Aerial view of the Hospital Civil in Malaga. SALVADOR SALAS
There is uncertainty and despair about the health service in Malaga province. The cutbacks which have been applied by the regional Health Ministry because of the economic crisis have made working conditions more difficult for medical professionals and lengthened waiting lists, and patients are also suffering long delays before they are able to consult a specialist, undergo surgery or be given tests.
In this article, five doctors describe the problems they are facing and they all agree that a lack of resources is making it more difficult to resolve these problems.
In barely two years, the health service in Malaga has lost nearly 800 workers. The contracts that are offered to doctors now are only for 75 per cent of a working day. The closure of wards and beds this summer highlighted the deficiencies and had a serious effect on waiting lists.
The two big hospitals in Malaga city, Carlos Haya and the Clínico Universitario, as well as having 229 fewer beds than in 2007, are immersed in a major restructuring process after their merger. The creation of inter-centre clinical management units is an unknown whose application may be beneficial or may be a failure. There are many questions without a clear answer. Meanwhile, patients are becoming resigned to a situation in which delays in receiving medical attention have become inevitable.
Cardiologist at the Clínico: “We’re seeing patients for checkups three or four months behind schedule”
Those who are suffering most from the cutbacks in the health service are chronically ill patients who are due for a checkup. A cardiologist at the Clínico Hospital says that outpatient departments are seeing patients for checkups three or four months later than these are due. Sometimes the delays can be as long as a year and a half. “The priority we have been given by the SAS health service is to see patients who have been referred by their GPs for the first time. This is to the detriment of patients with chronic conditions, because it creates a delay before we see them, and no maximum time period has been established before we have to attend to them”, says this specialist.
The doctor adds that the health service has also put pressure on the medical staff to make appointments for patients. “Before, the administrative staff used to make the appointments; now we do it. Patients complain to us about it. Most of them understand all the problems and delays. They put up with having to wait; they are resigned to it”, says this cardiologist at the Clínico Hospital.
In cases where the heart specialists consider that a patient needs immediate attention because a delay could be dangerous, they ask for what this doctor describes as “the personal favour system”: in other words they call the person who does the tests or carries out the surgery and tell them the story, asking them to give priority to the patient who needs urgent attention.
An average of 23 patients a day are seen for consultations (10 - 12 minutes for each patient), 14 of whom have come for their first appointment and nine who are there for checkups (six minutes dedicated to each). “We do everything we can, but our hands are tied because of the cutbacks. Everything is taking longer. The doctors are upset about it. We’re working more and earning less, so we’re not happy. The only reason the situation isn’t even worse is because our job is a vocation”, sums up this cardiologist at the Clínico Universitario Hospital.
Oncologist at the Carlos Haya: “The 75% contracts mean we are overloaded with work”
The main obstacle faced by staff in the oncology unit at the Carlos Haya Regional Hospital is that the contracts they have been given are for only 75% of a working day. Ten of the thirteen oncologists at this hospital are in this situation, and this is something which makes their working conditions harder. “The fact that ten of us are on 75% contracts instead of 100% means that sometimes we are completely overwhelmed with work and we just can’t keep up with attending to cancer patients”, explains one of the specialists in this department.
“Because of the characteristics of our patients, we make every effort to see them in as short a time as possible and speed up all the processes for the tests they need, but we often encounter numerous difficulties. On one hand, being on 75% contracts makes things really difficult for us. It’s something that is out of our hands, we can’t resolve the problem. On the other hand, the volume of patients we are seeing is increasing. The population is ageing and the diagnosis of tumors has improved, and these are two factors that mean that more patients need our services”, says this oncologist. This specialist also points out that during oncology consultations at the Carlos Haya, the specialists normally spend 20 minutes with each patient and 40 minutes if they are coming for the first time.
It is normal to see 17 or 18 patients a day, but sometimes there are many more and it is not uncommon for 26 to be seen, which increases the stress on the doctors because of the extra work.
“We oncologists just have to see more patients than we are assigned. This results in more delays and patients come for their appointments later than the time they have been given, but we either have to do this or not see somebody who needs attention”, stresses this oncologist. Although a first appointment is always within the guaranteed period, there are delays in checkups for cancer patients because of the overwhelming level of work.
Doctor in the Emergency Department of the Costa del Sol Hospital in Marbella: “The patients complain to us about the delays and we can´t do anything”
The doctors in the Emergency Department of the Costa del Sol Hospital in Marbella are putting 200 per cent effort into their work, says one of the professionals who is employed there. “The hospital is always full, the beds and wards have a very high occupancy level, and this adds to the pressure. As this is a tourist area, the Emergency department is as busy at five o’clock in the morning as it is at two o’clock in the afternoon”, explains this doctor, who forms part of a team of 40 emergency doctors. The direct repercussion of the increased delays and longer waiting lists is that the patients protest and express their anger to the doctors. “The patients complain to us and we have to put up with it. They never complain to the office of the hospital director, no matter why they are upset”, she says.
The cutbacks have meant a salary reduction for the medical staff. “We have lost 30 per cent of our purchasing power and, on top of that, proportionally, we are working ten hours free for the Administration. It is really frustrating, but that is the situation”, says this doctor. The Emergency Department of the Costa del Sol Hospital is directly managed by the regional Ministry of Health, and not by the Andalusian Health Service. “Our working conditions are worse now than they were a few years ago. There are hardly any contracts and the ones we are offered are for 75% of a working day. The delays in patients being seen are increasing. We are seeing more people all the time”, she says.
This doctor stresses that the relationship with the medical management team of the hospital is good, but not the relationship with the director. “He imposes his rules without listening to the professionals. There is a lack of dialogue when it comes to resolving problems”, she says.
General Practitioner: “The service at the health centres has taken a major step backwards”
A feeling of being powerless has extended through the doctors at health centres. This is because every day they see a deterioration in the conditions in which they have to work. “Primary attention has taken a major step backwards. It is a type of counter-reform, a loss of rights which affects patients and doctors too”, says a GP at a health centre in Malaga city.
As an example, he refers to the delays which now exist before patients referred by their GPs can undergo diagnostic tests. It can take 45 days to have an X-ray and between 80 and 100 days for an ultrasound scan, when these are supposed to be carried out in a maximum of one month. It can also take between four and five months for specialists to see patients for checkups, says this doctor. “The patients come to us in despair and ask us to phone up on their behalf. It is a problem that we can’t do anything about. It’s the same thing when the Diraya computer system breaks down, which happens regularly”, he explains.
One of the biggest problems affecting doctors at health centres is that, because no substitutes are assigned to cover colleagues who are on holiday or off sick, they are obliged to see the patients of their absent colleagues. A survey carried out at one health centre in the city revealed that in 278 days, 16,500 patients had to see a doctor who was not their own GP. “We are working in worse conditions. We are doing our own work and also that of the doctor who, for whatever reason, isn’t there on that day”, he explains. “We don’t have time to do anything else”.
The system of co-payment for people with few resources means that some chronically ill patients ask their doctor not to prescribe them medication when they realise that they can’t pay their share of the cost. Also, the suspension of the Law of Dependency has increased the difficulties of many families. “We come across some really desperate cases. The lack of assistance just makes these situations worse”, points out this GP.
Another effect of the crisis is that when a doctor tells patients they will have to have time off work, they refuse because they are afraid of losing their job. “There have been cases when I have had to tell a patient that he or she is in no state to work. We have gone from a situation in which people asked for a sick note for the smallest thing, to them not wanting one even if they are really feeling ill”, he says.
Another thing which is causing bad feeling among the doctors is that, as well as the increase in the working day, they have to work on Saturdays four or five times a year in health centres where they do not normally work. “This is another step backwards that we have taken, and it has an effect on your family life”, says this GP.
Intern at the Carlos Haya: “The hospitals function thanks to the huge efforts of the professionals”
It is the great efforts made by the professionals that permit hospitals to continue to function despite the difficulties. That is the point of view of a specialist in internal medicine at the Carlos Haya hospital. “We work more without being paid for it. We do it for the patients”, he says. He points out that the deficiences are made worse by the loss of over 300 hospital beds. “It just means patients are referred to private clinics”, he insists.
This doctor says that the lack of intermediary hospital care, the negligible number of beds for palliative patients and the precarious situation in the oncology department makes matters worse. “Now they want to send palliative patients to be cared for in their own homes, but there are only four personnel to cover the whole city”, he points out.