[Health expenditure on primary care in Spain: not enough to provide attractive services to patients and health professionals. SESPAS Report 2012]. / Gasto sanitario en atención primaria en España: insuficiente para ofrecer servicios atrayentes para pacientes y profesionales. Informe SESPAS 2012.

The relatively low health expenditure on primary care in Spain is a result of the status quo in the health system, in which hospital/specialized care is much more widespread and better financed than primary care. Another cause consists of the health policies developed in the last 30 years, which have prioritized the development of the private ambulatory health sector over primary care.

[Successes and failures in the management of public health crisis in Spain]. / Aciertos y errores en la gestión de las crisis de salud pública en España.

Health crises shock the population and overwhelm the health services. This article analyzes 30 years of health crises in Spain from a multifaceted perspective: population, patients, clinicians, public health practitioners, politicians, the media and other groups involved. The interaction among all stakeholders shapes the response and management of any health crisis. Heterogeneity of management and of health effects-contributing to inequalities in health-is common. The participation and coordination of the health services is crucial in detection of the crisis and in modulating the population reactions. Public health services characterized by their low public profile could gain public influence by their role in coordinating politicians and the media when solving important health problems. Analyzing the mistakes and successes in previous crises together with risk and vulnerability assessments, research and drills are essential to give a quick and adequate response to future crises.

[Case and disease management and improved integration of healthcare services in Spain. 2008 SESPAS Report]. / La gestión de casos y de enfermedades, y la mejora de la coordinación de la atención sanitaria en España. Informe SESPAS 2008.

The boundaries between health services levels are artificial as they are answers to health organizations' problems rather than to patients' needs. However, given that these boundaries are in place, coordination between these levels should overcome the difficulties so that patients receive the services they require. Case management (patients in specific situations, such as hospital discharge) and disease management (patients with specific diseases, such as diabetes) aim to solve problems of coordination either by improving the organization of health services or by adding a new structure to the already existing structure. These forms of management are highly attractive answers to coordination problems but have no scientific basis nor is there any empirical evidence of a positive impact on patients' health or the cost of services. Case and disease management programs are vertical structures that weaken the horizontal structure in Spain, i.e. primary care. The need for case and disease management programs is an argument to push for a pro-coordination reform of primary care that gives power, responsibility and autonomy to general practitioners, so that they would be able to coordinate clinical and social services according to patients' needs.

[Professional debate on shortage of physicians]. / El debate profesional acerca de la escasez de médicos.

We do not know the best answer to problems due to shortage of physicians (absolute number and by specialities) but perhaps what is important is the lack of a professional debate about what means 'to be' a physician. In this paper we address four key professional questions: 1/ the over-training of physicians when health demand now includes minor problems, 2/ predominance of physician-patient direct encounters in a world of telecommunications and indirect encounters, 3/ the need to delegate power and responsibilities to other health professionals as a consequence of new technology developments and changes in role-design, and 4/ too much emphasis in diagnosis with the danger to initiate cascades with its side-effects. Practical answers to these questions require changes in pre and postgraduate education, improvement in health services organization to profit the use of telecommunications and analysis and re-design of the limits in between professions, levels of care, institutions and health and social sectors.

GPs with special interests: unanswered questions.

The NHS Plan signalled the creation of GPs with special interests (GPwSIs) in the UK. The role of a GPwSI involves the acquisition of knowledge and skills that enable GPs to dedicate a portion of their time to performing the role of consultants to their colleagues within the ambit of general practice, and with respect to specific health problems encountered. The objectives behind the introduction of GPwSIs are to improve the patient's access to specialist care, to cut waiting-list times, and to save on referral costs, (and as a consequence to increase the prestige of the GPs involved). However, the reality may not meet these expectations. Before accepting the proposition for universal implementation of GPwSIs empirical evidence is required to demonstrate that overall health is improved (of patients as well as the population); patients, especially patients of doctors working alone or in small groups (specifically in rural areas) are not disadvantaged; referral is improved and made more appropriate to the requirements of patients and their health problems; real prestige is generated, not only among GPs and students, but also among patients; biological views typical of the specialist are not promoted; and a brake is not applied to other alternatives in, or the reorganisation of, primary care.

[Health system interventions assessment in Spain: an approach through the analysis of the time trends and the geographical variability of avoidable mortality between 1986 -2001]. / Medida del resultado de las intervenciones sanitarias en España: una aproximación mediante el análisis temporal y espacial de la mortalidad evitable entre 1986-2001.

BACKGROUND: Many studies have proposed Avoidable Mortality (ME) to monitor the performance of health services although its usefulness is limited by the multiplicity of the avoidable mortality lists being used. Time trends from 1986-2001 and the geographical distribution of avoidable mortality by provinces, are presented for Spain. METHODS: An Avoidable Mortality consensus list is being used. It includes avoidable mortality through the intervention of health services (ISAS in Spanish) and through health policy interventions (IPSI in Spanish). Time trends are analyzed adjusting Poisson or Joinpoint regression models and the annual percentages of change (APC) are estimated. Changes in geographical distribution between the first half of the analysed period and the second are tested by means of standard mortality ratios (SMR) and comparative mortality rates (CMR) for each province. RESULTS: Between 1986 and 2001 avoidable mortality decreased (APC: -1.68; CI: -1.99 and -1.38) slightly more than non-avoidable mortality (APC: -1.28; CI: -1.40 and -1.17). Higher reduction was observed for ISAS mortality (APC: -2.77; CI: -2.89 and -2.65) and an irregular trend for IPSI (between 1986-1990 increase APC: 4.86; CI: 3.32 and 6.41, between 1990-95 stabilization APC: -0.03; CI: -2.32 and 2.31 and finally 1995-2001 decrease APC: -3.57; CI: -4.72 and -2.40). CONCLUSIONS: Avoidable mortality decreased more than non avoidable mortality and important geographical variability can be observed among provinces which should be monitored in order to identify the health services weaknesses. The higher ISAS mortality was observed in southern provinces and the higher IPSI mortality in some areas on the coast. The pattern is somewhat similar for both analyzed periods.

[Diagnostic and therapeutic activity moderation. Quaternary and genetic prevention]. / Moderación en la actividad médica preventiva y curativa. Cuatro ejemplos de necesidad de prevención cuaternaria en España.

Medical activities have more positive than negative outcomes. Because this balance, medicine has a great social recognition. But with new technology and more aggressive diagnostic and therapeutic interventions, there is a decreasing gap in between benefits and harms. Risk increases because more interventions, and because placing patients in more technology environments. As a consecuence, patient safety decreases. Quantity becomes as important as quality, and the place of care is crucial for patient safety. Medical activities should be of <>, performed in the low level of care possible. Then, quaternary prevention (to avoid unnecessary use and risk of medical interventions) should be a continuous parallel clinical activity. I consider four examples of needed quaternary prevention, with Spanish data: 1) cardiovascular prevention (where there is an inverse use of resources, as patients who need more receive less); 2) use of new antidepressants (which has provoke an artificial epidemic of <

[The comorbidity in primary care]. / La comorbilidad en atención primaria.

As patients live longer, and more illnesses become chronic, comorbidity rates increase. This increase shows in attended morbidity registers, and its importance is revealed by the use of services, treatments, the survival rates and the patients life quality. A frequent coexistence of illnesses, such as diabetes and depression, increases the cost of primary care and emergency treatments and the number of hospital admissions; increases the probability of cardiovascular risk and non-adherence to treatment and diet; causes a perception of poor physical and mental health and, on the whole, increases global costs. The annual mortality rate shoots up when anemia and cardiovascular or kidney failure occur. Mental comorbidity has a greater effect on the patients perception of their life quality than physical comorbidity. Comorbidity increases the number of hospital admissions which could have been prevented, as well as the avoidable complications related to them. Suicidal thoughts occur more frequently in patients suffering from chronic obstructive pulmonary disease (COPD) than in those suffering from other chronic organic illnesses. In patients suffering from atrial fibrillation, the risk of acute coronary crisis increases as they age and the comorbidity increases the use of angiotensin-converting enzymes (ICAE), antidepressant drugs and the visits to the psychiatrist.

Recuperar las vocaciones perdidas / Rediscovering lost vocations

Un pequeño grupo de profesionales de la salud de Madrid ha creado una organización de investigación y asesoramiento cuyo objetivo es ayudar a médicos, enfermeras, farmacéuticos y otros profesionales a sacar mayor partido de su trabajo, dejando de lado actitudes rutinarias e irreflexivas y satisfaciendo las necesidades de la comunidad por métodos más directos, entre los cuales la prevención ocupa un lugar importante

Rediscovering lost vocations

A small group of health professionals in Madrid has built up a research and advisory organization whose objective is to help doctors, nurses, pharmacists and others to achieve greater job satisfaction by turning away from unthinking, routine approaches to their work and meeting the needs of the community more directly, not least through preventive measures