La atención primaria en Portugal / Primary care in Portugal

La crisis económica y el deterioro del Serviço Nacional de Saúde portugués han obligado a numerosos profesionales a abandonar el país. El portugués es un sistema nacional de salud que nació en 1976 pero no ha sido capaz de proporcionar a los ciudadanos las ventajas en equidad, gratuidad y acceso de los sistemas nacionales de salud de su entorno. El Serviço Nacional de Saúde está financiado con impuestos generales, aunque un 35% del total son ingresos privados. El presupuesto lo decide el ministro de sanidad y está basado en un sistema de financiación histórica y de capitación. Todos los ciudadanos portugueses e inmigrantes tienen derecho a asistencia sanitaria gratuita, aunque existe copago en la consulta, pruebas diagnósticas, farmacia y urgencias. La provisión de servicios es regional y una mezcla pública y privada ocasionando fragmentación de servicios y desigualdades importantes. Los médicos son funcionarios. El salario está regulado y depende del número de años trabajados y las guardias realizadas. Las funciones médicas son similares a las de los profesionales españoles. El médico tiene función de gatekeeper, pero el sistema es imperfecto y los ciudadanos con atención privada tienen acceso directo a especializada. La formación especializada tiene un sistema parecido al mir y la formación continuada no está regulada. El sistema portugués lleva desde 1979 intentando transformarse en un sistema nacional de salud, pero no ha sido posible debido a la inestabilidad política, la fragmentación de servicios, una división poco clara de la atención pública y privada y la existencia de copago. Las desigualdades sanitarias son un problema importante a reconsiderar en un sistema nacional de salud

The economic crisis and deterioration of the Portuguese National Health service has forced professionals to leave the country. The Portuguese National Health System was introduced in 1976, but it has been unable to provide citizens with the social and health advantages of an equality of access and free national health system. The Portuguese National Health System is financed by taxes. However, a 35% of its incomes are from private sources. The health minister decides the budget, and it is based on an historical financing plus a per capita system. Portuguese citizens and immigrants are entitled to free health care, but there is a co-payment for care, diagnostic, pharmacy, and emergency care. Health care provision is a mixture of public and private health care at a regional level. It leads to fragmentation of services and greater inequalities. Doctors are civil servants. Salary is regulated and it depends on seniority and on-call shifts. Primary care activities are similar to those of their Spanish counterparts. General practitioners have gatekeeper function, but the system is imperfect, and patients with private insurance get direct access to the specialist. Specialist training is similar to the training system in Spain. Continuing education is not regulated. The Portuguese Health System has been trying to become a national health system since 1979. Political instability, fragmentation of services, lack of clarity between public and private and co-payments are important constraints. Inequalities are an important problem to reconsider while discussing a national health system

La atención primaria en Italia / Primary care in Italy

Italia no es un lugar de emigración para médicos españoles, pues en dicho país también sobran profesionales sanitarios. El Servizio Sanitario Nazionale italiano es un sistema nacional de salud con algunas diferencias respecto del español. El Servizio Sanitario Nazionale está financiado con impuestos nacionales y regionales y copagos. Existe un presupuesto específico para la asistencia sanitaria y Atención Primaria recibe el 50% de este presupuesto. Todos los ciudadanos italianos y residentes en Italia tienen derecho a asistencia sanitaria gratuita, aunque existe copago en pruebas diagnósticas, farmacia, atención especializada y determinadas urgencias. El copago es diferente dependiendo de la región. La provisión de servicios es regional, provocando fragmentación de los mismos e importantes desigualdades. Los médicos son autónomos y desde el año 2000 hay incentivos para promover el trabajo en equipos multidisciplinares. El salario está regulado y es la suma de un pago capitativo e ingresos específicos por actividades complementarias. Las funciones de los médicos son similares a las de los profesionales españoles, aunque la atención es más personal. La relación entre Atención Primaria y Especializada depende de la afinidad de los profesionales entre sí. El médico de Primaria tiene función de gatekeeper excepto en ginecología, obstetricia y pediatría. La formación especializada es obligatoria para poder trabajar como médico de familia. El sistema sanitario italiano es un sistema nacional de salud similar al español. Sin embargo, los profesionales sanitarios son autónomos y existe copago. A pesar del copago, los italianos tienen una de las esperanzas de vida más altas de Europa y están a favor de un sistema sanitario universal y financiado públicamente (AU)

Italy is not a country where Spanish doctors emigrate, as there is an over-supply of health care professionals. The Italian Servizio Sanitario Nazionale has some differences compared to the Spanish National Health System. The Servizio Sanitario Nazionale is financed by national and regional taxes and co-payments. There are taxes earmarked for health, and Primary Care receives 50% of the total funds. Italian citizens and residents in Italy have the right to free health cover. However, there are co-payments for laboratory and imaging tests, pharmaceuticals, specialist ambulatory services, and emergencies. Co-payments vary in the different regions. The provision of services is regional, and thus fragmentation and major inequities are the norm. Doctors in Primary Care are self-employed and from 2000 onwards, there are incentives to work in multidisciplinary teams. Salary is regulated by a national contract and it is the sum of per-capita payments and extra resources for specific activities. Responsibilities are similar to those of Spanish professionals. However, medical care is more personal. Relationships between Primary Care and specialised care depend on the doctors’ relationships. Primary Care doctors are gatekeepers for specialised care, except for gynaecology, obstetrics and paediatrics. Specialised training is compulsory in order to work as general practitioner. The Italian Health Care System is a national health system like the Spanish one. However, health care professionals are self-employed, and there are co-payments. In spite of co-payments, Italians have one of the highest average life expectancy, and they support a universal and publicly funded health-care system (AU)

[Primary care in Portugal]. / La atención primaria en Portugal.

The economic crisis and deterioration of the Portuguese National Health service has forced professionals to leave the country. The Portuguese National Health System was introduced in 1976, but it has been unable to provide citizens with the social and health advantages of an equality of access and free national health system. The Portuguese National Health System is financed by taxes. However, a 35% of its incomes are from private sources. The health minister decides the budget, and it is based on an historical financing plus a per capita system. Portuguese citizens and immigrants are entitled to free health care, but there is a co-payment for care, diagnostic, pharmacy, and emergency care. Health care provision is a mixture of public and private health care at a regional level. It leads to fragmentation of services and greater inequalities. Doctors are civil servants. Salary is regulated and it depends on seniority and on-call shifts. Primary care activities are similar to those of their Spanish counterparts. General practitioners have gatekeeper function, but the system is imperfect, and patients with private insurance get direct access to the specialist. Specialist training is similar to the training system in Spain. Continuing education is not regulated. The Portuguese Health System has been trying to become a national health system since 1979. Political instability, fragmentation of services, lack of clarity between public and private and co-payments are important constraints. Inequalities are an important problem to reconsider while discussing a national health system.

[Primary care in Italy]. / La atención primaria en Italia.

Italy is not a country where Spanish doctors emigrate, as there is an over-supply of health care professionals. The Italian Servizio Sanitario Nazionale has some differences compared to the Spanish National Health System. The Servizio Sanitario Nazionale is financed by national and regional taxes and co-payments. There are taxes earmarked for health, and Primary Care receives 50% of the total funds. Italian citizens and residents in Italy have the right to free health cover. However, there are co-payments for laboratory and imaging tests, pharmaceuticals, specialist ambulatory services, and emergencies. Co-payments vary in the different regions. The provision of services is regional, and thus fragmentation and major inequities are the norm. Doctors in Primary Care are self-employed and from 2000 onwards, there are incentives to work in multidisciplinary teams. Salary is regulated by a national contract and it is the sum of per-capita payments and extra resources for specific activities. Responsibilities are similar to those of Spanish professionals. However, medical care is more personal. Relationships between Primary Care and specialised care depend on the doctors' relationships. Primary Care doctors are gatekeepers for specialised care, except for gynaecology, obstetrics and paediatrics. Specialised training is compulsory in order to work as general practitioner. The Italian Health Care System is a national health system like the Spanish one. However, health care professionals are self-employed, and there are co-payments. In spite of co-payments, Italians have one of the highest average life expectancy, and they support a universal and publicly funded health-care system.

La atención primaria en Irlanda / Primary care in Ireland

Los médicos siguen saliendo de España en busca de trabajo de calidad. Irlanda no cuenta con demasiados profesionales españoles, pero es interesante conocer su particular sistema sanitario. Irlanda se encuadra dentro de los sistemas nacionales de salud, aunque coexiste con un sistema de seguros privados. Todos los ciudadanos que llevan al menos un año en Irlanda tienen derecho a asistencia sanitaria. Las condiciones de acceso son diferentes dependiendo de la edad y la renta: gratuito para ciudadanos de categoría 1 y no gratuito para el resto. Esta división genera importantes desigualdades en la población. Los médicos son autónomos y trabajan independientemente, aunque desde 2001 se tiende a trabajar en equipos multidisciplinares para fomentar la atención primaria. El salario es la suma de las actividades pública y privada, que no están diferenciadas. Los médicos se ocupan del tratamiento de las enfermedades agudas y crónicas, cirugía menor, pediatría… No existe coordinación entre atención primaria y atención especializada. El acceso a especialistas está limitado por el coste de la consulta porque el médico de atención primaria no tiene función de gatekeeper. Son necesarios 3 años de formación especializada para poder trabajar. Después, la formación médica continuada es obligatoria y existen controles aleatorios anuales realizados por el colegio de médicos. El sistema irlandés es un modelo sanitario que no tiene cabida en Europa. La falta de una división clara entre asistencia pública y asistencia privada genera grandes desigualdades. La pobre coordinación entre atención primaria y atención especializada origina ineficiencias que Irlanda no puede permitirse después de la crisis económica de la década pasada (AU)

Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis (AU)

La atención primaria en Bélgica / Primary care in Belgium

Bélgica es un país atractivo laboralmente por ser sede de las instituciones europeas no solo para los médicos, sino para todos los españoles. El atractivo laboral sanitario es doble; por un lado, la oportunidad de encontrar un trabajo digno, y por otro, la de poder desarrollar las habilidades profesionales con pacientes de la misma nacionalidad en un sistema sanitario con un funcionamiento muy distinto. El sistema de salud belga pertenece al modelo de seguros sociales. Los servicios sanitarios están financiados por el estado, cuotas de seguridad social y seguros voluntarios privados. La atención primaria en Bélgica es muy diferente a la española. Los ciudadanos pueden elegir libremente el médico (generalista o especialista), lo que favorece la descoordinación entre atención primaria y especializada, genera graves problemas de seguridad para los pacientes y de pérdida de eficiencia para el sistema. Bélgica es uno de los países europeos con coberturas mejorables en actividades preventivas. Los médicos generalistas son profesionales liberales con autonomía de instalación y su salario está ligado a la actividad profesional. Las consultas médicas tienen copago y este hecho genera desigualdades importantes en el acceso a la atención. Las estadísticas hablan de una cobertura sanitaria universal, pero en el año 2010, el 14% de la población no acudió al médico por problemas económicos. El tiempo de formación para convertirse en especialista es de 3 años, y la formación médica continuada es uno de los requisitos fundamentales para obtener la revalidación del título. En general, los belgas y los españoles que viven y trabajan en Bélgica están contentos con el funcionamiento de su sistema sanitario. No obstante, los médicos debemos ser conscientes de que es un sistema donde el acceso todavía está limitado a una parte de la población y la cobertura de las actividades preventivas es mejorable (AU)

Belgium is an attractive country to work in, not just for doctors but for all Spanish workers, due to it having the headquarters of European Union. The health job allure is double; on the one hand, the opportunity to find a decent job, and on the other, because it is possible to develop their professional abilities with patients of the same nationality in a health system with a different way of working. The Belgium health care system is based on security social models. Health care is financed by the government, social security contributions, and voluntary private health insurance. Primary care in Belgium is very different to that in Spain. Citizens may freely choose their doctor (general practitioner or specialist) increasing the lack of coordination between primary and specialized care. This leads to serious patient safety problems and loss of efficiency within the system. Belgium is a European country with room to improve preventive coverage. General practitioners are self-employed professionals with free choice of setting, and their salary is linked to their professional activity. Ambulatory care is subjected to co-payment, and this fact leads to great inequities on access to care. The statistics say that there is universal coverage but, in 2010, 14% of the population did not seek medical contact due to economic problems. It takes 3 years to become a General Practitioner and continuing medical education is compulsory to be revalidated. In general, Belgian and Spaniards living and working in Belgium are happy with the functioning of the health care system. However, as doctors, we should be aware that it is a health care system in which access is constrained for some people, and preventive coverage could be improved (AU)

[Primary care in Ireland]. / La atención primaria en Irlanda.

Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis.

[Primary care in Belgium]. / La atención primaria en Bélgica.

Belgium is an attractive country to work in, not just for doctors but for all Spanish workers, due to it having the headquarters of European Union. The health job allure is double; on the one hand, the opportunity to find a decent job, and on the other, because it is possible to develop their professional abilities with patients of the same nationality in a health system with a different way of working. The Belgium health care system is based on security social models. Health care is financed by the government, social security contributions, and voluntary private health insurance. Primary care in Belgium is very different to that in Spain. Citizens may freely choose their doctor (general practitioner or specialist) increasing the lack of coordination between primary and specialized care. This leads to serious patient safety problems and loss of efficiency within the system. Belgium is a European country with room to improve preventive coverage. General practitioners are self-employed professionals with free choice of setting, and their salary is linked to their professional activity. Ambulatory care is subjected to co-payment, and this fact leads to great inequities on access to care. The statistics say that there is universal coverage but, in 2010, 14% of the population did not seek medical contact due to economic problems. It takes 3 years to become a General Practitioner and continuing medical education is compulsory to be revalidated. In general, Belgian and Spaniards living and working in Belgium are happy with the functioning of the health care system. However, as doctors, we should be aware that it is a health care system in which access is constrained for some people, and preventive coverage could be improved.

La atención primaria en Suecia / Primary care in Sweden

Suecia fue uno de los primeros países de la Unión Europea que vio una oportunidad en la libre circulación de profesionales. Las primeras ofertas se gestionaron en el año 2000. Desde entonces, muchos profesionales han aprovechado la oportunidad de obtener un trabajo digno y han cambiado España por Suecia. El modelo sanitario sueco pertenece al grupo de los sistemas nacionales de salud. El derecho a la asistencia sanitaria está ligado a la condición de ciudadano, la sanidad es financiada con impuestos regionales, pero existe un copago obligatorio independiente de la situación económica del paciente. La provisión de servicios está descentralizada a nivel regional y se realiza mediante un conjunto de centros públicos y privados. La medicina privada es muy escasa. La atención primaria es parecida a la española. Los profesionales trabajan en equipo con división de tareas. La coordinación entre primaria y especializada y las listas de espera son, como en España, los grandes problemas del sistema de salud. El paciente elige libremente el centro de salud y el hospital en su región. El acceso a pruebas diagnósticas y especialistas depende del informe del especialista. Los médicos son asalariados y su puesto de trabajo y salario dependen de la experiencia, la capacitación profesional y la necesidades de la zona. La función del médico es curativa. El médico de atención primaria es la entrada al sistema, pero no tiene una labor de filtro o gatekeeper. Los hospitales ofrecen un número de plazas de formación y se accede mediante una entrevista. La formación médica continuada es incentivada y financiada por el gestor del centro de salud porque la formación genera recursos económicos (AU)

Sweden was one of the first European Union countries that saw the opportunity in the free movement of professionals. First offers for jobs were managed in 2000. Since then, a large number of professionals have taken the opportunity of a decent job and have moved from Spain to Sweden. The Swedish health care model belongs to the group of national health systems. The right to health care is linked to legal citizenship. Health is financed through regional taxes, but there is a compulsory co-payment regardless of the financial situation of the patient. The provision of health care is decentralised at a regional level, and there is a mixture of private and public medical centres. Primary care is similar to that in Spain. Health professionals work as a team with a division of tasks. Like in Spain, waiting lists and coordination between primary and specialised care are a great problem. Patients may register with any public or private primary care centre and hospital provider within their region. Access to diagnostic tests and specialists are restricted to those selected by specialists. Doctors are salaried and their job and salary depend on their experience, professional abilities and regional needs. Medicine is curative. General practitioners are the gateway to the system, but they do not act as gatekeeper. Hospitals offer a number of training post, and the access is through an interview. Continuing medical education is encouraged and financed by the health centre in order to increase its revenues (AU)

La atención primaria en el Reino Unido / Primary care in the United Kingdom

La inadecuada planificación de profesionales sanitarios en España ha favorecido la salida de médicos al extranjero. Reino Unido es uno de los países elegidos por los médicos españoles para desarrollar su trabajo. El Servicio Nacional de Salud británico tiene un modelo sanitario similar al español. Los servicios sanitarios están financiados por impuestos. El derecho a la asistencia sanitaria está ligado a la condición de ciudadano y la provisión de servicios se realiza mediante una combinación de centros públicos y privados. La atención primaria en Reino Unido tiene una estructura similar a la española. Los médicos son profesionales cuasiliberales que se instalan en zonas predeterminadas por el gobierno. Tienen capacidad de autofinanciación y pueden formar su propio equipo de trabajo. El salario médico está ligado a la capacidad profesional y al currículo. La función del médico es preventiva más que curativa y el trabajo en equipo y la coordinación entre atención primaria y especializada está más desarrollada que en España. El acceso a pruebas diagnósticas y especialistas está regulado por las listas de espera y el médico de atención primaria actúa como gatekeeper. El paciente elige libremente al profesional sanitario y las consultas y estancias hospitalarias son gratuitas. En Reino Unido también existen regiones de salud con graves problemas de desigualdades sanitarias en acceso y tratamiento. Existe un periodo formativo al que se accede por currículo. El número de plazas formativas está regulado por las necesidades de la zona. La formación médica continuada es obligatoria y está controlada a nivel local y nacional. El sistema de salud británico sirvió como modelo a la reforma de la sanidad española en 1986. La atención primaria en España tiene calidad pero la eficiencia del sistema probablemente mejoraría si la gestión de los centros de salud se realizara de manera similar a la británica (AU)

The inadequate planning of health professionals in Spain has boosted the way out of doctors overseas. The United Kingdom is one of the countries chosen by Spanish doctors to develop their job. The National Health Service is a health system similar to the Spanish one. Health care services are financing mainly through taxes. The right to health care is linked to the citizen condition. The provision of health care is a mix-up of public and private enterprises. Primary Care is much closed to Spanish Primary Care. Doctors are "self-employed like" professionals. They can set their surgeries in a free area previously designed by the government. They have the right to make their own team and to manage their own budget. Medical salary is linked to professional capability and curriculum vitae. The main role of a General Practitioner is the prevention. Team work and coordination within primary and specialised care is more developed than in Spain. The access to diagnostic tests and to the specialist is controlled through waiting lists. General Practitioners work as gate-keepers. Patients may choose freely their doctor and consultations and hospital care are free at the point of use. Within the United Kingdom there are also health regions with problems due to inequalities to access and to treatment. There is a training path and the access to it is by Curricula. The number of training jobs is regulated by the local needs. Continuing education is compulsory and strictly regulated local and nationally. The National Health Service was the example for the Spanish health reform in 1986. While Spanish Primary health care is of quality, the efficiency of the health system would improve if staff in Primary Care settings were managed in a similar way to the British's (AU)

La atención primaria en Francia / Primary care in France

La inadecuada planificación de los profesionales sanitarios en España ha promovido un éxodo de médicos fuera de nuestras fronteras. Francia es uno de los países elegidos por los médicos españoles para desarrollar su actividad profesional. El sistema de salud francés pertenece al modelo bismarkiano. En este modelo los servicios sanitarios están financiados por cuotas de trabajadores y empresarios. El derecho a la asistencia sanitaria está ligado al trabajo y la provisión de servicios se realiza a través de aseguradoras privadas supervisadas por el estado. La atención primaria en Francia es muy diferente a la española. Los médicos generalistas son profesionales liberales que se instalan en cualquier parte del territorio. Esta falta de regulación de la instalación de los médicos a nivel estatal ha generado un grave problema de desertificación médica con problemas graves de acceso y desigualdades sanitarias. Los médicos franceses no se instalan en zonas rurales o en áreas periféricas de grandes ciudades porque «no son rentables». El salario médico está ligado a la actividad profesional. Su función es principalmente curativa y no existe el trabajo en equipo ni coordinación entre atención primaria y atención especializada. El acceso a pruebas diagnósticas, especialistas y hospitales es ilimitado, lo que genera duplicidad de servicios, graves efectos adversos para los pacientes e ineficiencias en el sistema. El paciente elige libremente al profesional sanitario y todas las consultas y estancias hospitalarias están sujetas a un copago. Se requieren 2 años de formación para convertirse en especialista. A partir de ese momento la formación médica continuada es obligatoria, pero apenas existe control. El sistema francés, calificado en el año 2000 por la OMS como el mejor sistema de salud del mundo, no lo es tanto. Aunque la atención primaria en España es mejorable, a Francia le queda todavía mucho camino por recorrer(AU)

The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career. The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of 'medical desertification' with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because 'they are not value for money'. Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings. Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated. Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain (AU)

[Primary care in France]. / La atención primaria en Francia.

The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career. The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of "medical desertification" with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because "they are not value for money". Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings. Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated. Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain.

[Primary care in the United Kingdom]. / La atención primaria en el Reino Unido.

The inadequate planning of health professionals in Spain has boosted the way out of doctors overseas. The United Kingdom is one of the countries chosen by Spanish doctors to develop their job. The National Health Service is a health system similar to the Spanish one. Health care services are financing mainly through taxes. The right to health care is linked to the citizen condition. The provision of health care is a mix-up of public and private enterprises. Primary Care is much closed to Spanish Primary Care. Doctors are "self-employed like" professionals. They can set their surgeries in a free area previously designed by the government. They have the right to make their own team and to manage their own budget. Medical salary is linked to professional capability and curriculum vitae. The main role of a General Practitioner is the prevention. Team work and coordination within primary and specialised care is more developed than in Spain. The access to diagnostic tests and to the specialist is controlled through waiting lists. General Practitioners work as gate-keepers. Patients may choose freely their doctor and consultations and hospital care are free at the point of use. Within the United Kingdom there are also health regions with problems due to inequalities to access and to treatment. There is a training path and the access to it is by Curricula. The number of training jobs is regulated by the local needs. Continuing education is compulsory and strictly regulated local and nationally. The National Health Service was the example for the Spanish health reform in 1986. While Spanish Primary health care is of quality, the efficiency of the health system would improve if staff in Primary Care settings were managed in a similar way to the British's.

[Primary care in Sweden]. / La atención primaria en Suecia.

Sweden was one of the first European Union countries that saw the opportunity in the free movement of professionals. First offers for jobs were managed in 2000. Since then, a large number of professionals have taken the opportunity of a decent job and have moved from Spain to Sweden. The Swedish health care model belongs to the group of national health systems. The right to health care is linked to legal citizenship. Health is financed through regional taxes, but there is a compulsory co-payment regardless of the financial situation of the patient. The provision of health care is decentralised at a regional level, and there is a mixture of private and public medical centres. Primary care is similar to that in Spain. Health professionals work as a team with a division of tasks. Like in Spain, waiting lists and coordination between primary and specialised care are a great problem. Patients may register with any public or private primary care centre and hospital provider within their region. Access to diagnostic tests and specialists are restricted to those selected by specialists. Doctors are salaried and their job and salary depend on their experience, professional abilities and regional needs. Medicine is curative. General practitioners are the gateway to the system, but they do not act as gatekeeper. Hospitals offer a number of training post, and the access is through an interview. Continuing medical education is encouraged and financed by the health centre in order to increase its revenues.

¿Sobran o faltan médicos en España? La migración, el eterno recurso / Are there too many or too few physicians in Spain? Is emigration the timeless resource

A finales del siglo pasado, numerosos médicos españoles tuvieron que emigrar buscando un puesto de trabajo digno que no ofrecían en España. La década pasada el problema era, sin embargo, un déficit de profesionales que creó tal alarma social que se pusieron en marcha mecanismos que llevaron a la formación y a la inmigración descontrolada de profesionales para cuadrar las cuentas. El resultado ha sido un exceso de personal cualificado que excede la demanda. Hoy, los médicos autóctonos y todos aquellos invitados a venir y formados para una realidad sanitaria concreta se tienen que ir. Una planificación sin precedentes, por lo ineficiente, en países de nuestro entorno, caracterizada por la incapacidad de aprovechar la formación de sus profesionales sanitarios –médicos y titulados de enfermería–, por la falta de educación para la salud de la población, por el derroche en formación y por una inmigración no controlada (AU)

At the end of the last century, several Spanish doctors had to migrate overseas looking for a decent job. No decent jobs were offered by then in Spain. Last decade, the lack of doctors was a problem and a great social alarm was born. Mechanisms to attract doctors form overseas and medical training, both uncontrolled, were settled in, to get the numbers right. The result was a surplus of qualified health professionals. Today, overseas doctors who were invited to come and native doctors, both, trained for specific health situations have to leave the country. An extraordinary planning never heard of in neighbouring countries due to its "inefficiency". It was characteristic its lack of capability to take advantage of health professional's abilities - doctors and nurses-, its lack of population's health education, its waste of resources in training and its uncontrolled immigration (AU)

Are there too many or too few physicians in Spain? Is emigration the timeless resource.

At the end of the last century, several Spanish doctors had to migrate overseas looking for a decent job. No decent jobs were offered by then in Spain. Last decade, the lack of doctors was a problem and a great social alarm was born. Mechanisms to attract doctors form overseas and medical training, both uncontrolled, were settled in, to get the numbers right. The result was a surplus of qualified health professionals. Today, overseas doctors who were invited to come and native doctors, both, trained for specific health situations have to leave the country. An extraordinary planning never heard of in neighbouring countries due to its "inefficiency". It was characteristic its lack of capability to take advantage of health professional's abilities - doctors and nurses-, its lack of population's health education, its waste of resources in training and its uncontrolled immigration.

El copago también puede ser una medida social / Copayment can also be a social measure

La psicología muestra que se valora poco lo que no cuesta. Los sistemas nacionales de salud gratuitos pueden bloquearse por abuso en su utilización hasta hacerse casi inviables. El copago ya existe en España. Se introdujo en la prescripción farmacéutica como medida social solidaria. Este copago ha generado abuso por los beneficiarios. La introducción del copago siempre se ha concebido desde el punto de vista de una medida cofinanciadora del sistema o disuasoria del abuso que se hace del mismo. La solución verdaderamente solidaria se perfila en una correcta organización de un sistema de copago como medida social junto con medidas de eficiencia y uso racional de los recursos sanitarios por todos los actores que participan en el sistema: gestores, profesionales y usuarios(AU)

Psychology shows that what is free is poorly valued. Free of cost national health systems may become blocked due to misuse and may even become unfeasible. Copayment already exist in Spain. It was introduced in pharmaceutical prescriptions as a solidarity measure. This copayment has generated abuses. Its introduction has always been seen as a co-financing action to the system or as a discouraging measure to avoid misuse. The truly solidarity action is a proper organization of a copayment system as a social measure together with efficiency measures and rational use of health resources by all participant actors in the system: managers, professionals and users(AU)

[Copayment can also be a social measure]. / El copago también puede ser una medida social.

Psychology shows that what is free is poorly valued. Free of cost national health systems may become blocked due to misuse and may even become unfeasible. Copayment already exist in Spain. It was introduced in pharmaceutical prescriptions as a solidarity measure. This copayment has generated abuses. Its introduction has always been seen as a co-financing action to the system or as a discouraging measure to avoid misuse. The truly solidarity action is a proper organization of a copayment system as a social measure together with efficiency measures and rational use of health resources by all participant actors in the system: managers, professionals and users.

Emergence and outbreak of carbapenemase-producing KPC-3 Klebsiella pneumoniae in Spain, September 2009 to February 2010: control measures.

This report describes the epidemiological features of the first outbreak caused by KPC3 carbapenemase-producing Klebsiella pneumoniae (KPC-3-KP) in Spain and how it was effectively controlled. From 16 September 2009 to the end of February 2010, seven patients infected or colonised with KPC-3-KP were detected. Stool surveillance cultures were recovered from patients, doctors, nurses, nursing assistants, cleaners and hospital porters working in the affected units. Hand swabs were taken from workers and patients' relatives for culturing. Environmental samples were also taken. Patients infected or colonised with KPC-3-KP were placed in single rooms under contact precautions and 4% chlorhexidine soap was used for their daily hygiene. Staff attended educational seminars and workshops on hand hygiene and isolation of patients. An alcohol-based disinfectant was used for surface cleaning and disinfecting. The floor was cleaned with a disinfectant containing benzalkonium chloride and didecyldimethylammonium. All samples collected were negative for KPC-3-KP. After implementing the control measures, no further cases were reported in the affected units. All cases had comorbidities, long hospital stay and aggressive/intensive antimicrobial treatment. This study emphasises the importance of early intensification of infection control to interrupt the transmission of KPC-producing organisms.

Europa, una buena alternativa / Europe, a good alternative

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