Anteporyecto de Ley de Gestión Pública e Integridad del Sistema Nacional de Salud represents one of the most important reforms of the organizational framework of the health sector in the last few decades.
The aim is to strengthen direct public management as a systemic vertebrate, limit indirect management to exceptional resources and increase evaluation and control mechanisms.
Nadie argues that the national health system is and must continue to be a public system with its finances, universal mission and orientation to the general interest. The effort to strengthen direct public administration is legitimate.
Precisely because of the transcendence of healthcare and the direct impact of its decisions on citizens, the debate on organization and management cannot be undermined by ideological positions up to the criteria of efficiency, functioning and guaranteeing the best possible care for patients.
And this is where the main concerns arising from the pre-project arise.
The regulatory text configures indirect management (including health care agreements and other forms of cooperation) as an exceptional mechanism that It can only be used if the impossibility of direct fulfillment or lack of own media is justified.
The question of the Spanish hospital.
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On paper, this formulation might seem reasonable if private sector cooperation were truly exceptional. But the reality is very far from this exceptionality. And the editorial brings up a relevant problem: it does not precisely define the assumptions under which a claim to exceptionality is justified.
Concepts such as “impossibility of direct performance”, “lack of own resources” or own “exceptionality” represent clear considerations that can lead to different interpretations between administrations, legal entities and courts.
This regulatory uncertainty can cause legal uncertainty, increase the number of lawsuits and delay or paralysis of administrative decisions.
In a complex health care system where rapid response is necessary to ensure care, legal uncertainty is not an abstract problem: it has direct implications for care.
This debate must therefore be placed in the context of the actual reality of the Spanish health system.
This finding shows us an extraordinary level of demand. Thousands of citizens are listed on hope lists for surgical interventions, specialized consultations or diagnostic tests.
In many cases, the time periods extend to months and even years.
The structural limitations of professionals in certain specializations, as well as the limitations of installed capacity, are summarized here and the increasing technological complexity of modern medicine.
This scenario is not cultural. It is the result of tension built up over decades.
In this context, any regulation that introduces additional barriers to the use of available tools to ensure health care needs to be analyzed with particular caution.
Cooperation between public and private provision is a consolidated structural reality in virtually all autonomous communities and is used to ensure continuity of aid, absorb peaks in demand, provide specialized services or compensate for shortfalls in resources.
It is not about ideological or economic decisions, into operational responses to real public health system constraints.
The previous project part was based on the assumption that strengthening direct public administration requires limiting the use of forms of cooperation with the private sector.
However, there is another way (more challenging, but also more robust) to strengthen public management: improve efficiency, organizational capacity, and lasting quality, until this method is clearly superior.
If direct public administration is the most efficient, fair and efficient model, it should be possible to demonstrate this through average and comparable results, not through regulatory restrictions on alternative models.
Limiting options does not encourage improvement. Competence for results yes.
It is clear that public administration support should not mean limiting cooperation. If we do so without increasing productivity and efficiency, it will only remain an opportunity for citizens.
Therefore, to deal with the least that does not happen, the solution to this problem will be to put into operation the regulation of indirect management through objective criteria that will prevent blocking and guarantee the continuity of aid.
The pre-formulated accusations that I have proposed therefore aim at a constructive plan: maintaining the principle of public priority, but define clearly enough that indirect management is considered justified.
Between them:
1. Conditions of inadequacy attributed to human resources, especially in special situations with structural deficits of professionals, which mean exceeding the maximum times of hope.
2. Non-existence or lack of public installed capacity to provide the service under reasonable conditions, which also means exceeding the maximum time limit.
3. One provider is available in a specific territorial area or highly specialized services.
4. Urgent or necessary situations to ensure continuity of assistance.
The definition of these above-mentioned items would make it possible to reduce legal uncertainty and to avoid the systematic legalization of necessary organizational decisions.
Similarity, it is proposed to legally clarify the validity of concepts such as “impossibility of direct provision” or “lack of own resources”.
For this reason, it would be necessary to introduce objective evaluation indicators (professional ratios, time periods, levels of assistant saturation) and also to distinguish between indirect structural management and ongoing or waste management.
Likewise, the principle of continuous assistance must be expressly incorporated, so the interpretation of exceptionality they do not threaten citizens’ effective access to health care.
To complete this, a guarantee of administrative agility must be created through the existence of areas with maximum resolution of previous evaluation procedures, including positive administrative silence and the creation of simplified procedures for urgent implementation or ongoing assistance.
Regularity with accuracy does not weaken public administration. Strength.
The vagueness or openness of the interpretations will only lead to an increase in court cases and thus to the paralysis of the assistance activity. And more in the context of increased political, union and institutional confrontation.
The healthcare system requires clear, predictable and operational regulations that allow quick decisions to be made without generating legal uncertainty.
The reality is that the debate about health care management models should not focus on the title of the provider until the results are achieved: accessibility, quality of care, response time, resource efficiency and patient satisfaction.
In the same way, healthcare should not be a space for ideological confrontation, but rather a necessary service, the ultimate goal of which is to protect the health of citizens.
However, you can brag about this or that model for ideological matters, at least let’s try not to worry about things.
Ultimately, the National Health System is one of the largest collectives in our society. Future sustainability requires reforms that are ambitious, but also prudent, realistic and results-oriented.
Priority of direct public administration It is not incompatible with the guarantee of legal certaintycontinuity of support and organizational flexibility. It is not just a matter of choosing between models, but ensuring that the system has all the necessary hardware to meet the needs of citizens.
Because in healthcare it is really important that the patient receives attention on time and in the highest possible quality.
*** Juan Abarca Cidón is the president of HM Hospitales.
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