It is not the same “hardening of the pandemic” due to the increase in infections than due to serious cases. A higher rate of infections requires more primary care and public health resources, more effort to follow up contacts and many tests. Greater weight of serious cases requires more hospital resources, hospital and critical beds, ventilators and intensivists.
The question could be reformulated as follows: To what degree of hardening of the pandemic could we face without the health system collapsing? Which leads us to examine the plasticity of our health, its ability to grow and reorganize in the short term. It also leads us to analyze the bottlenecks in the availability of supplies (medicines, PPE), structural resources (beds, ICU beds, ventilators), human resources (health professionals) and organizational resources.
So, is the Spanish health system prepared for a hardening of the pandemic? The short answers to that question are: 1) more than in February; 2) unequally according to autonomous communities; 3) according to the behavior of the population.
Better prepared than in February
In February, the Spanish health system was not prepared for a pandemic of this severity. We had not suffered the threat of SARS in 2003 and, unlike the countries that had faced it, we did not have contingency plans and we had not equipped ourselves with personal protective equipment. Furthermore, their populations had been wearing masks almost routinely for more than a decade.
In Spain, the experience had been rather the opposite. The “coming of the wolf” of influenza A had come to nothing, and tons of the antiviral Tamiflu and other expired drugs had to be destroyed a few months earlier. In addition, news arriving in January and early February from China suggested that the new viral disease was just the flu.
Other more far-sighted European countries, such as Germany, even without having suffered the previous epidemics, had strategic reserves of Personal Protective Equipment and access to other resources that were to become very scarce already in the first weeks of March, such as commercial kits for diagnosis by PCR or swabs.
To make matters worse, in Spain the public health structure was very weak. Barely 799 million euros of public health spending (1.1% of the total) was allocated to public health in 2018 , and the General Public Health Law had not been developed by regulation. The entire institutional architecture of the country, with 17 regional health services to manage the system and an Interterritorial Council used as a partisan political weapon, was clearly dysfunctional. In addition, primary care was suffering its own chronic crisis.
Obviously, today we are more prepared. The commission for social and economic reconstruction of the Congress of Deputies approved its opinion in early July 2020. It includes a provision on contingency plans for disaster preparedness, of this and other types, and strategic supplies reserves. In addition, the rescue funds inject financial resources to meet the unexpected needs to strengthen the health network, public health structures, trackers, IFEMAS and Noah’s coffers.
On the other hand, during the worst months of the first wave, health centers reorganized and adopted new technologies such as telemedicine – more progress was made in two months in this regard than in previous decades. New ways of working with collaboration between specialties and between professions were also redefined. The intensive care scientific societies agreed on clear protocols for action already in the first weeks of the COVID-19 crisis, which they jointly published in scientific journals.
Human Resources
The human resources of the health system are its main asset. During the first wave, some healthcare professionals were overwhelmed while others were left without tasks, because non-COVID-19 healthcare was drastically reduced. Partly due to supply reasons – the need to keep beds available in case the epidemic worsens – but also due to demand – the population’s fear of being infected.
During the worst weeks of the pandemic, except in Madrid and a few other locations, hospital occupancy was lower than ever. The need for more professionals and more versatile was revealed. Places were urgently called, but there were no doctors or nurses on the market. Already in the first days of confinement, Order SND / 232/2020, of March 15, was published, which made the hiring of professionals and the requirements for it more flexible.
For its part, the European Commission has tackled these two problems with individual provisions. The first on May 7, allowing some slack in the required accreditations to hire health professionals. And the second, organizing courses to train in the care of critical COVID-19 patients, between August and December 2020, to some 10,000 doctors and nurses from at least 1,000 hospitals in all European countries.
Unevenly prepared by Autonomous Communities
The preparation is not the same in both Autonomous Communities, nor has the virulence of the attack been the same. Those with better and more coordinated public health mechanisms and strong primary care were – and are – better prepared. Furthermore, the question is not whether the health system is sufficiently prepared. It is also necessary to consider whether it is coordinated with the rest of the pieces of that great puzzle, and in particular with social and health care. Because the preparation of the system also requires that Family and Community Medicine recover the C (for Community), attending the elderly in residences.
It should not be forgotten that the first wave in Spain has been so lethal due to the enormous number of deaths in residences. Coordination of the socio-sanitary device with Health, especially with primary care, is essential. We are better prepared now: systematic screening of residents and workers is carried out, protocols are being followed, and the reason for the so-called spring fiasco is being evaluated. Worthy of mention is the recent evaluation of residential care in Navarra.
The figure shows the endowments of family doctors by Autonomous Communities in 2018 (last year with information in the Primary Care Information System of the Ministry of Health), and the change since 2010. On the horizontal axis we represent the number of Individual Health Cards ( TSI), that is, the number of patients per family doctor in 2018, and vertically, the% reduction in this ratio since 2010.
The CCAA located to the left of the figure are better prepared, and those located at the top have improved their endowments in recent years. While the Basque Country, Extremadura, Castilla y León, Galicia and Navarra have good endowments and have improved their resources, the Balearic Islands, Ceuta and Melilla and Madrid stand out for their low endowments and for their deterioration since 2010.
According to the Primary Care Information System, in Madrid there are 252 family doctors with more than 2000 health cards assigned, and half (1824) have between 1500 and 2000 health cards. In a worsening of the epidemic, such as that of Madrid, Aragon or Navarra, primary care has to assume an enormous healthcare burden of detection and clinical follow-up of cases, which will be very difficult or impossible in the Autonomous Communities with few professionals, and in which primary care has been deteriorating.
Behavior of the population
The incidence (new cases of COVID-19) determines only to a certain extent the use of hospital resources and their eventual collapse. Between the two mediates the behavior of the population, which is not homogeneous. The big difference between the first wave and this second one that we are experiencing is that during the first wave the percentage of patients requiring hospitalization and the fatality rate were much higher because the most vulnerable were not effectively protected from risk.
In addition to official discriminatory measures, such as the prohibition of residents of social health centers from going out on the street (Order SND / 380/2020, of April 30), in Spain many older people have learned to protect themselves through preventive isolation, it would seem that they are almost voluntary house arrests. If the age profile of those infected in the second wave had been as in the first, the hospitals in some communities would have already collapsed in August.
The plasticity of the healthcare system
The first wave showed us an unknown plasticity of the health system, which has been able to grow rapidly in structural resources. The IFEMA field hospital was open for 40 days and treated almost 4,000 COVID patients. Critical beds in the country went from 4,446 before the start of the epidemic to 7,930 in just two months.
This apparent plasticity encompasses different definitions of a critical care bed. From the strictest, which only includes beds located in ICUs and dependent on their staff, to the most lax, which also include beds for post-surgical surveillance, coronary care and stroke units.
Critical beds were fitted out for COVID-19 patients outside the ICUs and ventilators, some of national design and production, were installed in emergency rooms and in hospital plants. The Spanish health system had in 2018 (last year with data in the Specialized Care Information System) with 2,765 intensive care physicians contractually linked to hospitals, 668 collaborators and 733 MIR in training. In addition, there were more than 10,000 doctors with contract or collaborators in the emergency room. But the flexibility has allowed a part of the other specialists to have learned and helped treat COVID-19 patients.
As of October 10, 2020, according to the report of the Ministry of Health, there are 1 585 patients admitted to the ICU, three Autonomous Communities are above 30% occupancy (Madrid, Aragón and Castilla León) and there is an 18% average occupancy of ICU beds in the country. There is still some margin for the worsening of the pandemic without the system collapsing, although renowned epidemiologists have questioned the data on the occupancy of ICU beds in Madrid.
Unfortunately, public data on the use of ICUs in Spain do not allow evaluations of the risk of collapse as in other countries (see, for example, the report of October 10 from the BIOCOMSC group).
How far can the health system grow to face a worsening of the epidemic? Possibly, in the areas most affected in the first wave (Madrid, some areas of Catalonia), structural resources could be increased as much or more than then. But, above all, better knowledge of therapeutic management of the disease and the training of professionals would make these resources be used more efficiently.
Although, obviously, the keys to avoid collapse are to slow down the rate of infections and protect those most at risk.
Beatriz González López-Valcárcel, Professor of Quantitative Methods in Economics and Management, University of Las Palmas de Gran Canaria
This article was originally published on The Conversation. Read the original.
