A tragedy in no man's land

Another weekend with several emergency services, including obstetrics, gynecology, and pediatrics, closed, and yet another tragic case to add to the previous ones. This scourge has become so frequent that it no longer generates outrage. Almost simultaneously, we hear union leaders asserting that careers need to be valued, that is, "paid more," and that this valorization is the only possible way to overcome this situation. Without forgetting the fact that Portugal is a country with low wages, as a result of its weak economy, there are more problems under heaven than those discussed by union leaders and union leaders.

Ana Rita Cavaco stated in an article here in Observador that behind much of this problem lies the fear all governments have of doctors. She gives a very current example, one that should spark, as one reader commented, "a civic shock": "Obstetric emergency rooms close with two doctors inside and the entire team of nurses, operational assistants, and administrative staff," while a growing number of babies are being born in ambulances in the hands of emergency medical technicians. Meanwhile, pregnant women desperately shuttle between hospitals seeking help.

Alongside this news, the media repeatedly reports that the National Health Service makes payments to small businesses that, in reality, merely sell the work of clinicians who are government employees, with all the protections afforded by this system, but in this way seek to circumvent incompatibilities and reduce taxes. In other cases, the additional services performed by the employees themselves at their workplace are paid in a manner that appears overly generous.

I recently witnessed an unequivocal demonstration of the spirit of dedication and service of professionals in the National Health Service, and I wonder how it is possible that, among doctors, nurses, and assistants—most of them respected, highly qualified professionals dedicated to their patients—a near-madness runs rampant, a heterogeneous mix of greed and effort, where references are being lost. Where the "fastest" fly from hospital to hospital with a speed that defies relativity, where time and distance are no longer limitations. Where the most dedicated must increasingly feel like "dumb people on duty."

There's a clear attempt to increase productivity in the public health sector and retain the best professionals, providing additional income in their work environment. It's clear there's a need to introduce a differentiating factor among professionals, something the status of public employees doesn't allow.

I believe that ambition combined with individual effort is a positive social force. Salaries should reflect the quality and quantity of work performed. I know of many cases where supplementary income is obtained in the private sector at the cost of enormous individual effort and long working hours. Differentiated compensation systems can be designed in the public service, but I always fear that the day the door is opened to differentiation without guaranteeing independent performance evaluation, we will only be fueling new injustices and new forms of cronyism.

And I still don't understand how a clinician can be any different from a company whose sole purpose is to sell their work. And how large organizations, such as Local Health Units, contract with small companies when the formal requirements of the Court of Auditors often hinder processes of clear public interest in areas where there are real risks to human life.

The uncontrolled mixing of the public and private sectors is denigrating a service that is essential to the Portuguese people, which is generally of very good quality, and which represents a significant contribution from the State Budget. However, the mixing of the two sectors is generating major distortions and amplifying conflicts of interest, where negligence in the public sector can be offset by brazenness in the private sector. Where the malfunctioning of a hospital or an entire healthcare system can, contradictorily, benefit its directors. And I'm discounting the scams that are purely and simply "police matters."

The Medical Association (like all others) should focus on upholding the quality of professional practices wherever they are practiced. Those in power must have the courage to adapt procedures to existing resources and organize their resources as best they can, knowing from the outset that they are not infinite and that they will face many misunderstandings and unreasonable expectations. But without fear of the multiple powers that seem to be benefiting from these difficulties.

Let's imagine for a moment that the government intends to increase emergency services in any specialty. It's a thousand times healthier to contract this service to the private sector, within a transparent process, seeking the lowest cost and the best possible service, and reducing these costs in the public sector. It may happen that good professionals migrate to the private sector and become future providers of the National Health Service, but each in their own field, with their own rules and ethics.

An expert in the field, which I am not, can certainly compare productivity, service levels, costs, and values, and establish decent and serious foundations for the government's contracting of health services. Without explosive combinations and conflicts of interest, benefiting from existing capabilities in the private sector and paying them fairly, openly, and transparently. But without crossing the no-man's-land that separates the public and private sectors, which is dangerous and full of traps. It lends itself to all kinds of arrangements and many tricks. We can only win by separating the waters.