Taking advantage of the ten conferences organized by EL ESPAÑOL and the Camilo José Cela University on Freedom in the 21st centurywithin the framework of its 10th and 25th anniversary respectively, I have given thought to a topic that is not discussed in the cycle, since we cannot talk about everything: freedom and health.
My father, Dr., said Juan Abarca Campalfor more than thirty years now, freedom in healthcare is not the same as healthcare in freedom.
My father advocated that the important thing is that freedom can be exercised in healthcare, because that pushes us to act within a framework that, if it were the opposite (healthcare in freedom), would not exist.
And that would give rise to debauchery: to the law of the west in healthcare.
Something that, without control, would go against patients.
But let’s go to the beginning. What do we mean by freedom and health?
Doctors in an operating room.
If what we defend is healthcare in freedom, the concept is very broad, ideological even. It means that the health model itself is based on the freedom of the individual as a structural principle, not as a concession. It is not “there is freedom within healthcare”, but healthcare is born free, operates in freedom and seeks to preserve freedom, not just health.
On the other hand, if what we defend is freedom in healthcare, we are starting not from freedom as a basic point, but from the prior existence of a healthcare system. And that means introducing the concept of freedom within the health system.
That is, talking about how the citizen exercises power within a system that already exists.
That is, healthcare in freedom implies a new moral, philosophical and political framework.
Freedom in healthcare is more reformist and modern (in addition, it induces citizens to exercise their rights within the system).
At the current time, no one is advocating, publicly at least, for a radical change in our healthcare system. Therefore, we are going to defend the model that defends that freedom can be exercised within an already existing health system.
But for that we must also analyze very well what are the brakes that can limit that freedom and why they arise.
The origin of our system is clear.
Our current National Health System (because the debate on this option must focus on the public health system) has its origins in the era of the dictatorship. Specifically, in the sixties, with the creation of the Social Security Basis Law of 1963.
The Franco regime then created a health model to protect the citizen with a suffocating paternalism, whose fundamental bases are still in force sixty years later.
This is the model that has survived to this day and is based on the idea that the system is above the individual and, therefore, is not accountable.
And that manifests itself in an absolute lack of transparency and information to the citizen.
We citizens have been made to believe that if you ask, choose or compare you are unsupportive. A moral discourse has been constructed that places the citizen in the perfect role: grateful, obedient and, above all, silent.
And meanwhile, without noise, the system has stopped being accountable to the patient.
He is accountable only to himself.
Congratulations for lowering waiting lists, when all you do is manipulate the definitions of wait.
Reporting a mammogram done months ago in thirty days is called success.
He measures his performance, not by what the patient feels, but by what is politically convenient for him to tell.
But the most dangerous thing about this drift is that it becomes normalized. Let society accept it as if it were an inevitable event. “It is what it is and what there is is the best in the world.”
That phrase has done more damage to health freedom than any decree.
We have become an anesthetized society. Trained to complain at the bar, but resigned to not demanding what belongs to her.
“Everything that brings freedom is stigmatized. Because freedom makes you uncomfortable. It forces you to give explanations. To compete. To justify results”
We have given up asking for information, transparency and decisions.
And when someone suggests that, perhaps, the citizen should be able to choose a hospital, professional or way of receiving care, the system responds with the magic word: “privatization.”
And all the alarms are raised.
Everything that brings freedom is stigmatized. Because freedom is uncomfortable. Forces to give explanations. To compete. To justify results. And that is what many within the system have avoided for years. They want everything to stay the same.
When talking about healthcare, the same argument is always used: there is a lack of resources. More money, more professionals, more investment.
And it is evidently true that we must invest more.
But it is worth unmasking something. This is not just a money problem..
It is a power problem.
Budgets can be doubled, thousands of new places created, and even the last clinic can be computerized. And even so, the citizen would still be without freedom if the design of the system continues to be tutelary.
If the system is still in charge and not the patient.
Because a system that does not allow the citizen to choose or change is a system that never has incentives to improve. Live comfortably. Self-satisfied. Armored.
Health freedom is being able to say: “if you don’t come, I’ll go with someone else, and thus force you to improve.”
How good a law of guarantees for any thirty-day diagnostic or therapeutic act would be for this country and for patients.
We would see how public health increased its productivity.
Primary Care Doctor in a consultation.
Freedom, in healthcare as in any other area, is not preached. It is guaranteed by creating real alternatives. And today, in Spain, the citizen has no real alternatives in the public system.
You cannot demand a second diagnosis if no one offers it.
You can’t look at a hospital’s complication rate to decide where to have surgery.
You cannot know how many days it actually takes to diagnose cancer in your community.
You can’t automatically switch teams when you feel abandoned.
All that freedom already exists in other sectors. But not in healthcare, because in healthcare there is an acronym that justifies everything: SNS. A word used as a shield to avoid accountability.
“One thing is certain. A system that does not compete, that does not listen, that is not accountable, is a system condemned to its own exhaustion”
A word that is directly opposed to another word that is much more revolutionary: citizen.
And this is not a question of ideology. The future of healthcare will not be played between the public and the private. Nor between more or less budget. It will be decided based on whether we continue to keep the citizen as a passive subject or finally place them as the axis of the system, with real power.
And having real power means having operational rights. Real rights.
1. Right to choose professional.
2. Right to know the health results compared by center.
3. Right to automatically change hospitals, public or private, if a reasonable period is exceeded.
4. Right to access all your clinical data in real time.
5. Right to be heard not as a favor, but as an obligation.
And that is freedom in healthcare
And if that makes you uncomfortable, it is because it means returning the system to its legitimate owner: the citizen.
We are right at the critical point. Aging, pressure on professionals, chronicity, the technological revolution. Everything is converging. We could use this moment to reframe the system around a powerful idea: responsible freedom.
Or we could, as so many other times, let everything slowly deteriorate while we repeat that “we have the best healthcare in the world”.
One thing is certain. Without freedom there will be no sustainability. A system that does not compete, that does not listen, that is not accountable, that does not allow alternatives, is a system condemned to its own exhaustion.
The real enemy is not the left, nor the right, nor the private. In fact, there would be nothing more progressive, more modern and more fair than giving power to the patient.
The real enemy is paternalism. A paternalism that makes the citizen a subject before the system. A system that, in addition, requires that you thank it, when its financing comes from the citizen.
And there will come a day when, if the system, to guarantee its survival, does not give answers to the citizen, he will demand to break the framework, start from scratch and will go from demanding freedom in healthcare to a new contract in which the freedom of the individual against the system prevails.
And then we will talk about healthcare in freedom.
*** Juan Abarca Cidon is president of HM Hospitales.