Private or public, Spanish general medicine proved its worth during the pandemic. No town was neglected. Family physicians know their patients well and accompany them in the long term. These were key strengths for identifying contact persons or following up on patients even from a distance.
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On March 13th, 2020, the family physician Luis Alberto Tobajas anticipated the decree that imposed the confinement throughout Spain the following day. In a video posted on Facebook, he and the nurse he works with asked their patients to take the #QuedateEnCasa (Spanish: #StayAtHome) challenge.
A month later, his small town of Membrio (province of Cáceres1, in western Spain, close to the border with Portugal) had no cases of Covid-19 among its 700 inhabitants, which includes about 100 elderly people. Dr. Tobajas attributes this success to the efforts of the confined citizens and to the excellent work of the staff of the two retirement homes "who followed with military discipline our indications, and those of the health authorities". But there is another element, a structural one, which may account for this result.
The Spanish health system guarantees universal and free access to health care. To this end, it relies on planning, prioritization and sectorization. Since the Spanish Health Law of 1986, a network of Health Centers2 has been established throughout the country, guaranteeing access to care even in the most remote municipalities.
There is no patient in Spain without a physician and no geographical area without a health center. The backbone of these structures is formed by physician-nurse pairs. They are assisted by other paramedical professionals and administrative staff. All are salaried by their region and only services such as cleaning or maintenance are outsourced. This system is based on a public service philosophy that is firmly rooted in the minds of Spanish family physicians from the very beginning of their training. Having become a specialty in 1978 under the name "Family and Community Medicine", Spanish general medicine is based on specific training, with a 4-year multidisciplinary internship.
Dr. Tobajas strongly believes in the strategic importance of this primary care organization during the pandemic: "Family Medicine followed 85% of Covid-19+ patients, those who had no hospitalization criteria. Its role was essential in avoiding exacerbation of chronic conditions," he explains. For him, family medicine specialists have less need to resort to complementary examinations to make a diagnosis. "The in-depth knowledge we have of our patients, and the relationship of trust we have built up over the years, enables us to optimize our clinical diagnostic capabilities, and to be very efficient with tools such as the telephone and teleconsultation." There is no doubt that family medicine is the key to early detection, contact identification, treatment and follow-up of patients. Without it, the Spanish health system would have collapsed.
Beyond the current crisis, family medicine should remain the mainstay of the health care system according to Dr. Tobajas. Accessible to all, it ensures integral and longitudinal health monitoring. Above all, it provides distributive and equitable justice. This is the belief of generations of Spanish family physicians, who claim their role as a public service and, at the same time, stand up against hospital-centrism: "If the health system is struggling to be economically efficient and sustainable, it is because we are putting patients in the wrong place. There is a need for more care in patients' homes and less in hospitals. We need to use new technologies to connect our patients and encourage remote monitoring. We need to give them more information and fewer prescriptions”, explains Dr. Tobajas.
Dr. Tobajas believes this is possible because he knows he can count on the public. "It has sufficiently demonstrated, during the health crisis, its ability to get involved in community health (...) Citizens have adapted to the instructions of the containment and they have made responsible use of the health system, avoiding coming to consult except for real emergencies" he adds. Dr. Tobajas would like the lessons learned during the pandemic to be used by policy makers tempted to continue privatizing the system. "Spain spends only 6.2% of its GDP on health financing, far below the European and US average. Eleven countries in Europe are ahead of Spain. We need to refocus our model, to promote prevention and limit hospital-centrism. Faced with the serious difficulties in our public health system, there is only one solution: to invest more in public health, and particularly in primary care, and therefore family medicine” proposes Dr. Tobajas.
1. Spain has 17 regions and 50 provinces. Health expenditure is mainly decided and financed by the regional governments, subject to compliance with the overall budget set at national level. Health care is free, almost entirely financed by taxes. There are no advance fees. The only exception to the free treatment is the pharmacy: approximately 40% of the price of medications is paid by the patient. However, pensioners and patients with certain chronic diseases are fully covered. Dental and optical care is not reimbursed by the National Institute of Health Management and is covered by private insurance.
2. Primary care must be available within a radius of 15 minutes from any place of residence. The main health care facilities are health centers, with multidisciplinary teams that include general practitioners, pediatricians, nurses and administrative staff and, in some cases, social workers, midwives and physiotherapists. The insured person is free to choose a general practitioner or pediatrician in the area where he or she resides, provided that the practitioner has not yet filled his or her enrollment quota. General practitioners act as care managers and coordinators. They ensure continuity of care throughout the patient's life. If necessary, primary care may also be provided in the home. This measure has fostered a real recognition of general medicine in Spain. The general practitioner has the role of gate-keeper: he or she is always consulted in the first instance and controls access to the specialist.