reduced immediately while GDP plummeted

(especially in the year 2009). Now GDP growth figures show a less dramatic reduction

but still remain negative and the debate over healthcare spending is a hot topic.

What needs to be clear before embarking in long justifications of the healthcare

system is that the expenditure was already increasing at a very fast rate and was

becoming a problem before the crisis struck. Even if it represented a smaller

percentage of GDP then, efforts should have been made in order to rein in the

spending. After all, why spend 42% more than in 2000 on a healthcare system that the

users perceive to be much the same as it was back then?

By observing the data it can be seen that the strain on public finances became larger

over time because of the general increase in healthcare expenditure but also because

of a shift from private contributions (patient payments) to public spending (see figures

5 and 6). This shift is probably a consequence of the difficulties brought by the crisis.

On one hand, patients can choose to endure a longer waiting time for a service that

they could have either through the NHS or by paying to a private provider. This

substitution effect means less business for the private hospitals and professionals and

a bigger strain on the public system. Another possibility is that patients are delaying

treatment of some minor issues as much as possible in order to save on the medical

expenses. Both effects are logical consequences of income loss. For the NHS the

existence of a substitution effect means that restructuring would be even harder since

now more people rely on public healthcare.

An implication of the financing breakdown shown in figures 5 and 6 is that any

reforms will have to be implemented by the Autonomous Regions, since they finance

the biggest portion of Spanish healthcare. But what scope do they have for reform?

What are their limits and compromises? The healthcare services rating varies from

region to region and complaints have been voiced over the differences in per capita

expenditure across the country. Circumstances vary between the Autonomous

Regions and they will need to be explained before undertaking an analysis that has to

be as general as possible.

6.2. Financial circumstances of the Autonomous Regions

In the year 2010 the per capita budget in the Autonomous Regions was as follows:

33

Figure 9: Per capita budget in Spain’s Autonomous Regions, 2010

Source: http://www.dondevanmisimpuestos.es/ccaa/

The variance observed between Autonomous Region budgets is roughly € 1 000 per

capita but when Navarra enters the calculations it soars to € 3 000. The difference can

be considered significant.

Healthcare expenditure budget data (which does not take into account extra

expenditure on care for the disabled and the elderly) for 2010 is shown in Figure 10:

Figure 10: Healthcare Budget per capita in Spain’s Autonomous Regions, 2010

Source: http://www.dondevanmisimpuestos.es/ccaa/

34

When considering the healthcare budget the variation between the average and the

lower limit is much smaller, because healthcare is a basic service, essential for

upholding the welfare state and fulfilling the equity principle that forms the base for

Spanish democracy. For this reason there is a common lower bound for healthcare

expenditure per capita that differs between Autonomous Regions but must be

respected by all of them.

Since healthcare is the most important part of any Autonomous Region’s budget and

income varies significantly between them, the financial effort for supporting the NHS

differs greatly in the different regions. Comunidad Valenciana spends 38.35% of its

budget on healthcare while Navarra assigns 22.06% to it. Thus, C. Valenciana has

smaller room for manoeuvre than other regions and the sustainability of healthcare is

a more pressing issue there. This is not to say that richer regions should not think of

healthcare reform, quite the contrary, but they can allow themselves to do it over time

and without causing big disturbances to the system in its current form.

6.3. Breakdown of public healthcare expenditure

The last year for which real expenditure data is available is 2008, and the dataset does

not include the extra spending on care for the elderly and disabled.

Figure 11: Public healthcare expenditure classified by expenditure item, 2008

Source: Personal compilation based on the Statistic on Public Health Expenditure (EGSP), 2002-

2011 series

According to the breakdown in Figure 11, primary healthcare services represent only

16% of spending even though their number is considerable since the condition for

their location is that users of the system must be able to arrive after a 15-minute walk

from any place.

55%

16%

1%

3%

19%

2%

4% Hospitals and specialized services

Primary health care services

Prevention and public health

Health services to collectives

Pharmacy

Patients transport & medical products other than drugs

Capital expenditure

35

Pharmacy spending is a big percentage considering that co-payment for the

acquisition of drugs is implemented.

The biggest expenditure item is the one that covers the hospitals and other

specialised services, because of their personnel needs and also owing to infrastructure

and technology necessities.

To touch briefly on another possible classification, it must be mentioned that for the

year 2008:

Personnel wages represented 42.2% of the total budget.

Contractual payments to private hospitals accounted for 11.1% of the budget.

Wages are by far the most important expenditure item and also the easiest way to

save a large amount of money. This justifies, in part, the salary cuts implemented

during the last two years.

Payments for the provision of services made to private hospitals could be re-

negotiated depending on the conditions stipulated in the contracts, in order to extract

some savings for the NHS.

6.4. Financial trouble in the NHS

As seen above, the budgets for the NHS are developed at the regional level, except for

some 6% of total expenditure that stems from the State and Social Security budgets.

In 2009 a reform to give more tax autonomy to the different Autonomous Regions

was approved. By virtue of it, starting in 2011, a bigger percentage of the tax merited

at the regional level would stay in the Autonomous Regions and so the State transfers

would diminish.

Ever since the crisis begun, tax revenues have been falling so what this move

accomplishes is, essentially, to shift some deficit from the State to the Autonomous

Regions. The need for the reduction of expenditure remained the same as it would

have been before the reform.

With decreasing regional revenues and costs that are difficult to handle, the NHS has

struggled in the crisis years. An added problem was the existence of accumulated debt

with private providers, essentially for medicines and medical devices. The debt levels

haven’t changed greatly since the crisis begun but the average time elapsed until the

providers receive payment has almost doubled. The obvious result is a hindrance for

the activity of the providers and a worsening of their economic position.

36

Debt in the NHS at the end of 2011

Based on a report published in February 2012 by the private foundation IDIS (Institute

for Development and Integration in Healthcare), NHS debt with its private providers

amounted to approximately 15 700 million euro at the end of the year 2011. The

detailed breakdown is as follows:

Debt with the providers of drugs to hospitals: € 6 369 million

Debt with medical technology providers: € 5 230 million

Debt with private service providers6: € 4 100 million

So far the Autonomous Regions with the biggest debt, far above the rest, are

Andalucía and Comunidad Valenciana. Their combined debt is in excess of € 5 000

million.

These debt levels are one of the chief reasons to undertake reforms as soon as

possible.

6 Private service providers include hospitals and laboratories but also non-healthcare services

contracted by the public hospitals

37

7. Sustainability Analysis of the Spanish NHS

So far it has been argued that:

Over the last 10-15 years healthcare resources have increased greatly,

especially in the publicly funded NHS. Be it hospitals, Primary Healthcare

attending points or personnel, there was a strong upward trend in all of them,

over and above the increase of the covered population.

The NHS doesn’t have the freedom to regulate its resources in the same way

that private hospitals do. This is evident by the evolution of the number of

public hospitals and healthcare personnel.

The comparison to OECD countries is favourable when considering the

availability of hospital beds and physicians. However, there is room for

improvement, for example by purchasing more high-technology devices. Since

there are different types of healthcare systems operating around the world, an

in-depth analysis of some of their characteristics could provide insight into

possible efficiency improvements. The OECD comparison is a first step

towards this goal because it provides the necessary benchmarks.

Improvements have been made in the sense that more resources are now

devoted to healthcare, but specific efficiency improvements have not been

shown.

The public’s perception of healthcare is influenced by their circumstances and

expectations. When the economy was buoyant expectations were high and

public opinion of healthcare services deteriorated with time. Now that the

public NHS is under threat they value it more. Both points of view contain a

degree of bias that must be taken into account.

Healthcare expenditure has increased steadily over the last 8-10 years, an

effort that went almost unnoticed while the economy was growing but that is

now becoming a problem.

The NHS has great financial trouble that requires action. The final

responsibility is for the Autonomous Regions and each of them faces a

different situation depending on its budget and circumstances.

After considering the resources, financing and organisation of healthcare in Spain it

becomes clear that the current system is not sustainable and it hasn’t been

sustainable for some time according to our definition. The expenditure increase was

much too great to be able to endure for a long time, and the definition of

sustainability requires that it should be able to maintain itself in similar shape

indefinitely. The public system is the one most at risk.

The context of the crisis has only shown this fact in a clearer light and made its

resolution a pressing matter. The level of debt that has accrued in the NHS is a sign of

38

the limited flexibility in regards to expenditure present in the system. Reforms are

needed and are being undertaken but the haste for their implementation only makes

the matter more delicate. If changes are not made with the long-term survival of the

system as the first priority, Spain will carry most of its current drawbacks into the

future and face the same trouble when another crisis strikes. In order to avoid such a

situation a priority analysis is necessary. Priorities are two-fold: short-term obligations

and foreseeable long-term issues.

7.1. Priority analysis

Short-term obligations

Reaching the EU deficit objective: less than 3% of GDP by 2016.

Reducing debt within the NHS.

Promoting growth: shift of priorities from healthcare to other sectors until the

crisis abates.

Long-term issues (implementation horizon – 10 years)

Stabilizing healthcare expenditure per capita within preset limits.

Ensuring that the NHS will be able to provide a similar level of service in the

future, when the effects of the demographic shift become more important.

Making sure that the chosen providers are the most efficient and economical.

Ensuring more equality between Autonomous Regions both in spending and in

the functioning of the Health Services.

Restructuring of Health Departments and Health Services to make their

composition simpler to understand and operate.

Cooperation between Autonomous Regions in order to improve efficiency

across the country.

Shift towards new technologies to lighten administrative costs and ensure a

better accountability and comparability.

Use of new technologies to improve treatment and diagnosis costs (eHealth).

Keeping up with scientific and technologic advance to improve the quality of

healthcare in Spain.

It’s easy to see that long-term concerns can be considered expensive and even the

measures to reduce costs usually require a big initial investment. It is for this reason

that they must be undertaken slowly and after careful planning. However difficult it

might prove, I believe that unless long-term issues are addressed in the next 10 years

it will be too late for action. This time limit must also be kept in mind when planning

short-term measures because they could influence negatively a future, more

important reform.

39

7.2. Current measures taken to address short and long-term problems

Since it became patent that Spain’s deficit and debt was unsustainable measures to

reduce them have been implemented.

Regarding healthcare, a reform was promulgated in 2012 with the aim of ensuring its

sustainability and reducing the NHS’s financial obligations. It introduced some

changes to the functioning of the system:

The beneficiaries of free healthcare were reduced, by basically excluding part

of the foreign population residing in Spain. While previously proof of residence

was enough to have the right to receive free healthcare now a residence

permit is required (except for persons aged 18 and under). The measure does

not apply to the treatment of pregnancies and serious illnesses or accidents.

“Healthcare tourism” measures. Foreign nationals coming to Spain benefitted

from the free healthcare service and an overlooked clause in the law meant

that Spain didn’t claim back the expenses from their country of origin. After

the reform healthcare tourism will diminish because of the rules for residence

permits.

State Fund that will finance any cross-region medical attention, in order to

solve the problems arising from concerns in the Autonomous Regions about

who should pay for the treatments.

Introduction of co-payment for non-urgent medical transport.

Modifications to the rules of drug pricing and establishment of a detailed

database that will allow physicians to prescribe the cheapest from all the

adequate medicines.

Introducing a common register containing the details of the professionals

working in the NHS. Harmonisation of their qualifications in order to ensure

mobility within the country. Since few new professionals will have access to

work in the NHS it is expected that in this way resources can be organised

more efficiently.

Ending the different service contracts that link professionals with the NHS,

leaving only two categories: personnel working for the NHS and personnel

working for other institutions (and therefore not recorded in NHS statistics).

Making use of economies of scale by purchasing products at the national level

and sharing one service provider between various centres.

Energy Saving Plans to be produced by the regional Healthcare authorities and

approved before year end 2013.

Apart from the above measures, depending on the Autonomous Region different

spending reduction schemes have been adopted. Some restrict the opening hours of

Primary Healthcare and Emergency services and others have tried to introduce a

40

payment for each drug prescription. Freezing wages has been a common occurrence.

In some cases the Courts of Justice have deemed the measures too extreme and they

have had to be revised.

Some of the measures implemented with the reform can be criticized because of their

impact on the principles of universality and equity. Denying free healthcare to illegal

immigrants residing in the country and establishing co-payment for non-urgent

transport fall into that category. But going further, other points of view suggest that

depriving a percentage (albeit small) of the population of healthcare is a threat to

public health. Judging by the financial data analysed previously, patient transport is a

very small percentage of total expenditure so it is highly probable that the measure

creates more trouble than positive results. I tend to agree with these criticisms and I

believe that it would be better to backtrack on these particular measures of the

reform.

Other changes are founded in the right idea but their wording means a patchwork

answer where a permanent solid solution could be reached. For example, the

residence permit clause is meant to deter healthcare tourism but there is no reason for

such “tourism” to disappear if a working compensation system is established. This

also applies to regional accounting problems which could be solved with a

compensation system between the Autonomous Regions.

In general all the measures that target harmonisation and rational decrease of

expenditure are welcome and the only concern would be with their correct

implementation. Still, it is striking to see that, even though it is well known that

centralised management is cheaper in some regards the competences on those

particular items were transferred to the Autonomous Regions along with other

management features. What the current reform aims to implement is a partial return

to the previous model.

I believe that complete re-centralisation of healthcare would be a very drastic

measure since decentralisation was implemented with the belief that it would bring

quality improvements to the NHS. However, other quality (and quantity)

improvements can be achieved by harmonising some aspects of public healthcare and

this opportunity should not be overlooked. The NHS could become better and

stronger after some well aimed reforms, looking forward without going back.

41

8. Outlook to the future

When defining sustainability it was stated that the system had to be environmentally,

economically and socially viable. In this case social viability is defined by the upholding

of the basic principles: universality, equity, free access at the point of use, public

funding. But there is another limiting aspect of social viability: the resistance to

change. The NHS is the best valued public service in Spain and the citizens would not

want drastic changes to the model. This is why privatisation is out of the question, and

even re-centralisation is quite drastic. This is why the reforms proposed below are

aimed mainly at achieving economic viability, since environmental viability is beyond

of the scope of this work.

8.1. Reforms for the NHS

To guarantee the financial sustainability of the NHS the current budget should be

reduced without detracting from the basic rights associated with healthcare. There

are two ways to achieve this: reducing the demand for healthcare and making the

supply of healthcare more efficient.

To regulate the costs of supplying the service, there should be a maximum limit to

total public expenditure on healthcare. This “roof” may increase with GDP growth.

However, it should have a moderate growth trend, lower than the growth trend of

GDP. In this way a boom in the economy will not cause excessive spending.

Another idea would be to establish healthcare spending as a percentage of GDP but to

have a different % measure for contraction and expansion periods and to keep the

percentage for crisis years low. The reason is that if healthcare expenditure is

optimised it will afterwards be impossible to decrease it without great disturbances to

the level of care. To keep it safe from spending cuts it should have its own efficiency

mechanism – the GDP percentage limit. In this way the sustainability of the NHS

would be guaranteed when other parts of the system falter.

After establishing the limit an effort must be made in order to reduce demand to

within-budget limits. The service provided must evolve in line with the shift in medical

requirements. For example, as the population ages it is possible that there will be a

bigger need for Health Centres, to keep track of certain health conditions on a walk-in

basis. Prevention should also be given a more important role since the modern

society’s problems frequently originate from avoidable abuses. This would possibly

reduce the need for hospitals which are much more expensive than prevention and

education campaigns or new Health Centres. It would also cause a personnel shift.

Predicting and managing healthcare demand can help in keeping healthcare

expenditure relatively stable and the only modifications required would be the relative

weights of the different spending items.

42

The “roof” can be established by going back to previous spending levels (since the

expansion has been too large). For example we could take the analysed increase (from

2003 to 2009) and reduce it by half. That would mean public spending of € 1 335 per

capita instead of the current € 1 589. The total reduction would be 12 000 million euro.

As it stands at the moment, even if the saving could be implemented over a single

year it still wouldn’t be able to cover the debt that the NHS has accrued. All the more

reason to make sure that the goal is achieved. The best course of action would be to

reach this savings objective by increasing resource efficiency and implementing better

practices.

If current public expenditure levels were decreased by 12 000 million euro it would

represent less than 6% of GDP, a value not seen since 2005. In this case 5% should be

set as the limit for expansion periods.

8.2. Key points for the reform

Solidarity

Co-operation

Efficiency

Harmonisation

Reduction of resources

Renegotiating contracts

Pricing system

Transparency

Solidarity: Because of the differing economic situations between Autonomous

Regions a system for the allocation of extra funding that favours those with bigger

financial trouble must be established. Part of it should be earmarked for the NHS and

it should be managed by the State in a transparent and justified manner.

Co-operation: The regional Health Services should establish a way of sharing

operational experience so that best practices are implemented throughout the

country. They should also improve their financial management by establishing a

transfer system for treatments outside the Autonomous Region of residence.

Efficiency: Taking advantage of the information sharing channel in order to improve

by comparison with each other. Designing new, more resource-efficient methods to

maintain the current quality levels. Reduction of administrative costs by

implementing harmonised digital forms, by restructuring the health departments, by

placing functional control in the hands of a single public body7, etc.

7 See Annex I

43

Harmonisation: Sharing providers as much as possible, implementing the same

accounting and information system and the same personnel classification system.

This should favour mobility (redistribution of resources) and reduce management

costs in the medium and long term.

Reducing resources: In the short term spending cuts will have to be enacted.

Hospitals with little demand should be closed and their resources transferred to other

places within the Network. Since personnel numbers cannot be reduced by laying

people off, their salary will have to experience a cut. However, their job circumstances

should be taken into account in order to avoid exacerbating the financial trouble of

particular collectives.

Renegotiating contracts: Contracts with providers should be renegotiated as they

expire in order to leave breathing room for the NHS. Long-term contracts should be

avoided as much as possible and when signing new agreements they should

incorporate clauses for similar contingencies.

Introducing a pricing system: One of the problems of the NHS is that it is not clear

how much a given treatment or diagnosis costs. If it were known, the public-private

healthcare debate would stand on a more solid ground. As it is, inefficiencies are

overlooked because of this ignorance of individual costs. Once it is introduced a fairer

pricing for the services contracted with the public hospitals could be established. It

would also provide a ground for competition and make it easier to settle financial

issues between different Health Services.

Transparency: Currently there is a lack of meaningful, comparable information on the

National Health System, especially when trying to compare across the different

Autonomous Regions. This problem needs to be solved by implementing a

harmonised information system with standard criteria for all Autonomous Regions.

The data obtained from this system should be made publicly available to third parties

in order to facilitate policy analysis and allow for quality and efficiency proposals.

8.3. The case for public-private agreements

As has been mentioned before, different kinds of contracts between the NHS and

private hospitals operate in Spain. There is a long ongoing debate about which form of

healthcare provision is more efficient and economical.

Although the different management systems have been operating for a considerable

amount of time, almost no studies are publicly available right now that could allow for

a meaningful comparison. This is a weakness of the healthcare system that mostly

reaps the bad consequences of this collaboration – the costs of managing multiple

organising models. It is not clear whether any cost reductions take place thanks to

these contracts.

44

Thus, yet another objective for the NHS appears: after establishing the quantitative

data for the public provision of the service it must be matched to all the different

management models operating in the country. The debate should finally be illustrated

by the real data in order to devise a more meaningful and sustainable future model for

the system as a whole.

45

9. Conclusion

Right now the Spanish National Health System is not economically sustainable. What

this means is that current spending trends cannot be allowed to continue into the

future because they would lead to healthcare becoming an expenditure item for the

country that is too big a percentage of State income. The bigger the spending

becomes, the more flexibility it takes away from the public budget. The State’s ability

to face economic and financial trouble is lessened when its flexibility is limited and its

long-term continuity becomes endangered. That’s why basic social services such as

healthcare must always operate at their most efficient, something that has not been

happening during the last expansionist decade.

Now comes the time for reform, for the best possible use of healthcare resources.

Priorities will become very important in the future management of the NHS because

sacrifices must not be made heedlessly, they must have a purpose. The people most

at risk must be considered at all times when enacting spending cuts and emergency

measures. The long-term survival of the NHS must also be factored into the equation.

A deep analysis of the NHS at the functional level is required in order to enact rational

spending reductions. Future reforms must be based on the following key-points:

Solidarity

Co-operation

Efficiency

Harmonisation

Reduction of resources

Renegotiating contracts

Establishing prices for the public services

Transparency

Assessment of the benefits of public-private agreements

The Spanish NHS might not be sustainable at the moment but it can definitely achieve

this goal in the near future.

46

Annexes

47

Annex I – Detailed breakdown of hospitals in Spain, sorted by functional control type

Public Entities Private Organisations

Year NHS Prison

Administra-tion

Autonomous Regions

County/Town Councils

Municipalities Public

Entities

Ministry of

Defence MATEP

Charity (Red Cross)

Charity (Church)

Other charities

Non-charity

TOTAL

2004 208 2 12 22 5 44 8 24 8 57 56 333 779

2005 210 2 10 20 5 45 8 24 8 58 58 335 783

2006 210 2 10 19 6 46 8 23 8 58 58 340 788

2007 217 2 9 16 3 54 8 22 8 56 56 349 800

2008 248 2 9 13 3 40 4 20 6 55 59 345 804

2009 254 2 11 13 5 41 4 21 6 53 57 336 803

2010 259 2 8 11 3 41 4 21 5 54 62 324 794

2011 254 2 13 10 3 42 3 21 5 53 59 325 790

2012 255 2 12 10 3 42 3 21 5 54 59 323 789

The above table illustrates the organisational complexities that Health Services have to manage on an ongoing basis.

“Public Entities” is the denomination associated to mixed management, when more than one public administration or service shares the

responsibility for a given hospital or medical complex.

The table has been compiled with data from the National Hospital Catalogue publications for the years 2005 through 2013.

48

Annex II – OECD data for selected healthcare indicators

Physicians per 1 000 population

2010 (or nearest year)

Nursing personnel per

1 000 population 2010 (or nearest year)

Australia 1 3,08

Australia 1 10,06

Austria 1 4,78

Austria 1 7,67

Belgium 1 2,92

Belgium 3 15,06

Canada 2 2,37

Canada 1 9,34

Chile 3 1,43

Chile 3 1,51

Czech Republic 1 3,58

Czech Republic 1 8,06

Denmark 1 3,48

Denmark 1 15,44

Estonia 1 3,24

Estonia 1 6,13

Finland 2 3,27

Finland 1 9,58

France 2 3,27

France 2 8,45

Germany 1 3,73

Germany 1 11,27

Greece 2 6,13

Greece 2 3,31

Hungary 1 2,87

Hungary 1 6,22

Iceland 1 3,6

Iceland 1 14,54

Ireland 2 3,13

Ireland 2 13,07

Israel 1 3,5

Israel 1 4,76

Italy 1 3,68

Italy 3 6,3

Japan 1 2,23

Japan 1 10,11

Korea 1 1,99

Korea 1 4,63

Luxembourg 1 2,77

Luxembourg 1 11,1

Mexico 1 2,03

Mexico 1 2,48

Netherlands 2 2,92

Netherlands 1 8,4

New Zealand 1 2,61

New Zealand 1 10,03

Norway 1 4,07

Norway 1 14,39

Poland 1 2,18

Poland 1 5,26

Portugal 3 3,82

Portugal 2 5,65

Slovak Republic 2 3,34

Slovak Republic 2 6,03

Slovenia 1 2,43

Slovenia 1 8,19

Spain 1 3,78

Spain 1 4,88

Sweden 1 3,8

Sweden 1 11

Switzerland 1 3,81

Switzerland 1 16,03

Turkey 2 1,69

Turkey 2 1,6

United Kingdom 1 2,71

United Kingdom 1 9,6

United States 1 2,44

United States 2 10,95

OECD AVERAGE 3,14

OECD AVERAGE 8,56

1. Data refer to practising physicians. Practising physicians are defined as those providing care directly to patients.

1. Data refer to practising nurses. Practising nurses are defined as those providing care directly to patients.

2. Data refer to professionally active physicians. They include practising physicians plus other physicians working in the health sector as managers, educators, researchers, etc. (adding another 5-10% of doctors).

2. Data refer to professionally active nurses. They include practising nurses plus other nurses working in the health sector as managers, educators, researchers, etc. (adding another 5-10% of nurses).

3. Data refer to all physicians who are licensed to practice.

3. Data refer to all nurses who are licensed to practice.

49

Medical graduates per

100 000 population 2010 (or nearest year)

Nursing graduates

per 100 000 population

2010 (or nearest year)

Australia 12,01

Australia 67,15

Austria 22,78

Austria 47,89

Belgium 8,99

Belgium 41,69

Canada 7,18

Canada 1 29,53

Chile 5,48

Chile 36,67

Czech Republic 13,86

Czech Republic 12,2

Denmark 16,35

Denmark 78,2

Estonia 11,12

Estonia 31,19

Finland 10,61

Finland 58,73

France 6,02

France 34,39

Germany 12,3

Germany 28,17

Greece 14,29

Greece 1 13,8

Hungary 10,4

Hungary 28,63

Iceland 13,84

Iceland 77,99

Ireland 17,54

Ireland 36,67

Israel 4,12

Israel 10,95

Italy 11,13

Italy 16,16

Japan 6

Japan 38,35

Korea 7,06

Korea 94,71

Luxembourg ..

Luxembourg 19,92

Mexico 11,55

Mexico 9,81

Netherlands 8,2

Netherlands 40,05

New Zealand 7,26

New Zealand 30,62

Norway 11,27

Norway 65,45

Poland 8,07

Poland 25,28

Portugal 11,86

Portugal 34,84

Slovak Republic 8,49

Slovak Republic 69,22

Slovenia 11,18

Slovenia 66,83

Spain 8,41

Spain 20,89

Sweden 10,66

Sweden 1 42,52

Switzerland 10,39

Switzerland 67,13

Turkey 7,02

Turkey 5,96

United Kingdom 9,25

United Kingdom 33,21

United States 6,62

United States ..

OECD AVERAGE 10,34

OECD AVERAGE 39,84

1. Data refer to professional nursing graduates only, excluding graduates from lower level nursing programmes.

50

MRI units per million

population 2010 (or nearest year)

MRI exams per 1 000

population

2010 (or nearest year)

Australia 5,64

Australia 23

Austria 18,59

Austria 1 47,6

Belgium 1 10,65

Belgium 52,8

Canada 8,24

Canada 46,7

Chile 4,12

Chile 7,4

Czech Republic 6,27

Czech Republic 33,5

Denmark 15,39

Denmark 57,5

Estonia 8,21

Estonia 48,1

Finland 18,65

Finland ..

France 6,95

France 60,2

Germany 1 10,3

Germany 95,2

Greece 22,55

Greece 97,9

Hungary 3

Hungary 2 31,7

Iceland 22,01

Iceland 74,2

Ireland 12,51

Ireland 1 17,3

Israel 1,97

Israel 18,1

Italy 22,35

Italy ..

Japan 43,1

Japan ..

Korea 19,94

Korea 14,7

Luxembourg 13,81

Luxembourg 79,6

Mexico 1,96

Mexico ..

Netherlands 12,22

Netherlands 49,1

New Zealand 10,54

New Zealand 1 3,6

Norway ..

Norway ..

Poland 4,69

Poland ..

Portugal 9,23

Portugal ..

Slovak Republic 6,81

Slovak Republic 33,2

Slovenia 4,41

Slovenia 1 2

Spain 1 10,66

Spain 1 45,6

Sweden ..

Sweden ..

Switzerland 1 17,77

Switzerland ..

Turkey 9,52

Turkey 79,5

United Kingdom 5,87

United Kingdom 1 40,8

United States 31,55

United States 97,7

OECD AVERAGE 12,48

OECD AVERAGE 46,28

1. Data include equipment in hospital only. 1. Data refer to exams in hospital only.

2. Data refer to exams outside hospital only.

51

CT scanners per

million population 2010 (or nearest year)

CT exams per 1 000

population 2010 (or nearest year)

Australia 42,81

Australia 93

Austria 29,8

Austria 1 145,5

Belgium 1 13,22

Belgium 179,3

Canada 14,19

Canada 126,9

Chile 10,2

Chile 50,2

Czech Republic 14,45

Czech Republic 86,5

Denmark 27,58

Denmark 105,2

Estonia 15,67

Estonia 275,4

Finland 21,07

Finland ..

France 11,81

France 145,4

Germany 1 17,73

Germany 117,1

Greece 34,31

Greece 320,4

Hungary 7,3

Hungary 2 76,2

Iceland 37,74

Iceland 159,8

Ireland 15,64

Ireland 1 75,4

Israel 9,18

Israel 127,2

Italy 31,58

Italy ..

Japan 97,27

Japan ..

Korea 35,28

Korea 106,2

Luxembourg 25,64

Luxembourg 188

Mexico 4,83

Mexico ..

Netherlands 12,34

Netherlands 66

New Zealand 15,57

New Zealand 1 22,4

Norway ..

Norway ..

Poland 14,33

Poland ..

Portugal 27,39

Portugal ..

Slovak Republic 13,81

Slovak Republic 89,2

Slovenia 12,69

Slovenia 1 12,8

Spain 1 14,96

Spain 1 82,8

Sweden ..

Sweden ..

Switzerland 32,6

Switzerland ..

Turkey 12,41

Turkey 103,5

United Kingdom 8,2

United Kingdom 1 76,4

United States 40,67

United States 265

OECD AVERAGE 22,57

OECD AVERAGE 123,83

1. Data include equipment in hospital only.

1. Data refer to exams in hospital only.

2. Data refer to exams outside hospital only.

52

Hospital beds per

1 000 population 2010 (or nearest year)

Australia 3,73

Austria 7,63

Belgium 6,44

Canada 3,19

Chile 2,04

Czech Republic 7,01

Denmark 3,5

Estonia 5,33

Finland 5,85

France 6,42

Germany 8,25

Greece 4,85

Hungary 7,18

Iceland 5,79

Ireland 3,14

Israel 3,31

Italy 3,52

Japan 13,62

Korea 8,76

Luxembourg 5,37

Mexico 1,64

Netherlands 4,66

New Zealand 2,74

Norway 3,3

Poland 6,59

Portugal 3,35

Slovak Republic 6,42

Slovenia 4,57

Spain 3,16

Sweden 2,73

Switzerland 4,97

Turkey 2,52

United Kingdom 2,96

United States 3,08

OECD AVERAGE 4,93

The figures represent a small part of the OECD Health Data 2012 statistics, available

at:

http://www.oecd.org/els/health-systems/oecdhealthdata2012-

frequentlyrequesteddata.htm

53

Annex III – Selected questions from the “Healthcare Barometer”

Q. 2

Which of the following statements expresses your opinion on the functioning of the Healthcare System in our country more accurately?

It works quite well in general

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 21,34 18,41 18,58 19,80 19,40 19,16 20,05 19,23 21,20 23,86 24,24

It works well but some changes are necessary

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 45,46 47,67 47,61 47,10 48,30 50,53 47,35 48,86 48,00 50,02 48,88

It needs fundamental changes although some things work well

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 25,51 27,31 26,96 27,10 26,00 24,97 26,85 26,17 25,30 21,60 21,91

It works so bad that it needs to be completely redone

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 6,38 5,51 5,60 5,00 5,10 4,42 4,69 4,88 4,70 3,51 4,20

Q. 3

In general, are you happy or unhappy with the way the public healthcare system works in Spain? Use a scale of 1 to 10 to answer, where 1 means you are "very unhappy" and 10 means you are "very happy".

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value

5,94 6,05 6,12 6,14 6,23 6,27 6,29 6,35 6,57 6,59

54

Q. 8

Based on your personal experience or your understanding of them, I would like you to assess the following aspects of public healthcare which refer to the assistance provided by family doctors and pediatricians (primary healthcare). The scale goes from 1 "completely insatisfactory" to 10 “completely satisfactory”.

The proximity of the centres

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 8,00 7,39 7,36 7,80 7,62 7,68 7,64 7,53 7,74 7,85 8,06

How easy it is to get an appointment

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,17 6,61 6,51 6,70 6,59 6,63 6,45 6,54 6,51 6,89 7,06

The opening hours

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,44 6,82 6,78 7,20 7,10 7,10 7,05 7,14 7,18 7,35 7,57

The treatment that healthcare personnel dispense

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,82 7,22 7,23 7,40 7,38 7,36 7,33 7,35 7,42 7,50 7,75

The care provided by medical and nursing personnel during home visits

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,41 6,77 6,82 7,00 6,93 6,94 6,87 6,91 6,96 7,13 7,29

The time the doctor spends with each patient

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,07 6,40 6,38 6,50 6,49 6,49 6,32 6,40 6,58 6,76 6,98

55

Q. 8 Continued

Based on your personal experience or your understanding of them, I would like you to assess the following aspects of public health care which refer to the assistance provided by family doctors and pediatricians (primary healthcare). The scale goes from 1 "completely insatisfactory" to 10 “completely satisfactory”.

The doctor's knowledge of patient medical history and the follow-up provided on each patient's particular health problems

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,40 6,77 6,83 7,00 6,97 6,97 6,89 6,95 7,05 7,26 7,52

The confidence and assurance transmitted by the doctor

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,74 7,10 7,15 7,40 7,40 7,38 7,27 7,35 7,40 7,54 7,77

The waiting time for consultation

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 6,00 5,42 5,31 5,60 5,59 5,58 5,48 5,52 5,56 5,79 5,93

The existing equipment and technological resources in the centres

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,08 6,27 6,42 6,70 6,48 6,71 6,55 6,49 6,66 6,87 6,92

The information received about your health problem

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,41 6,72 6,83 7,20 7,16 7,11 7,06 7,06 7,20 7,34 7,50

When you need it the family doctor refers you to a specialist

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 4,56 5,71 5,76 7,20 7,10 7,20 7,09 7,17 7,19 7,26 7,39

56

Q. 8 Continued

Based on your personal experience or your understanding of them, I would like you to assess the following aspects of public health care which refer to the assistance provided by family doctors and pediatricians (primary healthcare). The scale goes from 1 "completely insatisfactory" to 10 “completely satisfactory”.

The waiting time for diagnostic tests

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value - - - - - - 5,26 5,22 5,24 5,45 5,66

Q. 13

I would like you to assess, based on your experience or the notion you have of them, the following aspects of the care provided in public hospitals. Please use a scale of 1 to 10, where 1 means "completely unsatisfactory" and 10 means you value it as “completely satisfactory”.

The number of people sharing a room

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 5,64 5,24 5,29 5,40 5,50 5,38 5,44 5,32 5,47 5,65 5,84

Accommodation aspects (meals, toilets and general comforts in the rooms)

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 6,71 6,11 6,14 6,40 6,39 6,34 6,40 6,25 6,27 6,47 6,56

The administrative requirements for hospital admission

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 6,27 5,70 5,76 6,40 6,05 6,09 6,12 6,11 6,19 6,33 6,47

Waiting time for non-urgent admissions

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 4,26 4,11 3,97 4,30 4,18 4,45 4,53 4,46 4,54 4,74 4,84

57

Q. 13 Continued

I would like you to assess, based on your experience or the notion you have of them, the following aspects of the care provided in public hospitals. Please use a scale of 1 to 10, where 1 means "completely unsatisfactory" and 10 means you value it as “completely satisfactory”.

The care and attention provided by the medical personnel

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,47 6,75 6,97 7,10 7,20 7,21 7,12 7,08 7,19 7,24 7,35

The care and attention provided by the nursing personnel

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,61 6,87 7,04 7,20 7,30 7,29 7,21 7,14 7,25 7,26 7,44

The treatment received from non-healthcare personnel

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,41 6,71 6,90 6,90 6,99 6,99 6,89 6,87 6,89 6,83 6,97

The existing equipment and technological resources in the hospitals

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 8,23 7,46 7,53 7,70 7,61 7,68 7,58 7,61 7,72 7,76 7,91

The information received from the hospital personnel about the evolution of your health problem

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Value 7,34 6,67 6,92 7,10 7,11 7,12 7,02 7,05 7,15 7,22 7,38

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Q. 15

Do you thing that the health authorities are acting to reduce waiting lists?

Percentage of the survey respondents who believe that YES, they are

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 40,49 41,62 42,99 46,40 45,70 48,53 47,27 42,32 41,30 36,92 33,19

Percentage of the survey respondents who believe that NO, they aren't

2000 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 15,06 22,25 29,62 30,10 32,20 30,13 31,94 34,05 35,40 33,53 36,34

Q. 18

In your opinion, has each of the following healthcare services improved, worsened or remained at the same level in the last 5 years?

Percentage of the survey respondents who believe that Primary healthcare has improved

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 51,65 50,67 51,70 47,60 48,28 47,44 41,79 42,30 42,73 41,14

Percentage of the survey respondents who believe that Primary healthcare has worsened

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 4,73 5,21 4,50 5,00 5,18 5,86 8,79 8,30 7,87 10,71

Percentage of the survey respondents who believe that Primary healthcare has remained at the same level

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 36,97 37,64 36,40 40,20 39,70 40,27 41,43 41,80 42,32 41,52

59

Q. 18 Continued

In your opinion, has each of the following healthcare services improved, worsened or remained at the same level in the last 5 years?

Percentage of the survey respondents who believe that Specialised consultations have improved

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 44,80 40,65 44,40 38,80 40,55 40,50 35,90 35,80 36,31 34,72

Percentage of the survey respondents who believe that Specialised consultations have worsened

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 6,50 6,53 5,70 7,20 6,49 6,92 9,50 9,70 8,88 11,83

Percentage of the survey respondents who believe that Specialised consultations have remained at the same level

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 38,87 42,30 38,20 42,00 41,39 41,11 42,26 42,70 43,53 42,18

Percentage of the survey respondents who believe that Hospital care has improved

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 48,02 44,05 47,00 41,60 43,18 42,30 37,78 37,60 39,35 37,72

Percentage of the survey respondents who believe that Hospital care has worsened

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 5,56 5,70 4,80 6,00 5,25 6,43 8,60 8,90 7,47 10,52

Percentage of the survey respondents who believe that Hospital care has remained at the same level

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 36,59 39,25 36,40 39,40 39,12 39,80 40,57 40,80 40,61 40,21

60

Q. 21

Now that all Autonomous Regions are responsible for their own healthcare provision, do you think that they should all reach an agreement when considering the provision of new services to the citizens?

Percentage of the survey respondents who believe that Autonomous Regions SHOULD reach an agreement

2003 2004 2005 2006 2007 2008 2009 2010 2011

Percentage 75,33 80,10 82,90 83,97 85,83 86,21 84,90 83,62 84,68

Source: Barómetro Sanitario, historical series 1995-2011

61

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