Primary Health Care Centres management notes

It is not the same to sail with no wind as it is to sail with a swell, it is not the same to manage a health unit in calm weather as in a pandemic. But it is useful to learn from storms because, as the sailor knows, they never come alone. 

Europe's public health systems are huge structures that could be likened to a fleet with hospitals as huge ships and Primary health centres as smaller, more agile ships. In these days of disruption with a shower of protocols from the general command but without a clear vision of what we were up against, each unit did what it could. Some maneuvered quickly, others less so; some did so skillfully, others were overtaken by circumstances.

In my case, I witnessed a good example of self-management and teamwork that managed to get ahead of the game and choose courses of action that were appropriate. If we had waited for the official slogans we would have certainly had more casualties among the population and the health workers themselves. 

However, the health system does not allow the self-management of the health centres, which are subject to a rigid operation subordinated to a management that works from a distance, following quantitative indicators and measurements of results, but that still does not evaluate qualitatively and consequently develops an incomplete function. If there is a dead calm, the system works because it must be left to its own devices, following the drift imposed by its inertia. But with wind or dangerous circumstances things change quickly and the chain of command stops working because of the consequent slowness and lack of agility.

In these weeks, putting on the table a bold proposal such as diagnosing and treating mild pneumonia in young patients without comorbidities in Primary health centres to alleviate the hospital emergency inevitably came up against the impossibility of a system that is not capable of making its way of doing things more flexible. On the one hand, because coordination with hospitals is very limited and, on the other hand, because the novelty is not usually welcomed by managers who value the safety of the system more than it has always done. This is understandable since it is the norm in the state's civil service structures. 

Proposing that professionals on sick leave or in quarantine could remotely access medical history systems electronically was also not considered feasible. Despite the fact that the proportion of casualties is very high and there is a lack of personnel everywhere. 

The only way to innovate is not to ask permission. But of course, this is very limiting in professions as standardized as health care where it is quite difficult to go off track. 

One example is the use of photos or video conferencing with patients within the telemedicine work we have developed. Many patients sent us photos of their skin lesions, of their red throat, of an irritated eye... With others we proposed the video conference to assess general condition, breathing and other factors. In all these cases we did it putting the interest and the security of the patient in the first place but lacking the permission or authorization since these activities are not contemplated in the sanitary organization. 

This small reflection serves to highlight the fact that in an increasingly complex world that faces a horizon of difficulty and uncertainty the only way to survive is to adapt and that implies flexibility, creativity and innovation. Health systems are going to be subjected to overloads, dangers and circumstances that are going to demand much more of them than has been demanded up to now. If we keep the hands of professionals tied, it will not be possible. Issues such as the self-management of centres, the optimisation of existing technology, the reduction of bureaucracy to give professionals more time and capacity and the encouragement of creativity instead of punishment are courses of action that we will have to dare to implement. Society won’t let us being not better prepared next time. 

Salvador Casado

Family Doctor. Villalba. Servicio Madrileño de Salud


Link to blog "La consulta del Doctor Casado"