Health in Portugal: a challenge for the future

Interview to Lord Nigel Crisp

The Gulbenkian Foundation recently set up a Commission to create a new vision for health and healthcare in Portugal. Could you tell us what is the main purpose of this Platform?

The background is that there is widespread support in Portugal for the continuation of an equitable national health system, accessible by all citizens and based on principles of social solidarity. However, there is equally a general recognition that the current system, which has led to enormous improvements in the past, cannot satisfactorily meet the needs of the future in its current form and is increasingly unaffordable and unsustainable. This, of course, is true in most countries in Europe, including my own where we are also facing considerable financial problems.

Many countries are responding to this with short term measures by cutting costs and entitlements. In the longer term, however, I believe that we need to make some big changes in the system itself. We need, for example to focus on the promotion of health and prevention of disease; the provision of more varied community based and integrated services to meet the needs of the growing number of people with long term conditions; greater participation of citizens and patients: and the potential impacts of new knowledge and technologies. Against this backgrounds the Gulbenkian Foundation has decided to establish this Commission in order to create a new vision for health and healthcare in Portugal, to describe what this would mean in practice and set out how it might be achieved and sustained. At its heart, I believe, will be a vision of a healthy and prosperous population and society where individuals are able to live lives they value and where, when they need to, they can access high quality, affordable and sustainable health services.

 

Which areas will be considered for the study and also who will be involved?

We are going to look at a lot of things. Firstly, of course, we will want to understand the health needs of the country and how these are changing as the population ages and we see more long term conditions such as diabetes and high blood pressure. Understanding these needs will be crucial in determining the future vision. Healthy ageing is obviously going to be a big theme and so is maintaining the big improvements in health that have been made for children in recent years. There is a great deal to build on. We will also want to consider the overall structure of the health system, the ways the different parts relate to each other and how funding is organised.

Health is about people and about families and we will pay particular attention to what happens at home and in the community and at the clinical level. Here, I believe there are enormous gains in both quality and cost to be made. Let me give you 2 examples.

Portugal has done a lot about educating citizens about health, but there is much more to do. We can also do more to engage patients in their own care. In some parts of Spain, for example, they use so-called “expert patients”, people who have suffered from a particular disease like diabetes or arthritis for a long time, to help and support others and even to train health workers in the appropriate care for people with that condition. The patients are the experts.

In England we have done the largest scientific study (6000 patients) of using new technology to monitor patients in their own homes and enabled them to ring the doctor or a nurse when they need help instead of using our NHS in the traditional way. It has had astonishing results in only a year. Hospital admissions for this group has reduced by 20%, attendances at the Emergency Department by 14% and mortality by 45%. Running costs reduced by 8%. We are now rolling this out to cover the 3 million people in the UK whom we think will most benefit.

I don’t yet know Portugal well, but I am sure that there are many similar examples of good practice. The key for us will be to identify them and spread them.

The process adopted by the Commission will itself be important in building the motivation for change and the energy and momentum to carry it through the inevitable challenges. The process will be open and engaging, seeking ideas from and consulting with all sectors of the population, and drawing on experience and expertise from around the world. Whilst the Commission will build on the successful history of the last 40 years, it will ensure that as wide a range of ideas as possible are considered from Portugal and around the world – no matter how radical – that they are submitted to rigorous analysis and tested out with stakeholders.

Although the Chairman and 3 of the 6 other members of the Commission are from abroad, the study itself will involve around another 30 Portuguese citizens in its Working Groups and will be firmly based in Portuguese culture. In essence it will be a national study with global implications; facilitated externally but firmly rooted in Portugal.

 

With your long experience and knowledge on global health and international development, do you think this work focusing the Portuguese problems could help to have a wider and global view about the European health system?

The Commission will focus on Portugal but its work will have global relevance and resonance. Portugal faces many of the same issues as other countries from the growth in non-communicable diseases to tough financial constraints and its health outcomes and expenditure are consistent with international norms. The Gulbenkian Commission and Platform can show the way for other countries to follow.