Movimento pelo Doente - MD (Rallying for the Patient)

The MD’s program is meant for all citizens, giving however special attention to the less favoured, and will try, when possible, to communicate in a practical and simple form, allowing any citizen, who able to read, to contact the Movement and be understood. This program is based on the experience of the common citizen who feels the problems of day-to-day life, meaning also that it is a program which has been created from the citizen for the politics.

Considering:

Introduction

Now that 26 years have passed of the coming into force of the Constitution of the Portuguese Republic.
We have been living, until the present day, a lapse of time which serves to make history and analyse its effects.
And what is the conclusion?
The Rights and Duties of the citizens, expressed in the Constitution, are far away from the maturity which has been allowed. In reality, and even there have been some improvements, in response to the citizen's rights, the basic reforms of Justice, health, education and others, did not come out of the "Experiences" phase. Regarding the Duties , corruption, Bureaucracy, the economic/fiscal crime, the violence, the disrespect of the Authority and the law, postponing, disorganization, set up in the Portuguese society, and what should be a duty is many times, a way to reach personal benefits, instead of serving or respecting the other’s rights. Do on to Others what you would like to be done to you is a saying which for many people, has been forgotten.

Facing this reality, a group of citizens has been fighting, since 1995 for a higher quality of services and attention of the various Public Services to the Portuguese Society, both in the Continent or the autonomous Regions (not forgetting the many Portuguese living abroad), especially at the SNS (National Health Service), as mentioned at the article 64th. of the Constitution of the Portuguese Republic - "Everyone has a right to Health Protection and has the duty of defending and promote it". It must be clear that Health is not only the lack of health, because injustice, unemployment, a bad education, a bad quality of life, violence... are implied, undoubtedly, with Health.

Accordingly,

Principles

The MD participates in public and political life in view to promote and defend actively, in every sphere of the portuguese society, the Justice, Peace, Solidarity, the rights and duties of the citizens and the fundamental rights and, in particular, the derived social rights, namely, the basic right to health protection, through a continuous appeal to the State’s responsibilities and the public opinion, including the portuguese, everywhere throughout the world, to the need and urgency of the respect for the ethical humaneness which vivifies, since its origin, the portuguese culture, participating, together with other political parties, in freedom and equality, in the moulding and the expression of the people’s will, and to the organization and activity of the political power, through the respect of the rules of democratic plurality, of the Constitution and the laws.
The political activity of the MD , namely in the necessary critical position of the Government’s activity and that of the Public Administration, as well as the elaboration of the electoral programs, will be based on studies, considerations and internal discussion which, through their objectivity, rigour and serenity, may participate with dispassionate knowledge of the problems and lead the way to the search of realistic and fair solutions; its internal life and its public activity will be guided by the principles of democracy, transparency, participation and respect of the options of living, by the religion and the philosophical and political conceptions of its members and generally all citizens.
MD is prepared to collaborate with national institutions which aim for the same principles and may establish normal and regular cooperation with foreign and international institutions, according with the rules established in the Articles of Association the MD.

Competences

As established by the rules of the MD (art. 25th) and until the conclusion of the actions of the 1st Session of the National Congress, which will occur at least till April 22nd of 2004, the competences of the National Political Commission, as designated in the Articles of Association, will be carried out by an Installation Commission, formed by all the members of the Board and the Fiscal Council of the Association called “Movement Organized Against the Waiting List of the Health Assistance – MOCLES”, NIPC 504344730, whose registered offices are at the “Rua Conde Alto Mearim, 1193, 1st, Room 1, 4450 – 036 Matosinhos, and until seven representatives of the General Assembly of the same Association, by them elected, and presided by the Chairman of the MOCLES.

The program of the MD will obey a real and outstanding dynamic, not only to be different from others but because its experience will result in a simple action which may be resumed as follows:

Actions to be undertaken
(Without obedience to protocolar rigour)

- Set up an important group of counsellors, composed by citizens who, through their knowledge, experience, sensibility, honesty and competence, may help the MD, through their advice and interference;
- Salute the President of the Republic, as the first person of the nation;
- Send a written communication to the President of the Republic Assembly and to all the Parties wich are represented there;
- To request an audience with the Prime Minister;
- To request an audience with the representative body of the Magistrates;
- To request an audience with the President of the Medical association;
- To request audiences with the Order of Doctors and Nurses;
- To request audiences with the President of the Bar Association;
- To request audiences with the representative bodies of the Medical and Justice Unions;
- To request audiences with the Union of the Organizations of Mercy;
- To request audiences with the Associations of Doctors and Hospital Attendants;
- To request audiences with Associations for the Defence of the Rights of the Patient;
- To request audiences with the League of Hospital friends;
- To promote meetings with the Regional Health Administrations;
- To promote meetings with the media;
- Create and enforce the humanistic and ethic values, which are present in the Portuguese culture since Ancient times;
- To develop from youth upwards the liveliness and enthusiasm for the search and maintenance of ancestral traditions of the portuguese people;
- To visit Hospitals and Health Centres;
- To contact the police forces, through their national divisions;
- To relate to the Portuguese community living abroad MD’s purposes;
- To promote activities with the members of Parliament of other nations, with a seat at the European Parliament;
- Obtain information about the state of public and private health at a national level (and consult the site “National Health Observatory” on the internet);
- Provide a site on the internet with a dynamic information, compilation and exchange, related to the MD ;
- Create a department for the gathering of suggestions, ideas, complaints (without backstairs influence);
- Other actions in course, to be executed as soon as possible.

Objectives

Some reflections and practical proposals for the change at different levels of the nation’s activity (concluded through the Government’s action), with incidence on the SNS (National Health Service).
These reflections and proposals are not necessarily new, but, because of the author’s experience, are seen from a different point of view.

Recollection
The lack of capacity to respond to the needs of medical assistance in relation to a large part of the population on the part of the SNS, predominantly regarding the less favoured, and the consequent suffering, and in many cases, causing the irreparable increase of clinical patologies and even death.
Perception
Our perception is that the basic incapacity is due to lack of efficiency, taking in account two essential perspectives: one, humanistic, at the level of the suffering of those who do not have the means to look for other solutions; and another, political, due to the bad use of public moneys by the political power or agents of the respective sector, not using them the right way.
Public moneys
We must refer the need to check the undue use (even criminal) of those public moneys . One example, among others: the bad use in public hospitals, of equipments of high medical technology, at high costs, leaving them to dilapidation. Is there someone responsible for this?
- The lawyer, Dr. António Arnaut, a former Health Minister, declared in an interview given to the “Jornal de Notícias” on the 24th June, 2001, page 26, that there exist “irresponsible waste” and defends the reforming of the health system and the political and even criminal responsibility of all the agents of the sector, “including the government responsibles foremost”. “The fault may not remain unpunished. There is a need for responsibility and conscientiousness. Those who disrespect these elementary principles must be made responsible”.
And who has assumed this responsibility? Who has been judged in Court? Is there no need to investigate the recent-past, when the State’s budget for health exceeded the budgets by hundreds of billions escudos? What about the passing resolution of the Ministers Cabinet, n. 13/96, of January 24th, with financial costs, creating the Councel of Reflection on health, who after a long and worthy work, with special commitment of Prof. Dr. Daniel Serrão, published in 1998, a “blue-book”, named “Recommendations for a structural reform”, which has been “put in the drawer”?
Waiting lists at the SNS («National Health Service»)
It could be interesting to promote and find someone to sponsor a serious study on the problem of the waiting lists at the SNS in Portugal, considering:
- The exact number of hospitals and services;
- The estimation of the rate of increase/decrease and position at this time;
- Origin of the problem;
- Evaluation of the two programs for the reduction of the waiting lists, already performed by previous governments;
- Analyse of the present program;
- The flow of integrants of the lists between the SNS and the private.
Knowing how to do better
More than words and promises, more than writing or making theories, more than spending money, it’s urgent to do better . It is urgent to reform the SNS, endowing it with capable administrators at any level, from the medical services to the administratives, requiring more organization, discipline, responsibility and stimulation for those who act better; avoiding waste, taking all necessary steps to avoid misuses and misappropriations; lowering the waiting lists at surgery, consulting-rooms, diagnosis, hospital’s internement, social action.
All these actions fitted in a time period, which will not provoke health problems or interfere with welfare of the sick, or suffering due to the delay.
Directors / Administrators
We are aware that the existence of good and highly competent hospital directors and administrators, not necessarely doctors, to whom the Government gives the necessary resources and essential power for their activity, depends on a good team, and consequently offer a qualified service and satisfaction to the sick.
One must not forget that “human weakness” may lead to the appointment of a director/administrator thanks to “backstairs” or political influence.
Directors of hospital services
On the hospital organization level exists, in our opinion, a corner-stone for the good functioning of the institution: the services director. He should be responsible for all the human and material means affected to those services.
This director must have a high technical competence and good management capacity, his requirements being strickly linked to those demands, as well as a salary adequate to a person, of his great responsibility.
Some examples to keep in mind: the Cardio-Thoracic Surgery Services of the Hospitals of the Coimbra’s University, directed by Prof. Dr. Manuel Antunes; and as a posthumous tribute, the Pediatric Services of the Hospital de S. João, at Oporto, when Prof. Dr. Norberto Teixeira dos Santos was director.
Exclusivity
To revise the hospital’s rules (legislation) referring to the exclusive services, making them more efficient, controlled and consequently, avoid possible misuses.
Tracking the SNS
Watching and foresee the citizen’s health, especially those recommended by WHO (World Health Organization), which recommends the tracking or early detection, means “spending money” now in view to save more in the future, and offering welfare for the citizens. The tracking, in due time , of cancer, infectious diseases…, are a good example, as well as the preventive examinations during the seasonal diseases (allergies, influenza, …). One example/question: which costs are supported by the SNS with the hospital’s infirmaries crowded with sick people, especially the elderly, who, if clinically observed, and in time, could avoid worse, sometimes chronicle, illness?
And furthermore on this matters, why not create:
Recourse Hospitals
“Hospitels”, as they were called by Dr. Paulo Mendo, doctor and former Minister of Health.
Aged people are appearing more frequently at the central hospitals; for reasons linked to their age, these people need more time to recover.
After the stabilization of their illness (or accident), they could be transferred to these “Hospitels”, or recovering hospitals, with less medical care and thus at a lower cost and more humanity, allowing the central Hospital to the important cases they have to resolve.
And incriminate (and legislate if necessary) those who forsake an ill familiar or handicapped person, ascendant or descendant, or of acknowledged responsibility.
Humanization
Humanization is more and more necessary, and especially by those who will one day become health professionals, to whom Psychology must be instilled as a vocation, permitting a better contact with the ill. They also must be taught to apply a “speech therapy” with the patient, with surprising results, during their career.
We propose to include in this theory a fact, which usually is taken as “normal”, but which is not, because it leaves the health professionals marked with sensitivity and affection: the death of “their” patient. It is presently known that, during the preceding moments of death, there exist some clear indications that it will happen and are often detected by the health professionals who are near to them; those professionals should be allowed to inform, by phone (which usually appears on the patient’s file), a family member, friend, voluntary, permitting the presence of someone of his near relations during his last moments of life. For the patient, especially if he has some lucidity, the perception of a lonely death means a great suffering and loneliness, impossible to describe. We can testify this, even when the moribund is “apparently” in a comatose situation. When he has some company, his nature, at those times, tries in several cases, to look for a special and unknown forces, of a surprising serenity that we ignore, but that one can feel, or even see, on the face of those who are taking their last breath.
Medical Home Visit
Drawn up procedures, simple but rigorous, between the SNS and private doctors, under a strict control of the Regional Health Administrations (ARS), permitting the consultation and advice to those confined to bed, occasionally or long illness, when duly proven.
With respect to the bed-stricken, and with difficulties (even with their family help) in being looked after at all levels in their home, this duty done by local authorities (civil parishes), Parishes and Red Cross, …, has been remarkable. However, this task should be fulfilled by the Health Ministry, through the ARS, which must promote and cherish this work, with incentives for the best performers.
At this level, we still refer:
Homes for the bed-stricken
They are spread all over the country, but in a small number. About those which are known to us, we must point out as examples to follow , one at Beire, Paredes, and another at Oporto. The first one, “O Calvário”, belongs to a charitable fund, directed by a priest (Father Baptista), which offers outstanding work and assistance to the sick, a humble dedication and a brilliant example of brotherhood. It is a home for uncurable sick persons. The other belongs to the Parish of Carvalhido, also for uncurable persons, inspired by the example of the first one.
Insurance Companies
The injured people, who are sent to emergency services of the Central Hospitals, under the responsibility of the Insurance Companies, should be transferred from these hospitals to the direct responsibility of the Companies (Private Hospitals), as soon as there are no risks of life for the injured. If this is not possible, the costs of hospital care should include a supplement.
Informatization of the SNS
Health reform is not possible at the present times without the complete informatization of the SNS. In a first stage , all the staff of the Central Hospitals would get an intensive and qualified preparation, in accordance with their functions as part of a group of professionals. An equal treatment should be given to all the staff of the ARS.
In a second stage , all the other Hospitals, Health Centers and other would be given the same preparation.
N.B. : why not organize a public referendum, if necessary, using the database with medical information of the Patient (which will always remain confidential), and allow the medical services (and only them), to consult the personal file of the patient under the Doctor’s responsibility of secrecy to which he is obliged? In case of a injury/emergency of a Patient with a medical “file”, this file would be of special interest. Since it also represents a sensitive issue but of relevant interest, why not use the same system for the human organs donors in case of proved death? (those who do not agree may declare it at an adequate time).
Regionalization of the SNS
Reform the ARS (starting with the Central Services of the Health Ministry itself), cleaning them of the “vices” that have been accumulating throughout the years, proceding to an evaluation of the functions and productivity of those who work for the SNS, the staff as well as people undertaking other functions, directing them to other functions or providing them with professional training, rewarding them in accordance with the work to which they were designated: good services to the population . That is why their work is paid for with public money. Once this task is achieved, the ARS should be given power to make its own decisions, according to a set budget and personalised and creative programs, limited to their geographical populational area, and integrated in a Central Evaluation System of the Health Ministry, in Lisbon.
Health Centers in the inland regions of the Continent, Azores and Madeira
Since the regional Health Centres lacks the capacity to respond to the medical needs of their population, central or regional Health Centres should be created (in existing, new or rented sites), at central locations, permitting a regular medical assistance, also covering the neighbouring parishes, the expenses of transport being paid by the government, at pre-established rates. The payments could be made through travel tickets, furnished by specific entities, not excluding the administrative Councils near to the residence of the patients or the existing Health Centres.
This program would free Doctors and nurses, enabling them, through incentives, to become more interested in joining the centralization.
Even the regional Hospitals, under-used, could benefit from centralization.
The Media could represent an important role, including the local press, radio and television, and the Parishes, by providing careful information for the local users of these medical services.
As to the existing local Health Centres, without Doctors, and the distant parishes, these could be useful as first assistance and information posts, using the remaining human resources of the centralization.
The Health Centres, with Doctors, which provide quick and qualified services, would be maintained.
Preventive medicine with especially equipped vehicles
There exist inland centres in the Continent, Azores and Madeira, with few inhabitants and away from the more important centres, which should be visited periodically by medical teams, particularly specialist, permitting the prevention and detection of diseases, in cooperation with the Regional Health Centres. There already exists a Ministry Instruction of 1986, of the former-Health Minister, Dr. Leonor Beleza, which deals with this problem. However, nothing has been done.
Hospitalar Emergencies at Central Hospitals (cities)
There is a tendency on the part of the people who “feel” ill to go directly to the Hospitals emergency services, not using their local Health Centres, for various reasons, but more especially because they know that the Central Hospitals have better equipment and resources than the local centres: Specialists, CAT, X-Rays, clinical analyses, etc.
Most of these patients do not realise that their presence may “obstruct” the Emergency Services, provoking serious problems to the patients who really need these services. At the same time, they tire the Health Profissionals during their service. Frequently, these “Patient” persons who are going through the selection of the Emergency Services become angry and nervous and may, on rare occasions react on a violent manner.
Anyway, and regarding the reaction and normalization of the majority of the citizens , it would be recommendable that these cases, not considered as emergencies, be directed to an area in the hospital where a permanent consultation service can take place, served by General Practitioners, and where the diagnostic and conclusion of the destination of the patient would be indicated, being then discharged from the hospital or directed to the Emergency Services. The Santo António Hospital, at Oporto, began with this on an experimental basis during the services of its former Director, Dr. Luis de Carvalho, which was then abandoned by other doctors, replacing it by an evaluation of British origin: the Manchester’s selection. But we are Portuguese...
Regarding the necessity of General Practitioners, some could be transferred to regional Health Centres, being to refer once again the necessity of organization, order and application must be rewarded by the respective responsibles... and put in practice.
Pediatric Emergencies Hospitals
A sick child must always be considered as an emergency, untill the diagnostic has been confirmed, respecting, however, the hospital’s practicing.
The Hospitaly Emergencies and the lack of Doctors, mainly specialists
The making of a Doctor takes many years, and in case of a Specialist may take up to 14 years. Some hospitals are near to the breaking point, and some are, sometimes, unable to find a right solution for the needs of a patient who need emergency treatment, having to be transferred to another hospital. And we are talking of Central Hospitals.
The Hospital’s Emergency Services are usually assisted by a majority of young Doctors, the main part full of goodwill and with a spirit of cooperation, however with a certain lack of experience. We must keep in mind that a patient who goes to an Emergency Service with an emergency problem must be seen by experienced doctors, since life or physical incapacity of those patients may be in danger .
At the present moment, the patients who call in someone’s medical help are attended by medical teams, mainly young..., who have almost 12 or 24 hours continued service, and who must examine and attend them, being poor or rich, Doctor or relative. And the “backstairs help” may, sometimes, be present. It is known to happen that “special” patients who need assistance and enter the Emergency Services, do not succeed in being recognized in time to be “recommended”. That means Just Equality...
Confronted with this given situation, and until there are no other solutions to fill the gap of medical teams with more experience and in greater number (which will still take some years), MD shall make an appeal to Doctors (individually and through its official representatives), who are not obliged to assist Emergencies, especially because they have arrived at their deserved years of rest, to give some assistance, considering the time they can spare from their normal life, and with a convenient financial reward, and an humanitary way, sworn in their Hipocrate’s Chart, and to the fidelity to the noble exercise of their profession. All the medical people, in the same conditions, will be asked for the same cooperation.
PATIENT PEOPLE: Rights and Duties
We know that the Portuguese society, in a normal situation and in accordance with its origin , is rich of traditions but poor in education. They are quickly aware of their rights, but also quickly forget their duties. This reality is always present when they appeal to any service and especially in case of Hospital Emergency. If possible, they would become gate-crashers. Some attend the Hospital’s Emergencies, especially on Mondays, to obtain a confirmatory formula to prove, before their professional responsibles, that they are unable to work. And when the Doctor refuses.... It becomes necessary to explain to the Portuguese that they have duties, using all the psychological means at the right times.
University studies
One must reward the best classified applicants and especially the OUTSTANDING ones, to help them in their vocation. The same treatment should be given to the professors.
Regarding the scientific experiences, we must allow the outstanding students, after a convicted desire on what they pretend to learn, to follow their vocation, after the recommendation of their specific professors, national or foreigners. We have a lot of “grey matter” which is not been put to use and financial resources being badly spent…
Alternative Medicine (so called)
We must recognize that they may be useful and can resolve some Health problems by natural means and physical exercises. When recommended and undertaken by people of recognized technical capacity, they may be useful. However, we propose that their honorability and technical capacity should be controlled by the “Medical Association” or another entity recommended by the Health Ministry. One may not forget that the use of such treatments, if not controlled, may be extended beyond the necessary time, provoking an immoral financial charge.
Local Authorities
We appeal to avoid the luxurious municipal buildings in favour of Institutions defending the public Health, such as providing drinking water and the improvement of sanitary conditions. We must convince ourselves , once and forever, that we are a small country with reduced financial resources and a lot of them being misused or used in the wrong way. We have thousands of children (and adults) who drink water from public fountains and springs without quality, playing in poluted water which provoke, in many cases, “silent” diseases, which later may become severe diseases. The air pollution also represents worrying statistics, causing allergies, some of them uncurable, chronical diseases, so often observed. Without speaking of the sound pollution...
Courts
We appeal to the Civil Officers, begging them to put the laws of this country into operation, everyone is aware of the delays of the Courts, and to exercise their influence to become a real state of Rights, where the Justice is applied in a swift way. The slow reply of the Courts, facing an abnormal quantity of proceedings, is enough to provoke severe diseases in citizens, especially of psychiatric origin, and leading them to violent reactions and family problems. Even the law officers and public prosecutors are suffering due to these problems related to delays.
Bureaucracy
A lot of promises, spoken or written have been expressed, but the failures of the system of organization of the nation continue, excepting a few cases, due to personal dedication and efforts, have resulted in some improvements in the nation’s administration. It is necessary to give better training to the people responsible for ruling the nation, rewarding seriously those who are giving a good example. Sometimes, bureaucracy leads to corruption and stress, which provoke a loss of time and the use of medicines. Is that the way to rule a country?
Security of the citizens and their assets
Even more citizens (and the children) fear violence, and this problem is presently one of the main concerns of the Authorities and is being studied and analysed by responsible people. This violence has provoked and is still the origin of fears, nervous diseases, hospital treatments, physical incapacity and even deaths. The action of the police authorities is often said to be inadequate, because of possible violent intervention. There are inquiries related to the action of the police and some are taken to in Court. There have been discussions in the Parliament and some politicians are seriously divided. The citizens are anxious and apprehensive and want to express their problems within their democratic rights, as it is only fair, through their legal representatives: the Deputies. Everyone, before the revolution of April 25, suffered the violence of the authorities. However, are the new authorities acting as in the past? What do the people think today? Who represents the citizens and defends the lack of security and the violence? All the politicians elected by these people? Does the existing legislation not need to be changed, permitting the Civil Officers to propose more efficient means, more severe and more respectful measures for the rights and duties of today’s and future citizens?
Promises
Considering the Program of the present Government and especially the public announcement by the Health Minister, of the SNS for the reduction of the waiting-lists for health care, it is quite soon to evaluate the efficiency of the announced measures.
We are waiting for the evolution of the program which will transfer the surgery operations to the private institutions, impossible to execute at the Public Hospitals, and whose discussions will take place at the Parliament, as well as the new proceedings of Hospital management, provided by the basic law on Health. However, we suggest that these measures would be backed by legal and complete procedures, approved by the Surgery Services which performed the surgery, since, after the operations, the patients will return to their usual Public Hospital, to be examined to obtain their discharge or to continue in medical care, for the necessary time.
We take the opportunity to remember the days of the former Health Minister, Dr. Paulo Mendo (1995), who proposed a daring program for the reduction of the waiting list in surgery (PERLE), which consequently provoked some abuse relating to the ideas of its author.
We also propose that precautions be taken to avoid dubious situations between Public and Private Hospitals.

Conclusion
We wish to invite all those who deal with the National Health System, and especially the politicians, to assume their responsibilities and to find in the short-term solutions for an efficient Health Reform, without personal or political claims.
We believe that the Intelligence, Understanding, Honesty and Goodwill will have the last word and put the DEMOCRACY at the service of the good Portuguese people.
And let us not forget the other urgent Reforms already mentioned.

Oporto, MD, July 2002