The pandemic and the agony of primary care

Andreu Segura
 

I thank Xavier Blancafort for the photograph, as well as 

his suggestions, I also thank Laia Riera and Vicente Giner.

COVID-19 has been a real stress test for Spanish health system as a whole, especially for primary care services (PC) ‒particularly in the most advanced phases of the pandemic‒ and public health facilities (SP) in general, although these are rarely the object of evaluation, although we have all paid for their limitations and deficiencies. For some time now, both levels of the national health system have been languishing as illustrated - although, in my opinion, this is not the worst - the continued decline in the proportion of the public health budget that corresponds to them, especially in the SP, which does not reach 2% of the total. Of course, the proportion of spending is not a sufficiently precise indicator of the efficiency neither of the efforts nor the value that its activity contributes to improving and maintaining the population health. That is why I consider the absence of health strategies more serious and, even worse, healthy public policies, since the appeals to health in all policies have been above all rhetorical. Healthy public policies should naturally include health policy, so that it could effectively contribute to the collective promotion and protection of community health, as one more element along with educational, labour, urban, economic policy, etc.

Patient safety and iatrogenesis

Andreu Segura

Among the most important public health problems today, the harmful effects associated with clinical and health care practice stand out, the relevance of which is unquestionable given their impact and, above all, their aetiology. Hence the development of the so-called patient safety strategy, the purpose of which is to limit as much as possible the damage that medical and health care interventions can cause provided that such damage can be avoided.

Misappropriation or necessary contribution?

Andreu Segura

If we understand that health is not, as suggested by the Andrija Stampar definition adopted by the WHO in 1946, the mere absence of disease or insanity, but something else, whether it’s well-being as the aforementioned description affirms, it’s a reasonable ability to functional adaptation as René Dubos proposed, it’s easier to understand the importance of the so-called social determinants of health, among which health care is but one more.

These comments don’t imply any disregard for health care, given its ability to ease a good part of the disorders caused by diseases and, sometimes, to cure them definitively. Incidentally, insanity is, according to the dictionary, madness or mental disorder, a distinction that highlights the specificities of psychiatric pathology.

The topography of overuse

Andreu Segura

More and more voices warn about the damages associated with the excessive use of health services, although those who claim for the negative consequences attributable to precariousness and the cuts suffered by public health still prevail.

Of course, some protests as well maybe relevant since the health damages related to medical and health care are a consequence of both the action and the omission. And it isn't strange that both coexist because, for example, the abuse of imaging tests leads to an increase in the waiting list of patients who are candidates for exploration, so that the higher the proportion of superfluous prescriptions, the more they will be delayed those that are necessary, those whose result can modify the clinical decision for the benefit of the patient.

When the health care does not work well, better not have?

Andreu Segura

Almost twenty years ago, the report of the Institute of Medicine “To err is human" estimated that medical errors caused more annual deaths than AIDS, breast cancer or traffic accidents. A few days ago, at The Lancet, Margaret Kruk and her Harvard global health team warned us that poor health care is causing five times more deaths than AIDS in countries with fewer resources. Even more deaths than those of people who die without being able to access health.

It is obvious that to be useful, health activities must have a positive effect on the health of the people served. In health and survival or, even more precisely, in survival in good health. Elementary. As it is also to think that this value depends largely on doing things right. And it is not enough to have facilities, equipment and health personnel. They need to work properly.