“The ULS were not sufficiently prepared. They were made in a hurry. The model needs adjustment, and perhaps the adjustment is to eventually separate the areas [hospital care and primary health care]. There is enough time to realize that it is not possible to manage these two areas in the same way. They are very different cultures, very different care organizations, and this must be taken into account,” stated the president of USF-AN.
In statements to Lusa, on the eve of the National Health Service (SNS) completing two years of national coverage under the ULS model, André Biscaia admitted that “a concept of common administration” might be maintained, but considered that it should allow for “a focus also on primary health care”.
“It is not that what has been done so far needs to be completely erased, but this system must evolve, and the evolution is this,” he emphasized.
Recalling that the first USF-AN statement on “the idea of expanding the ULS” was released at the end of 2022 and that the expansion came into force at the beginning of 2024, André Biscaia said that “there was enough time to make a significant change that should have gone well, but in fact, it was not planned, structured, or prepared with the necessary resources.”
“Suddenly, five ARS [Regional Health Administrations] are ended, 55 health center groups are ended, and 39, plus 31, are formed, adding to the other eight ULS [that already existed]. All this is a very profound change that needed more care. There were major failures in supporting the units on the ground, throughout the chain of command,” he lamented.
Pointing out that the change began “with a hospital culture,” André Biscaia reported that “for six months, it was not clear how to process the wages of primary health care professionals,” and as a result, “the previous system prevailed, and in a way, primary health care was lost within the system.”
“The idea of the ULS is a good one in theoretical terms. What is really intended is the integration of care. Now, to say that a ULS is integration of care by itself is another matter,” he summarized.
Since January 1, 2024, Portugal has been entirely covered by 39 ULS. The reorganization was announced as aiming to facilitate access for people and their movement between health centers and hospitals. The ULS integrate hospitals and health centers under a single management, and in parallel, the ARS disappeared.
“At the time, it was often mentioned, even in an article, that the executive director of the SNS would be able to gather the 39 presidents of the ULS in a medium-sized room. But a governance model where the central part has to relate to 39 different board presidents is very difficult. The previous governance model, which included the ARS, allowed for certain proximity,” he analyzed.
Recalling that “Portugal is not very large but has very disparate situations,” André Biscaia considered that “it is difficult to work with general determinations and guidelines.”
Referring to a study by USF-AN presented in October, the association’s president pointed out that only 40% of Family Healthcare Unit (USF) coordinators think there has been an improvement in the integration of care, while only 55% believe the ULS respect their autonomy.
“And then, there are failures in what was said the ULS would improve, which was the whole provision, technical support, recruitment of professionals. What we see is that the logistical support from the ULS to the Family Healthcare Units (USF) is positively evaluated by 22% of the coordinators. Meanwhile, 99.6% of the USF experienced failures in the IT sector, and only 59% of the USF have a complete team,” he added.
For André Biscaia, it is imperative to ensure a “more or less protected” budget for primary health care, maintaining the ULS board but creating two “more or less autonomous” departments, one for hospital care and another for primary health care.
“And there was a whole support structure for primary health care, which is what is missing. Proximity management is fundamental in any system,” he concluded.
