“We are in a moment of disruptive change in human beings’ relationship with the healthcare system,” commented Francisco Longo, Associate Director General of ESADE, at the presentation of the latest ESADE–“la Caixa” Social Confidence Index at CaixaForum Madrid. “And this is happening in the context of perceptions that are difficult to verify, from diffuse discomfort to society’s habituation to expansive demand, as well as a demand not only for services that heal but services for carers.” The index offers a semiannual indicator of citizens’ social confidence in the ability to access elements that provide them with security in their daily lives and guarantee comfort, autonomy and well-being. According to the latest index, healthcare is one of nine indicators – along with pensions – for which trust has fallen (a decrease of 0.7 points from 84.9 in the previous edition, published in September 2016). However, the forecast for this area (86) suggests the possibility of a slight recovery. “Citizens’ perceptions continue to suggest mistrust more than confidence, although this has improved substantially since September 2016,” added Prof. Longo. 

Effect of the crisis on the Spanish healthcare system

After the impact of the economic crisis, despite the relative recovery of the budget, the Social Confidence Index indicates that confidence in the healthcare system remains stagnant; for certain groups, confidence in healthcare has even decreased. “Young people play a decisive role in the final score and have a very negative view of the healthcare system. This is surprising because members of this group are less likely to need healthcare,” commented Guillem López Casasnovas, Professor of Economics at Pompeu Fabra University (UPF) and former board member at the Bank of Spain, who analysed the current situation and future prospects of the Spanish healthcare system for the new edition of the Social Confidence Index. “Pensioners rated healthcare more highly and their trust in the system has even increased incrementally,” added Prof. López. “The economic crisis has reduced the growth rate of public health spending. However, the restriction caused by the spending cuts has been smaller than alleged. In some cases, nominal increases have even been seen.” 

Trinidad Jiménez, Director of Global Public Affairs Strategy at Telefónica and former Spanish Minister of Health, Social Policy and Equality, observed: “This edition of the Social Confidence Index clearly shows that there is social discontent with regard to the public healthcare system, regardless of the fact that there may be more or less investment or public infrastructure, among other factors.” Ms. Jiménez expressed her agreement with Prof. López: “When society expresses confidence in the system – or lack thereof – it does not do so in such a sophisticated manner as academics and professionals do. People generally do not take into account the increase in life expectancy or the incorporation of technological advances. Distrust in the system is due to a problem of expectations. As reflected in the Index, this is an expression of protest.”

Future prospects: challenges and responses

The increasing demand for health services and the growing supply are the main concerns identified by the analysts. Demographic change, patients’ tendency to overuse health services, and medicalisation have all led to an increase in demand. At the same time, technological innovation has increased the supply in the healthcare sector. According to Prof. López, “The technological push entails arbitrating responses in advance that avoid improvisation, discretion and excessive attention to pressure groups.” He added, however, that “this criterion must not consist solely of reaping the benefits of innovation without considering the costs”. 

“The universalisation of the system must be understood as full potential eligibility for all citizens,” commented Prof. López. “However, this does not mean that the filter of necessity and/or of testing should not be present. Equity in access does not guarantee equal consumption or equal outcomes. The opportunity costs of access have bias and are linked to socioeconomic factors.” Ms. Jiménez commented: “The healthcare system has been able to react through the incorporation of reforms and new decisions, but we are at a crossroads. Now is the time to be creative and honest. We cannot exponentially increase our public spending.” She added: “Digital solutions and public-private partnership agreements can offer alternative solutions in this debate that is taking place today.”

Autonomous communities: equity and decentralisation of the system

“It is necessary to make decisions for the system as a whole and have a state agency dedicated to the decentralisation of services,” commented Ms. Jiménez. “Management cannot be separated from leadership.” Prof. López commented: “The autonomous communities have adapted their health resources quite well to the needs of their respective populations, particularly in relation to inter-regional equity and the decentralisation of the system, which has increased its dynamic efficiency – that is, its capacity to reform institutions, adopt international experiences and innovate – as well as the visibility of health policy, cooperation, competition between autonomous governments, and local controls.” Prof. López also observed: “Decentralisation would not bring about a supposed increase in disparities in the management of public health spending. In a group of decentralised countries, Spain has the lowest level of inequality in this regard, although the data provided are from 1997.” He concluded: “The inter-regional inequalities indicated by the atlas of variations in medical practice are more remarkable.”