So just wait awaits our health service?

It’s the elephant in the room, actually. With elections just around the corner, the PSOE hasn’t dared touch Spains health care – but everyone knows that whoever wins, come January, the Spanish health service is going to take a large hit. And it’s already happening, in quiet little corners of Spain, as the federal regions that politically can start to save cash where-ever they can.

Griñán himself admitted this today, in an interview with Ideal, where he said his 2012 budget would implement “a more efficient spend” on the health service, “at all times respecting the health rights of the citizen” (El Ideal). What this means is anyones guess. Frankly, seeing as to how 2012 is an election year, my guess is that the money physically isn’t there, and he has to cut the budget in real terms – with the Andalucian economy in a recession free fall, he’s already run out of cash for 2011.

Health care in Spain is devolved to the communities. So you have the Andalucian health service, the Murcian health service, the Catalonian Departament de Salut, etc. They all have to reach a minimum level of care, but anything more is up to the regional government.It’s supposed to be overseen by Madrid, which funnels the cash into the federal governments.

The central government, together with the EU, has spent the last two decades pouring a vast amount of cash into building a large and efficient modern health service in Spain. Most villages will have a modern new GP surgery, every area has its own large hospital, helicopters ferry the wounded to some of the worlds best regional hospitals for emergency service.

However, this money has now dried up. From 2012, the EU’s FEDER fund is being redirected -assuming the EU has any cash left over from bailing out the banks- into the new developing countries of Eastern Europe. Spain now has to take this network and run it on its own resources. Or, more accurately, it has to split up the network, then let each of the federal regions run their own bits.

For cash strapped regions, the health service is a massive cost which is ripe for the picking. As I said, the November elections are postponing any massive cuts to the health service, but nobody is in any doubt that they are coming. In fact, I notice that all of the main parties are avoiding the issue – if the PP use the issue to attack the PSOE, then they have to outline their own cuts, and vice versa. It’s the elephant in the room, if you will.

That’s not to say that Madrid hasn’t been planning some cuts. The marvellous Real Decreto-ley 4/2010, de 26 de marzo, de racionalización del gasto farmacéutico con cargo al Sistema Nacional de Salud tells pharmacies to start doling out the cheapest available medicine unless a prescription indicates a specific brand name (in which case the Doctor must justify choosing that product over a cheaper one). It’s interesting that this law actually states that the measure is prompted by a contraction in the Spanish GNP of 3,6% in 2009. It also makes medicines cheaper, by cutting markups, forcing distribution networks to cap their profits and stops industrially produced national medicines from generating more profit than is deemed necessary. Medicines that have been on the market for more than 10 years had a 25% price cut. Etc. The idea was to save 1,500 million euros a year, starting from 2011.

Now, this is interesting, but what hasn’t been mentioned is the single biggest change to the Spanish funcionario system since democracy – the first steps have been taken to strip all of Spains civil servants (which range from office workers to teachers to bureaucrats) of their cosseted private health service -the Mutualidad General de Funcionarios Civiles del Estado-, and put them all into the general health system. It’s a massive shakeup that is being carried out very, very, very quietly but which is accelerating – meaning that as from next year, no more private doctors or private clinics for funcionarios. It’s down to the local GP with the rest of the unwashed masses for them.

La crisis has forced some administrative efficiencies to be made. For example, the communities finally agreed to implement a single unified health card for the whole of Spain, instead of the current federal region card which will have “significant financial and administrative savings” according to the health minister. The digital prescription service will finally be rolled out across the whole of Spain. Both projects were supposed to have been completed by 2005, but different regions held up the process for various ridiculous reasons.

In July, Madrid announced that it was giving an extra 8000 million euros to the regions. There are many official reasons why this vast amount of money is being given out. In reality, it’s to keep the regions running until the end of 2011, as shortfalls in predicted tax revenue meant many communities were in danger of running out of cash. Leire Pajin, the health minister, admitted that “much” of this money will go towards the cost of running the regional health services.

Of course, the health service is a cornerstone of modern Spain, and the Spanish love their doctors. So any major cutting of services would probably lead to civil strife, especially in the current climate.

The dirty word in Spanish society at the moment is “copago”, co-payment: making the patient pay a portion of their medical bill. Every major politician has had to come out, from every party, to deny that they will allow this to happen. But they can’t quench the rumour that it’s on the books. Despite the fact that introducing copago would lead to a huge upheaval in society. The fact that most regions have started to give out “fake invoices” to patients is reinforcing the rumours. These fake invoices details the cost of the patients medical treatment, and are supposed to be a PR exercise to make people think about the cost of health before visiting their GP for trivial issues. The Spanish are, in their usual cynicism whereever the government is involved, assume that the fake invoices are the first step towards billing them in a copago system, and who’s to say they aren’t correct?

A more likely, especially in the short term, route is that taken by Catalonia. As I said before: Griñán simply can’t touch the health service in Andalucia at the moment, with national elections in November and his federal elections in spring 2012. He has to get the cash from somewhere to keep things tottering along until then. But he may be tempted… After all, he’s put into place a “sanitary cent” tax, a flat rate tax of 0,025€ per litre of gas and diesel, which goes towards the Andalucian health service. (Just one of the reasons that fuel in Andalucia is so much more expensive than in Murcia.).

Catalonia has announced, or rather, was forced to announce after starting the programme, that it has implemented a “rationalisation” of local medical services. The idea, according to the Generalitat, is to close non-essential medical centres at low times, depending on local usage. In some cases this means closing the medical centre just at night, but many medical centres, especially in mainly industrial zones, will now be closed on weekends and holidays. The idea is to save on overtime. Indeed, in Barcelona alone, most of its major hospitals will operate only basic services over the major holidays from now until the new year, in an attempt to save the city 70 million in overtime. This has not gone down well with the Catalans, and it remains to be seen what they will think of the idea once it’s gone into effect over the holidays.

And over the weekend, the Instituto Catalán de la Salud has announced it intends to save 45 million euros on its wage bill by the end of the year. The ICS, which manages 8 major hospitals, and 450 local medical centres, employs 40,000 workers in Catalonia. It has been told by the Generalitat that it is facing a shortfall of 75 million euros in funding for this year. It intends to cut out all overtime, and may lay off temporary workers in a series of planned short term redundancies (the idea is that the workers are sent to the dole for, say, six months before being invited back). A series of major strikes by doctors for October have already been announced, but the director of the ICS warns that further “great sacrifices” will have to be made in 2012 and 2013.

Meanwhile, Galicia, which on the one hand can’t find the cash to pay its doctors, presses on with Spains largest current investment in public health, a modern 1,450 bed hospital in Vigo. It’s being financed via the “German model”, as the Spanish politicians call it in order to reassure the voters – companies build the project for free, in exchange for gold plated maintenance contracts over the next 20 – 30 years. Hmm. I wonder if this is really going to be any cheaper than borrowing the money today from a bank to complete the work? I’ve been nasty about the “German model” elsewhere on this blog, especially when it comes to building out local Almanzora motorway, which is being paid for via this method.

The fact of the matter is that for 2011 Spain is looking at a shortfall of 15,000 million euros in its health budget. Most of this is being covered by not paying providers, by the 8 billion Madrid has doled out to the regions, and at the end of the day by savage cuts in workforce, as we are seeing in Catalonia and now the Balearic Iles.

As Spain continues to suffer falling tax revenue, borderline recession, a collapse of international trust in its banking system, and ever higher repayments on its debt, severe reorganisation of the health service in Spain is needed in order to prevent the much vaunted “sociedad de bienestar” from going under. The PP has hinted quite clearly that the only way forwards is to re-merge these powers from the federal regions back to the state, and here I tend to agree with them. There are too many overlaps and inefficiencies in the current system, where each region runs its own health service.

Jose Blanco -Minister for Development and the government spokesman- said it best when he was recently overheard admitting that Spain “has lived beyond its means for some years now and must, this year, face the consequences”.

But make no mistake, vast cuts are coming. My worry is – what if the politicians decide that these “furrigners” living in Spain, mainly retired northern Europeans who, being older, logically need more medical care, are a drain on the system and a potential source of income? Will 2012 be the year in which expats are suddenly forced to take out private health insurance, or hit with a modified version of copago, in which they have to pay their own health bills in Spain? They are a tempting target…