Since 2008 and the consequences of the economic and financial crisis, Spanish hospitals have been hit by budget cuts and creeping privatisation. These austerity measures are being reflected in a deterioration in working conditions and the quality of the care provided. In the face of all this, trade unions, employees and user associations are striving to defend a universal, high-quality health system.

The panorama is not very flattering for hospital management bodies. Beds are crammed into corridors and single rooms. Emergency exits are blocked and the work of care staff is being hampered. With the increase in winter illnesses, services quickly become saturated. Most patients are elderly and require special attention. The cramped conditions exclude any privacy. While some are having bedpans emptied, others are being served meals. The ambient smell is unpleasant. The tension among care staff is palpable. The accident and emergency department at 12 October Hospital, south of Madrid, seems on the cusp of melt-down.

'I’ve had enough!', sighs a nurse while taking a blood sample from an elderly woman. The nurse is hoarse, the patient too, but she cannot take a break. If she did, her workload would immediately fall to one of her colleagues. 'Absent staff are not replaced', explains a colleague. 'And then there are also new economic sanctions.' In 2012, Mariano Rajoy’s government (People’s Party, right-wing), changed the system of daily allowances paid to civil servants unable to work owing to non-occupational illness and accidents. So a nurse will see her allowances reduced by 75% from the fourth day of absence and up to 100% from the twenty-first. The hoarse nurse is still furious: 'How can I recover when I am in constant contact with sick people? Not to mention that I have to be careful not to infect anyone myself'.

These worrying scenes are commonplace. In another Madrid public hospital, San Carlos Clinic, saturation of the accident and emergency department has forced the institution to cancel long-scheduled operations so as to free up beds and staff. A few months earlier, the accident and emergency staff at Madrid’s La Paz Hospital were also bemoaning the serious deficiencies in their care unit: '22 beds for 45 patients'. The Spanish press has echoed the general warnings of the care staff and theindignation of the population in the light of several deaths. They spent up to four days in the accident and emergency department after nine months on a waiting list!

Increase in cases of medical negligence

The Defensora del Pueblo (the Spanish equivalent of the Ombudsman), Soledad Becerril, recently published a highly critical report on the situation of the accident and emergency departments in public hospitals. It pointed out, among other things, that 'the situation of saturation of accident and emergency has become permanent' and 'is resulting in more cases of medical negligence'. Reyes Gallego, a nurse at 12 October Hospital and a member of the Unified Health and Safety Union (Sindicato Único de Sanidad e Higiene, SUSH), confirms these risks: 'When there are three patients in a cubicle intended for two, corridors full of beds and a patient needing urgent attention, the potential errors rises exponentially'. For their part, hospital management bodies and health authorities invariably refer to 'isolated situations'.

It is difficult to quantify the extent of medical negligence. There are no published official statistics. In 2005, the Spanish Institute of Statistics stopped publishing indicators for the quality of care in hospitals. Only the Defensor del Paciente (Defender of the Patient) association, established in 1987 to come to the assistance of victims of medical negligence, publishes an annual report based on complaints made against accident andemergency departments. According to their data, the number of cases of presumed medical errors has been increasing relentlessly since 2010, rising from 12 162 complaints (including 554 deaths) to 14 749 (including 835 deaths): a rise of 21% in four years. It is for the medical experts and possibly the courts to determine whether there have been any professional failings and whether such failings are directly responsible for deaths. 'On average, year on year, 40% of the cases that come to the association are confirmed as medical negligence', says Carmen Flores, president of the association. What about the remaining 60%? The available data do not distinguish between rejected complaints and those not followed up, patients’ legal fees being a deterrent from pursuing claims.

The users’ association is faced with another phenomenon: complaints concerning the length of waiting lists. 'These complaints concern delays in obtaining a specific treatment, being referred to a specialist or simply obtaining a diagnosis. Of the total number of complaints we receive, two thirds relate to waiting lists', explains Carmen Flores. These, too, have been increasing for three years. According to National Health System statistics, between June 2012 and December 2013 the average wait for an operation rose from 76 days to 98 days. Almost one patient in six across Spain has been on a waiting list for at least six months. For Carmen Flores, there is no doubt about the cause of these cases of negligence and these delays, it’s the budget cuts imposed by the government.

The Spanish Government uses a euphemism to describe this: 'urgent measures to guarantee the sustainability of the national health system and improve the security of provision'. These measures are reflected in the abolition of 19 000 jobs throughout the country between January 2012 and January 2014, i.e. 7% of public health staff (272 000 doctors and nursing staff). The budget allocated to the public health system fell by 11% between 2010 and 2014. Apart from the deterioration in working conditions and the quality of the care provided to patients, this austerity policy has given rise to an exodus of care staff out of Spain (see the article on p. 26). 'In the last three years, 7 378 doctors [out of a total of 232 816 doctors registered with the Medical Association in 2013] have applied for a certificate of qualification in order to go and work abroad', calculates the Medical Collegiate Organisation, which oversees the profession. 'This figure gives a good illustration of the crisis passing through the medical profession in Spain'. The number of certificates awarded has almost tripled since 2010. In parallel, the number of unemployed nurses has multiplied by five, with 20 000 care staff out of work at the end of 2013.

‘We are suffering enormous stress’

'Public health is clearly being ill-treated in Spain', protests Reyes Gallego, of the minority trade union SUSH. 'We are overworked and our efforts are valued by neither the hierarchy nor even society. How can we be motivated under these conditions?'. Very often, staff are the direct target for users’ annoyance, considering them to be responsible for their long wait for care. 'We are suffering enormous stress. Sometimes, at the peak ofactivity in accident and emergency, a doctor comes and tells us to stop what we are doing and to examine another patient. These are far from the optimum conditions taught at nursing college for this type of work,' says Mar Coloma, a nurse at the Ramón y Cajal public hospital in Madrid. 'This pressure means that nurses live in constant fear of making errors, never mind the damage this causes'. She remembers an overworked nurse whose finger had been severed in a lift door a few months previously.

Everywhere, quantitative evaluation, through budget management, takes precedence over evaluation of the quality of care and the treatment of patients. 'As a departmental manager, if you show the management that you are capable of managing the budget allocated and, better still, if you can make savings on the budget, you are rewarded', says Luis Fernández of the Paediatric Cardiology Department at Ramón y Cajal hospital. 'Otherwise, you are penalised with a budget reduction for the following year.' The situation in the clinics is hardly any better. 'The organisation of work has deteriorated in recent years. Before, we had an evaluation system, greater participation in decision-making and regular dialogue with our superiors. All that has disappeared with the present government', says Rosa Bajo, who works in the Campo Real clinic, 30 kilometres from the capital. 'We now have the impression that the hierarchy places more value on our ability to reduce costs and manage the budget rather than improve the living conditions and health of our patients. It’s highly discouraging.'

Rather than 'guaranteeing the sustainability of the national health system', the Spanish government is accused of undermining it, to the advantage of private clinics. The process of privatisation of the health sector began in 1991 under the term of office of the socialist Prime Minister, Felipe González. At that time, a parliamentary report was already talking about 'a certain fatigue in the health system'. 'Since then, successive governments have deliberately allowed the public health system to decline. They have constantly reduced its budgets and staff numbers and outsourced services, so as to push the public towards private operators', complains Juan Antonio Recio, a former nurse and member of the Anti-Privatisation of Public Health Coordinating Group (CAS), which includes health professionals, users and trade unions opposed to the austerity measures. In 2013, the unionist went on hunger strike for 40 days at Princesa university hospital to protest against privatisation.

Rampant privatisation

Requesting to be treated in the public sector and being directed towards the private is what happened to Juan José Martín. He needed an operation for varicose veins. First of all, he had to undergo cardiological examinations and have a consultation with a specialist. However, the Madrid public health system now has a computerised service, managed by a private company, which centralises all consultations and redirects them directly towards specialists, depending on the state of their diaries. Initially sent to a private institution, Mr Martín refused on principle, wishing to support public services. Response of the Madrid health service: his consultation requested in January 2015 will not be granted until next October. 'This is a tactic to discourage patients and direct them towards the private sector, where they will not have to wait months to obtain a consultation', he explains.

Manuel Rengel, a nephrologist at Princesa university hospital confirms this strategy. The patients he receives have initially been systematically directed towards private clinics, under contract to the state, for the initial examinations, which also causes problems with regard to patient follow-up, since, although the consultations are centralised, the transmission of medical records seems to fall between the cracks. 'There is no communication with the private doctors conducting the initial examinations', complains the specialist. 'Therefore, if there is a problem, I don’t know whom to approach. Even if I do know, I have to request authorisation from the hospital management to make contact with an outside doctor with respect to a patient.' Bypassing the computer system, the nephrologist therefore insists that all examinations take place in his department so that patient follow-up is not fragmented.

A report by the Trade Union Confederation CC.OO. (Comisiones Obreras), published last September, gives a detailed analysis of the changes in the budgets allocated to the public system and to the public-private partnerships with respect to health. Whereas the cash passed to the public care structures is decreasing, that sent to the public-private partnerships is increasing. In ten years, from 2002 to 2012, it has risen from 3.6 billion euro to 5.7 billion, an increase of 63%. Eight new hospitals managed by the private sector under the terms of a partnership with the state have opened their doors in the Madrid region. Public sector care staff have been transferred to them. Are the working conditions and the quality of the care provided still satisfactory? A study undertaken by the Anti-privatisation Coordinating Group after these hospitals opened tends to indicate theopposite, having gathered dozens of witness statements.

Operating theatres flooded

'Transfer to the new hospital was the worst year of my life, with toxic relations between professionals and a deteriorating quality of care. Whenever we started to protest, we had huge problems with the management. Some of our statements found their way into the press and we received direct threats', says an accident and emergency doctor at the privatised Majadahonda hospital. 'Although the team is quite young, 30 to 40 years old, absences from work are becoming longer and longer, with obvious depression. I’ve seen doctors snap and go home in tears', says a nurse at the same hospital. The very design of these new hospitals is questioned by the staff working there. 'There are leaks everywhere, the pipes drip. When it rains, the water comes under the emergency exit doors into the operating theatres, even though these are meant to be completely watertight! The only thing the management suggests is to use buckets', says an auxiliary nurse at Infanta Leonor hospital.

The reaction to this degradation of the Spanish health system first came from the anti-austerity movements, born in the wake of the 'indignant movement'. Following the announcement in April 2012 by the

Regional Minister of Health, Javier Fernández Lasquetty (People’s Party) of several measures – fall in the public health budget by 7%, total privatisation of several hospitals and clinics –, many groups of citizens were formed to protest against the budget cuts and privatisation. Then, 'white tides', comprising health professionals, patient associations and trade unions (including the two main confederations, CC.OO. and UGT), flooded the streets of Madrid in support of a 'health system under public, universal and high-quality management'.

In January 2014, the Supreme Court of Justice in Madrid decided to implement a preventative suspension of the process of privatisation of six hospitals. This extensive privatisation could 'do irreparable damage' to users and medical staff in Madrid, the judges considered. At the same time, the regional government announced that it wished to abandon these privatisations. This suspension of privatisation does not resolve the upheavals with respect to the organisation of work and the outsourcing of services affecting care staff. At Princesa university hospital, the cleaning services have been sold to a company in the ACS group, which is active in construction and public works and services. Consequence: 'Our team has lost 45% of its staff', says one of the employees, who prefers to remain anonymous. 'They are asking us to provide the same quality of work as before, but it’s impossible! We have written several letters to the management to tell them that we do not accept responsibility for the condition of the hospital with respect to hygiene.' The anger becomes all the greater since the groups profiting from these privatisations are often implicated in corruption scandals associated with the illegal financing of political parties. The Spanish public health system is really suffering!•

Special report - The nursing world at tipping point

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Spain: at the bedside of a public health service verging on melt-down