"The problem of suicides is not tackled only with drugs"

• A health in crisis (VI) Nel González: "The prescription of psychotropic drugs is a revolving door where people are victims of a chronification is not desirable"
• A health in crisis (V) Javier García Alegría: "We have public funding in Health that is 25% lower than that of other EU countries"

As a former director of Public Health, Ildefonso Hernández knows well the seams of Spanish healthcare, its strengths and weaknesses. He believes that there is a lack of political will and real commitment to assume that the National Health System (SNS) must be redesigned, because until now "it has been 'pulled', because it seemed that 'nothing happened' and no decisions have been made in time." The pandemic has highlighted the needs and exacerbated the underlying problems.

As Professor of Medicine P

reventiva and Public Health of the Miguel Hernández University and member of the Spanish Society of Public Health and Health Administration (Sespas) puts the accent on socio-sanitary policies, "to achieve a healthy aging of it is not good that people from 60 years the only thing they have are three or five or more drugs. There are no benefits to keep people healthy."

They say that the crisis of primary care is only the tip of the iceberg of the health situation in Spain...

It is a topic that has been dragging on for some time. There has been no political will at any time to change things. To sum it up: it has happened to him like public health, as the effects are not seen a priori, they are not quantified quickly and it seems that it is not noticeable. But now we are seeing the magnitude of the problem.

The reality is that the problem is entrenched and the damage to the system has been accumulating year after year. How is it corrected?

It's complicated. It has been 'pulling', because it seemed that 'nothing happened' and no decisions have been made in time. You have to redesign the model and change some fundamental things. The same Spanish Society of Public Health (SESPAS), in its day, and the Association of Health Economics have made several reports to change and promote modifications of the model.

Are the changes that are needed so profound?

A lot of time has been left without adjusting the architecture of a model that was fine. Obviously Spain has good health figures and health service performance, but in order to maintain it you have to make changes that are important. What the pandemic has done is highlight many of the underlying problems, as has happened in all countries of the world.

What would be those changes that would have to be made?

There are several issues that are key. The problem is not just a system that has to be more focused on chronic patients. You have to change a system. that it has resource losses and has governance problems that cause some of the fundamental issues to be ignored. They are not simple or simple changes, it is not focusing on one type of patient. It is a transformation from an exclusive biomedical care model to one in which the solutions are not drugs or surgeries or super-expensive devices, but are social benefits.

An example?

To get an idea: the lack of response to mental health problems is now more evident. That has to do with the fact that there have been too many biomedical responses, of drugs that do not alleviate the origin of the disease. That is, the problem of the increase in suicides in young people cannot be answered with drugs. Spain is one of the countries, with Portugal, that consumes more anxiolytics and antidepressants. This is serious because the underlying problems are not rectified. There are problems of malaise underneath that have to do with social policies, with responses from the system in the field of primary and community care.

Does the medicalization of the patient leave out other types of necessary approaches?

Of course. Many simplify in the famous medicalization and we stay there. But you have to look at the set of needs. As for benefits, in mental health and other diseases we only medicalize, but other types of aid should be carried out hand in hand with rehabilitation and physiotherapy. This is another type of assistance. It is easier to give a pill than to try to correct a habit.

Or are they thought not to be as effective?

Indeed, these alternatives are also considered to be soft from the point of view of scientific evidence, when it is not true. It has been shown that many of these interventions, in the field of physiotherapy and in others, have very high gains in terms of years and quality of life per euro invested. These benefits are virtually non-existent. And the system has to be transformed towards this because otherwise we will not respond to the health needs of the population, especially because to achieve healthy aging it is not good for people over 60 years old to have to take 12 or 15 drugs. There are no benefits to keep people healthy.

But will there be a way to measure the impact, the cost-effectiveness of these non-pharmacological therapies?

Perhaps it has not been measured or yes, but it has not been able to expose that cost-effectiveness that often has to be demonstrated, even with drugs. In this case it is necessary to be able to demonstrate that this investment is also real in this type of interventions. There are large investments in biomedicine and there is absolute contempt and a delay in investment in alternatives. There are research policies that are systematically forgotten, only productivity is looked at. It is not seen that part of the economic profitability has to do precisely with ensuring that people do not spend, that they do not have problems that involve an expense. They have forgotten about social benefits. An example is children in vulnerable families who need assistance because they do not receive it and accumulate problems throughout their lives, themselves and their environment.

So, are social and health policies the ones that have lost that prominence?

We must prevent situations in vulnerable families, in childhood and adolescence through investments that have a profitability not only human, but economic, very high, of course. This has been demonstrated in Sweden. From the point of view of public health, we are still thinking about changing the system to make it sustainable, but we do not think about the package of legal and fiscal rules in health. It took a long time to push through the gambling law and develop regulations for the protection of minors. Because we all know the impact of addictions, including gambling, that create social situations. But we must go further: regulate food labeling, condition access to processed products... We have and want a high life expectancy and this is the answer. Because there is nothing worse for the health system than an 80-year-old dying in an ambulance leaving to put another dose of extremely expensive chemotherapy without having received good care at the end of life.

Along with all this are the problems suffered by health professionals who are the key figure who has sustained the seams of this cracking system.

Just. The labor relations of the health systems create disease to the health workers themselves, instead of taking care of them, of valuing them. And not only should it be changed with better conditions and contracts, but also providing them with professional development. And this has to do with what we said before medicalization. It is that primary staff are not trained or offered training within their working hours. And if they are formed it is thanks to the congresses organized by the industry, in which pharmaceutical novelties are exposed. It is not that I criminalize the industry, which is brilliant, but I miss a training agenda drawn up to respond to the health needs of the population.

One issue that concerns him is the new public health law and the future agency. Will this project that has been stuck since 2011 be completed this year?

Things have not just come to fruition. The draft they have made is not complete, especially in the part of independence of appointments. We need an agency that is independent, that does not depend on the ministry, that recruits people by merit, ability... We also ask for this for the Agency for Health Technology Assessment and Interventions. Because then it sounds strange that the Ministry itself has appealed the request for transparency on the way things have been arranged with some drugs. That cannot be the case. The public health law has to have guarantees of compliance, and it does not. Nor has a section on conflicts of interest been developed. And that has nothing to do with political color, but with the will to do things well.

In the end, are there many unfinished business in this legislature?

The problem is that it is not prioritized, but nobody wants to do it, there is no explicit policy. Government programs are quite regrettable because they have no real analysis of the problems. All electoral measures are neither specified nor adjusted or simply remain populist measures at the time of announcement. They don't become tangible. Having a Minister of Finance who knows health well, why nothing has been done with the taxation of tobacco and alcohol, with the impact that these addictions have on public health.