Dragging his flip-flops with socks and clutching his cane, Manuel Fernández, 90, crosses the threshold of his nurse, Jaione Pérez, at the Besòs primary care center in Barcelona. He goes to a control of the sintrom (an anticoagulant to prevent blood clots), but, incidentally, tells the nurse about the bad life that is giving him a knee. “It was turning 90 and it seems that everything hurts. I was better before meeting them, ”the old man grumbled. He has an appointment with the GP the next morning, but Pérez fixes the schedule so that he can see him today and avoid another trip. Manuel has spent a year without visiting the health center and, although he admits that in the last month and a half he has made up for the absences, two tears come to his eyes when he mentions to his doctor and nurse: “Let’s see, the best thing is not having to come, but they are wonderful. Very good. Forever”.
The last year has been long for everyone. The pandemic filled the consultations with uncertainty and drove patients away from health centers. The outpatient clinics had to reinvent themselves to overcome the threat of the virus and, in turn, respond to everything that came through the door, to their usual patients and to the barrage of covid suspects that plagued the clinics. The telephone became an ally to maintain contact with the sick when the world was confined to home, although the doors of health centers, the toilets qualify, were never closed.
In fact, rather, primary care tasks have multiplied during the last year: from case detection to contact follow-up, through care coordination in nursing homes and, in recent months, vaccination campaign against covid. “We professionals are exhausted”, ditch Cristina Sánchez Quílez, technical secretary of Primary Care of the Confederation of Medical Unions of Spain (CESM).
The health crisis has not given primary care a break, but now that the storm subsides and the vaccination boom is pushing the epidemic curve down, health centers are taking stock of the damage. “We came out of this much worse than we entered. The needs of primary care are much greater now because the staff and resources have not grown, ”says Sánchez Quílez. Rosa Magallón, president of the Spanish Primary Care Network of the Spanish Public Health Society (Sespas) agrees: “The pandemic has further undercapitalized primary care. There is an under-resourcing and it is dying. We are in a situation of significant physical and emotional exhaustion ”. The CESM estimates that it would be necessary to incorporate 5,000 more family doctors into the system to alleviate the deficiencies in the sector.
Health center workers have been demanding more human resources and investment for years to sustain primary care. Public health spending amounts to 75,000 million euros (6% of GDP). That is, 1,594 euros per inhabitant. But only 16% are dedicated to primary care. “Our healthcare model is hospitalocentric. There is a great deficit of resources. In Europe, primary care accounts for 25% of health spending ”, points out Diego Ayuso, secretary general of the General Council of Nursing. The pandemic, they insist, has only exacerbated these deficiencies. “Primary care is the pillar that nobody sees and nobody cares for. Clinics are closed, professionals are displaced to provide more precarious care and those who take vacations or leave are not replaced, ”laments Sánchez Quilez.
And the professionals are at the limit of their strength: tired and exhausted, but also frustrated. “We have gone from applause to insults. We are in a situation of abandonment. It has not been explained that we have never been closed and the user’s perception is different. These plans that there are now to retake the presence deeply offend us because we have never been closed. We are seeing 70 patients a day, 20 of them in person ”, protests Magallón. The same feeling of “abandonment” refers Lorenzo Armenteros, president of the Spanish Society of General Physicians: “The citizen has been told that it is primary care doctors who do not want to see patients in person and that is not true. We are looking forward to doing so, but we must establish organizational mechanisms to dedicate the time they need ”.
The telephone visit has served to overcome the social limitations of the pandemic, but it is not a panacea either, professionals warn: it does not solve all the queries nor is it necessarily more agile at all times. “We have a lot of workload. The telephone consultation is twice the work because it involves covering more data, asking more questions and reviewing the medical history several times so that, in the end, you end up having to arrange a face-to-face meeting because you do not solve the problem, ”says Ana Arroyo, a doctor at Mérida and vice president of the Spanish Society of Family and Community Medicine.
The CAP Besòs, located in one of the most disadvantaged neighborhoods of Barcelona, also claims presence. The center has organized agendas to avoid crowds in the waiting rooms and to facilitate visits in person. Last fall, they admit, it was difficult for them to cover the quota of presence due to the population’s fear of being infected, but things have changed. “People have already lost their fear of coming and they know that the doors are open,” says Roser Masa, a doctor and assistant to the center’s management.
In a consultation, Dr. Fran Montoya visits Liria Trujillo, 49, for a catarrhal condition: “I had it scheduled as a telephone visit, but since today I had the calmest day, I told her to come and explore it.” Little by little, health centers return to relative normality and recover their usual patients, but the pandemic has disrupted the reason for consultation. To begin with, chronic patients arrive more decompensated, especially diabetics, who have the most uncontrolled disease due to the sedentary lifestyle of confinement. “Now we have more dense consultations because they explain everything that has happened to them in this time and new pathologies have also appeared: I have three or four patients with persistent covid. But the volume of consultations that has increased the most is for mental health ”, adds Masa.
The damage to mental health is the great inheritance of the pandemic: fear of returning to crowded spaces, agoraphobia, mood disorders… “Last week I saw four patients who told me: ‘I look at the window a lot’. There is great social isolation, especially in young people, and an exacerbation of extreme precautionary behaviors against the virus also in older people that cause a lot of loneliness, mental illness and the desire to disappear, ”says Magallón.
Primary care health workers look to the future with uneasiness. The pandemic is on the decline, but the workload is not. And there are no hands, they match. “There are deficits in patient care. Adequate follow-up is not being done and care has slowed down. The ratios are insufficient and the nurses cannot cope: they are saturated and have the feeling that they are not able to fulfill their work with quality ”, Tercia Ayuso. Each community also has its own organization: the Valencian Community, for example, will only extend 6,000 of the more than 9,000 reinforcement contracts for the covid, although those that remain will go to primary care and emergencies. In Madrid, on the other hand, the Center Assistance Directorate, on which 49 outpatient clinics depend, proposes a restructuring in phases to overcome the shortage of personnel and the summer, in which the last step is to close 41 of these centers.
Primary care professionals ask to be heard and, above all, more human resources. Attractive contracts so that doctors who finish residencies do not go to the hospital emergency with more favorable conditions and nurses do not flee to other countries because they pay better. “Right now we are all overloaded. There is not a single doctor in Spain whose demand for visits is adjusted to what is scheduled ”, reflects Armenteros. In Spain there are 43,000 doctors and 39,000 nurses in primary care. The ratio per inhabitant among physicians is one doctor for every 1,342 inhabitants —one for every 980 in the case of pediatricians—; in nurses it is one for every 1,485, according to the Ministry of Health.
The health workers also demand more autonomy to manage their agendas and more agility in communication and referral to specialized care. “As in the first wave we were denied being able to do PCR, now we are still being denied the management capacity that would be good for us to reduce waiting lists,” says Magallón. Primary and specialized care are communicating vessels: if one clogs, the other also suffers. “What we have noticed is that the hospital has leaked a lot and they have discharged many patients with the aim that they continue to be monitored by the family doctor. They visit the patient much less and do more telephone consultations. But the overload of others also affects us, ”says Masa.
Arroyo warns of the risks of dismantling primary care: “The most vulnerable are left unattended and hospitals collapse. If primary care doesn’t work, the whole health system goes to hell ”.