Society 12/07/2021

Antoni Sisó: "If strengthening the Health Centres means building modules and setting up tents, nothing has been understood".

5 min

BarcelonaThe pressure primary care is under is unsustainable, warns the president of the Catalan Society of General Practitioners (Camfic), Antoni Sisó. The first level of care is diagnosing over 20,000 infections a week -these positives are only a third of all the tests it carries out- while relentlessly vaccinating at primary care centres and mass vaccination points across the country and trying not to continue care for chronic patients and diagnose other diseases. The large community transmission in the country has forced the department of Health to deploy the mitigation phase, meaning it is now impossible to track all cases - and to approve the Delta Plan, which, among other things, involves not testing symptom-free close contacts of positive cases.

Health centres are saturated.

— I am running out of adjectives to define the situation we live in. We no longer have a curve of cases, it is a vertical line and we have to flatten it however we can because hospitalisations will also increase. Since the appearance of the delta variant, which is much more contagious, we recovered social relations and removed masks, we have an incidence of covid like we have never seen before. In urban areas, especially in Barcelona, we have spectacular and very long queues of people with respiratory symptoms who need to be tested and all of them have similar ages, between 16 and 35. And while we collect this avalanche of diagnoses, we also maintain vaccination. The situation is already difficult to contain and we need help

The Health Department said that hospitals would now vaccinate and test.

— If there is a hospital or an annex that is empty, go ahead. We have no hands, we lack nurses especially, so all professionals are welcome. To do tests and vaccinations we need nurses. As if they want to send instrumentalists. They are nurses too, aren't they?

At the moment, the fifth wave has stopped the recovery of patients turning up in person for consultations.

— Only three weeks ago there were centres that were considering closing some covid spaces and recovering the face-to-face visits because during 2020 we have missed out on the diagnosis and care of many pathologies. Lung cancer diagnoses have skyrocketed because we do more lung ultrasound due to covid, also anxiety, but we have missed out on a lot of detection of hypertension, diabetes, chronic kidney disease or breast cancer. This is the toll of prioritising covid attention. And in early June, when it seemed that the pandemic was decreasing and we could recover it, the delta variant entered the equation and we have received a tsunami that has taken us back to starting point.

Unlike last year, however, you now have diagnostic tests.

— Yes, back then we didn't have PCRs and there weren't even antigen tests, but we never sat back. We asked people about their symptoms and categorised them by the degree of severity of lung involvement with ultrasound. Before the Ministry of Health did it, we already did a seroprevalence study to see how many people were affected and with no budget. We have also tracked close contacts because the Public Health Agency was saturated. Months ago we took care of detection, diagnosis and clinical monitoring of covid; we also did it in care homes. And in December, when vaccines arrived, we took over the vaccination

CAMFiC has produced a guide with 15 points for a revolution in primary care in the post-covid era among which you demand a larger budget, more recruitment and more control of the agenda

— Most of the demands go back to long before the pandemic. To give a chronological account of the facts, we should go back to 2018, to a very important strike by primary care doctors from all over Catalonia which had great support. They are not asking for more money, but for better working conditions. Throughout 2019, the current Catalan Minister of Health, then director of the Catalan Institute of Health (ICS ), tried to solve this by recruiting more professionals. But they did not get most of the things that were asked, among other things, because there were no professionals. And in 2020 came covid and strangled primary health care that was already very tense.

You said that in Catalonia between 900 and a thousand GPs are needed.

— And we do not have them. In 1996 43% of new doctors in the state were GPs and by 2021 this had dropped to 21%. In 25 years we have lost fifteen percentage points, while other specialities have skyrocketed. It is clear that it is normal: how many GPs are there in universities to explain the medicine we do to health centres? Very few. And professors? None. And there are literally only four lecturers in Catalonia. The profession is not visible in medicine degrees.

But politicians fill their mouths saying that primary health care is the backbone of the system.

— And it is true and we have to make it real. We are the centre of the health system because we guarantee universal and free care and we make the system sustainable. Hopefully one day we will succeed in getting the top political, economic and media class to come to a Health Centre. On that day we will have triumphed, because one can only value and estimate what one knows. For the moment, we have had enough of diagnoses and roadmaps for health centres that are never carried out. We want tangible and assessable facts

As for example?

— That they should recruit 100 new junior GPs in 2022 . Does this solve the problem in the short term? Not for another four years, but it is a political gesture that projects a desire to understand the problem and provide the tools to solve it. They should set up a competition with a €4m fund for research projects. Dr. Argimon is our partner and I think he has all the predisposition to dialogue, but doctors also have memories and we have seen in the last 14 years many ministers and many failed attempts at change.

Speaking of the minister, last week he presented his government plan for the next four years and one of his priorities is to strengthen mental health care.

— 80% or more of mental health problems are detected, diagnosed, treated and accompanied in primary care and not in mental health centres or hospital psychiatric services; so is male violence. Social, economic and cultural determinants can trigger a health problem and we, as GPs, are in a privileged position to address them. If all people with mental health problems had to go to a psychiatrist, we would be Woody Allen's psychiatrised society. But this is the American model, not ours. Here your family doctor will never discharge you. If you don't get a referral from him, you will change doctors until you find a doctor with whom you can have a bond of trust, because the strength of the primary care is this bond.

To do this you need economic and material resources.

— Of course. This 25% of the health budget that has to be allocated to primary care is a figure that we have been defending for years. It currently stands at 14.5%. If we really want to transform primary health care as they say, we need more doctors, nurses and assistants, but also new professionals such as psychologists, nutritionists and physiotherapists. We also need to improve and modernise the infrastructure, because there are Health centres with pre-constitutional furniture, to put it in a way, or that do not have windows to ventilate, or spaces to hold workshops or preserve privacy and confidentiality. It costs little to build a hospital, doesn't it? The pandemic has shown that it is a matter of months and money.

The Department says they have already injected resources to strengthen primary healthcare.

— Yes, €300m in three years out of a budget of €11bn. And what are they being used for? To build prefabricated modules that don't even have windows or set up tents. If this is what reinforcement is all about, the managers have not understood anything. This is not a reinforcement plan, much less a transformation plan, but a contingency plan. A rescue.

You also advocate for greater autonomy for teams.

— Of course. The director of a primary healthcare team has to be a leader, a manager, and has to have the financial possibility to buy specialised care himself. If you have to send a patient to a cardiologist, you have to be able to choose where he goes, because maybe one hospital doesn't give you good service and another one does. And that means having the money for contracting. That would be a real revolution, that can generate clashes with other health sectors, but that has to be done. Let's try it in a limited environment, in a not very large territory and let's give them a margin of 24 months. It will turn out well, I'm sure it will