5.3. Primary / ambulatory care

A mix of public and private health service providers deliver Portuguese primary care. These include primary care units integrated in the NHS, the private sector (both profit and non-profit) and groups of professionals in private offices.

The primary care network ensures, simultaneously, health promotion and disease prevention, including the management of health problems, through a person-centred approach oriented towards the individual, the family and the community.

The number of publicly funded primary care centres and health posts continued to grow throughout the 1980s and mid-1990s, showing a slight decrease since then with a total of 387 primary care centres in 2012, covering the whole country. However, the number of primary care facilities, including all health posts that are part of PHCUs and FHUs, reached 1772 in 2015, including Madeira and the Azores (see section 4.1.2). In October 2016, there were 459 active FHUs in Portugal (SNS, 2016).

The facilities provided by each primary care centre vary widely in structure and layout: some were purpose-built to a reasonable size, with a rational distribution of space, and discrete areas for different purposes; some, mainly in large cities, were incorporated into the residential buildings and are poorly designed and not patient-friendly; and some, mainly in rural areas, were established in old hospitals. Relatively few outpatient contacts were made in Portugal in 2012 (4.1 per capita) compared with other European countries, being much lower than the EU average (6.9) (WHO Regional Office for Europe, 2016). This is consistent with the disproportionately and, arguably, inefficiently high use of hospital care, in particular for emergency services.

Primary care in the public sector is mostly delivered through publicly funded and managed groups (ACES). Each ACES has organizational (but not financial) independence and is composed of several units, which are integrated in at least one primary care centre (see section 2.6). In practice, the ACES coordinate primary care provision but do not have financial autonomy, which belongs to the corresponding RHA.

The ACES mission is to guarantee the primary care provision to the population of a given geographical area. To do so, the ACES develop prevention, diagnosis and disease treatment through planning and provision of care to the individuals, family and community, as well as specific activities to address situations of greater risk or health vulnerability. The ACES also provide mechanisms to connect the population with the long-term care network. There is a legal maximum of 74 ACES across the continental territory. The geographical area under the jurisdiction of ACES is set by the Decree-Law No. 28/2008, of 22 February 2008, corresponding either to NUTS III (Nomenclature of Territorial Units for Statistics), a municipality or set of municipalities (e.g. Lisbon has three ACES, each one covering around 250 000 people; a similar size of population may be covered by an ACES for the area of eight municipalities), taking into account the available resources and several sociodemographic conditions, including:

• the number of residents in the area, which should be between 50 000 and 200 000 inhabitants;
• the organization of the population in the area;
• the age structure of the population; and
• the population’s access to the hospital in the referral network (hospitals in which patients receive care, considering their residence area).

In Lisbon and Oporto, ACES are defined at a parish level (within municipalities) given the large population living in those cities. The aim is that ACES have a balanced composition in terms of population, ageing structure and location towards the referral hospital. This means that the rule for their composition is not strict and can change over time. For example, ACES located in the city of Lisbon were recently rearranged in terms of the parishes included in their respective areas.

The Ministry of Health allocates funds to the RHA, which in turn negotiates contracts (contrato-programa) with each ACES (see section 3.3.3).

Most primary care is delivered in the NHS by GPs as well as nurses in the primary health settings, together with local units and long-term care units, among others. The rest of primary care is delivered by private providers. Some primary care centres also provide a limited range of specialized care.

The health centre, which was created in 1971, is the result of the integration of social welfare medical services into the NHS started at the beginning of the 1980s (see Box5.4). Specialists who had worked for the Department of Social Welfare were transferred and given contracts in the newly established NHS primary care centres.

Box5.4

The specialists who work in primary care centres belong to the so-called ambulatory specialties, such as mental health, psychiatry, dermatology, paediatrics, gynaecology and obstetrics, and surgery. The current trend to provide some of these hospital specialties in primary care settings aims not only to improve access to the population but also to avoid hospital overuse. The range of services provided by GPs in primary care centres is as follows:

• general medical care for the adult population
• prenatal care
• children’s care
• women’s health
• family planning and perinatal care
• first aid
• certification of incapacity to work
• home visits
• preventive services, including immunization and screening for breast and cervical cancer and other preventable diseases.

Patients must register with a GP, and can choose among the available clinicians within the primary health care unit of their residence area. Some people seek health care services in the area where they work, but most choose a GP in their residential area. GPs work with a system of patient lists, with an average of approximately 1900 patients. People may change GPs if they write an application, explaining their reasons for the change to the Executive Director of the ACES. There is no statutory limit to how often people can change their GP.

Data from 2015 show that 7.2 million NHS users had at least one medical appointment at primary care centres (ACSS, 2016c). Between 2011 and 2015 there was a 6.3% increase in the number of NHS users who had at least one medical appointment at primary care centres, but a 6.0% and 9.6% reduction in the number of overall medical appointments and face-to-face medical appointments, respectively. Home visits showed a 3.0% increase during the same period, but are still very limited: 198 993 in 2015 (ACSS, 2016c).

Despite a reduction of 27% in one year, by the end of 2016 the number of NHS users not registered with a GP was 769 537 (ACSS, 2017) (see section 6.2). Thus, because they may not get a timely response, many patients go directly to emergency care services in hospitals or the private sector where the full range of diagnostic tests can be obtained in a few hours (see section 5.5). In fact, a patient who is not registered with a GP faces long waiting times at the primary care centre and hence, the patient usually prefers waiting for a long time in the emergency services. This leads to excessive demand on emergency departments and considerable misuse of resources as expensive emergency services are often used for relatively minor complaints.

The major problems currently faced by primary care include:

• an inequitable distribution of health care resources (staff shortages in remote areas), resulting in limited access to health care services for poorer and geographically isolated people;
• difficult access, resulting in emergency department overuse;
• very limited public provision of services in continuing and home care, despite recent developments (see section 5.8);
• mixed opinions by sectors of the population about the public primary care system;
• scarcity of quality control programmes, despite efforts by the DGH (e.g. launching programmes to improve quality) (see subsection Health care quality and safety in section7.4);
• a lack of motivation of GPs working in remote areas for fixed salaries; and
• a shortage of qualified ancillary staff in primary care centres (see section 4.2.2).

A series of health care reforms, initiated in 1995/1996, aimed to tackle these problems by increasing accessibility, improving continuity of care, increasing GP motivation with a new payment system (see subsection Doctors in section 3.7.2), stimulating home care services (see section 5.8) and improving quality.

The NHS has restructured the primary care services (see section 6.1) and this intervention included:

• implementation of local health units (Unidades Locais de Saúde) (since 1999; see Box5.4);
• development of information systems (mainly since 2007);
• implementation of the FHUs (2007);
• reconfiguration and autonomy of primary care centres, by creating the ACES (Decree-Law No. 28/2008, of 22 February 2008); and
• restructuring of public health services (2009).

The initial phase – the one that has had most public visibility – was the creation of FHUs, which consist of small teams of three to eight GPs, the same number of family nurses and a variable number of administrative professionals covering a population between 4000 and 14 000 individuals. These teams have functional and technical autonomy and a payment system sensitive to performance that rewards productivity, accessibility and quality. Their main goal is to maintain and improve the health status of people covered by them through general health care delivery in a personalized, accessible and continued way. In 2014, the Ministry of Health created the role of the family nurse. The Ordinance No. 281/2016, of 26 October 2016, acknowledges the need to create the specialty of Family Nurse, to be recognized by the Portuguese Nursing Association.

In October 2012, the Ministry of Health and medical unions signed a new labour agreement, that was intended to lead to an important (work) reorganization within health care facilities of the NHS, increasing access for patients to GPs and reducing overtime pay (i.e. the money received if GPs work more hours than those established). Overtime pay had not been in the agenda until the introduction of the MoU. The new agreement increased the number of patients on the list of a GP (i.e. the list of patients registered with a GP) from 1550 to up to 1900, and introduced a weekly reference number of hours (up to 18 hours) devoted to emergency service, which are included in the 40 weekly hours. Additionally, a special pay scale was put in place, with monthly (gross) salaries ranging from €2746.24 to €5063.38. This introduced flexibility in the allocation of physicians’ working hours. The previous agreement (2009) set the schedule at 40 hours/week, but there were additional dispositions for specialized work in emergency care, intensive care units, which implied extra and overtime payments. The new agreement allows the inclusion of some of these extra hours (which are paid at a higher price) into the normal (average price) payment system. Finally, the agreement added a new ruling, allowing for supplementary pay by the NHS associated with seeing patients who are not in a GP patient list.

Box5.4 discusses the integration of hospital and primary care, and health care and social support units. Box5.5 provides an assessment of the strength of Portuguese primary care.

Box5.5