In recent days, serious problems with the SNS began to lead the national news agenda; in particular, after the sad case in which a pregnant woman lost her baby.
These problems are old and no government has been able, to date, to solve them adequately; not for lack of good ideas from some ministers of health. But because little was put into practice.
Is the problem structural? Conjunctural? In my opinion, the problem is structural and the portrait has been around for a long time. There is no shortage of doctors, there are doctors, but they run away from the SNS. The finance minister even says that the problem is not financial; therefore, it will have its roots in the mismanagement and strategy adopted over the years by the various governments.
In 2017, “Integrated Responsibility Centers (CRI)” were created with the mission of ensuring the development of best clinical practices focused on the needs of users, adapting the internal organization of SNS entities to efficient management; to foster clinical governance processes that contribute to the continuous improvement of the quality of care provided in the SNS; increase the accessibility and response times of the SNS to citizens; to maximize the installed capacity on the public SNS network; promote the autonomy, involvement and accountability of professionals in the management of resources, encouraging them to exclusively develop their activity in the SNS; increase the levels of productivity and satisfaction of SNS professionals,
The question that arises is, why do the CRIs work well, for example at Hospital de São João, in Porto (by the way, a hospital that has had a strong dynamic and administration), and in other hospital centers it has an image “ ghost"? A case to say “It has to be investigated”, as our President says.
In the next few lines, I will give some focus to oral health, despite knowing that in other areas of health, chaos reigns and care for life is compromised. But I will speak, because oral health is itself at risk and if it is not restructured, it will be on the verge of extinction. And at this point I have to talk about sustainability, based on three essential pillars: social, economic and environmental (with an emphasis on waste).
In the social chapter, accessible oral treatments are essential to improve health conditions and reduce the disparities that exist between populations; as well as to limit the health burden on the population and reduce socio-economic inequalities. Social disparities in health and health care are particularly evident in the oral cavity. There is a clear association between poor oral health and chronic diseases such as diabetes, cardiovascular and respiratory diseases. Many people are chronic carriers of infections in the oral cavity, limiting themselves to overloading the emergency department in case of an exacerbation, where they are often prescribed palliative antibiotic medication. In addition to not solving the pathology, it entails significant costs.
It should be noted that in 51 hospital centres, there are 27 Stomatology Services where 145 stomatologists work.
On the other hand, most dentists are self-employed in the private sector, as there is no career that allows these professionals to be integrated into the NHS staff. However, the lack of proximity responses in oral health has led some health centers to enter into “service contracts” with dentists; there are, today, around 135 to 150 dentists in health centers, providing primary care.
Interestingly, the number of dentists in Portugal, per capita, is 1 dentist for 884 inhabitants, more than double the number recommended by the World Health Organization, which is 1 professional for 1500 to 2000 inhabitants. Of course, as the market does not absorb them, more than 20% either emigrated (12.72%) or gave up the profession (7.96%), according to data from the Portuguese Dental Association.
Arrived here, there is still a huge need on the part of the population to receive oral health treatments in the SNS, which does not respond to these needs. Stomatologists work in tertiary hospitals and are scarce; on the other hand, and while there are almost no dentists working in the SNS primary care, the unemployment or underemployment of dentists reaches numbers never imagined.
The real encounter between patients and dentists or stomatologists is reserved for those who “can”. This is the true expression of waste and the inverted pyramid.
There is a great need for the training of integrated teams of dentists and stomatologists in the SNS, as well as the creation of more oral medicine offices, in health centers and in public hospitals.
Addressing the environmental aspect , we found that private offices, with the implementation of Decree Law 108/2018, which sets safety standards regarding protection against the hazards resulting from exposure to ionizing radiation (relative to our rx devices) combined with a evident lack of knowledge by its national editors of the reality of the Health sector, namely Oral Health and Veterinary Medicine, is proving to be impossible to implement, leading to the ruin and extinction, in a few months, of two sectors of human health and animal. I am also referring here to Veterinary Medicine, which has provided valuable services to the country and which in recent decades has had a development, recognized by all.
However, the aforementioned legal diploma hands over to the Portuguese Environment Agency (APA), the inspection body, which is neither more nor less than IGAMAOT - general inspection of agriculture, the sea, the environment and spatial planning, which inspects and imposes fines. , which can range from 24,000 to 5,000,000 euros. I ask: what do our little rx's do to the environment? Radiation is minimal, incidentally described in scientific articles. Does not make sense. If, on the one hand, Rx are essential diagnostic tools, the professionals who deal with these devices meticulously comply with the entire safety protocol. Concern for the environment has always been important for health professionals.
In blatant panic, dentists in the private sector cannot help but wonder: are public health establishments and private hospital groups subject to the same rigorous scrutiny as the imaging activity, or is this yet another attempt to crush small health providers? health?
Will the practice of Oral Medicine be the new nuclear disaster of the 21st century? Given the surprising possibility of fines in the order of tens of thousands of euros, which could reach hundreds of thousands, would it not be financially more reasonable to close dental practices?
From an economic perspective, it is imperative to try to assess the future financial impact of full coverage of the entire national territory, taking as a goal the existence of 1 dentist for every 1500 inhabitants on the poverty line, thus assuming a more universal and equitable access to oral health care.
Considering the need to hire 1379 professionals and an annual cost of €41580 per dentist + assistant (estimating €1600 + €800 of gross salaries + social charges), the financial impact for the total coverage of the population on the poverty line is €57,338,820 per year.
According to the State Budget report for 2021, it was expected that the Budget (consolidated revenue) of the Ministry of Health would amount to 12,565.4 million euros. It would thus be an increase of only 0.46%, and we would have served the fringe of the most needy population. I'm only talking about the most needy, because let's forget about a universal SNS that can serve the population as a whole.
Private oral health clinics are closing due to the bureaucratic impositions required and difficult to comply with, the millions of Portuguese who seek the SNS find a “band-aid” in all areas of medicine, and the chaos seems to last.
And because we must think of solutions, together with dariacordar/zerodesdicio, chaired by Paula Policarpo and where I am the oral health coordinator, we have a 360 sustainable project thinking about the three aspects of sustainability for oral health.
Also at SEDES, together with dentists and stomatologists, we wrote a document containing possible solutions for oral health, which will be published together with all the recommendations of the different groups included in the SEDES observatory.
Ana Sofia Lopes
