Context
The Portuguese NHS has faced several budgeting problems in recent years. In fact, the budgeted funding for the NHS is not enough to cover its real spending, resulting in long waiting lists for appointments or surgeries, as well as an increasing struggle for hospitals in hiring human resources.
To tackle this problem, the government has elaborated a plan to improve the responsiveness of the NHS, focused on three main goals: achieve better access, improve health care workers’ motivation and increase investment in the NHS network.
Improving the NHS responsiveness means to promote a better and faster response from the NHS to the citizens, together with better salaries for health care workers.
Impetus of the reform
The Portuguese Government has given a special focus and relevance to the need of increasing investment in the NHS, without abandoning the quality and levels of public spending and budgetary sustainability of the health sector. The consolidated total expenditure in the Health Budget for 2020 is €11.3 billion, while the initial NHS budget is €941 million higher than in 2019.
Additionally, the NHS debt to suppliers is constantly increasing, reaching €2 billion in November 2019. The predicted NHS deficit for 2019 is €447.2 million, with total spending being €10.6 billion.
To achieve these goals, the government proposes robust management, to increase the value of program contracts, to correct persistent budget imbalances, to modernize and qualify facilities and equipment and to strengthen recruitment and motivation of health professionals, all materialized in the Plan to Improve NHS Responsiveness (Plano de Melhoria da Resposta do SNS) (1,2).
Content of the reform
The Plan to Improve NHS Responsiveness is based on a framework for multi-annual investments, which integrates and expands investments: NHS investments include the construction of hospitals and improvements of facilities and equipment. The main objective is to achieve a progressive and sustained reduction in the level of under budgeting in the NHS, allowing the reduction of deadlines to suppliers.
The phased elimination of under budgeting in health is accompanied by a reduction in the NHS global debt, by reducing the deadline of payments. Between 2015 and 2019, overall annual spending increased by 18% (€1.6 million), mainly due to increasing spending with health care workers (+26%) and medicines and medical devices. As a result, the Plan reinforces the Health Budget in €800 million for 2020 and reinforces the 2019 budget with an additional €550 million to pay the NHS debt. It also approves the framework for multi-annual investment program in a total of €190 million. During the next four years, new hospitals will be built, with a total estimated impact of €950 million, €102 million of those in 2020.
The Plan recognizes the need for a framework to recruit health workers and for incentives to increase performance of the NHS units and address health needs. As so, it establishes a framework for recruitment of 8 400 new health workers between 2020 and 2021 and it reinforces the autonomy for recruiting health workers of all NHS public enterprises.
In terms of the management of the NHS, the Plan defines €100 million to operationalize performance payment schemes in Integrated Responsibility Centres in NHS hospitals. This means there is a reinforcement of intermediate management in NHS hospitals, with internal contracts and incentives for results both to professionals and to institutions. The estimated financial impact is €100 million. Hospital administrations will have tighter accountability rules so that patients’ access and overall efficiency increase.
Nevertheless, management premiums in NHS public enterprises hospitals are dependent, inter alia, on the absence of late payments and the approval of management contracts and activity plans and budgets. Management premiums are financial incentives similar to those in place in primary care (salary bonuses) when certain targets are met: number of appointments, number of surgeries, decreasing of waiting lists, etc.