There are not enough doctors in Catalonia. Unions and the Catalan government acknowledge it. The deficit of physicians affects Barcelona’s metropolitan area, but it is in small towns where it is particularly challenging.

Without a school or a doctor, villages are condemned to disappear. Mayors are aware that maintaining essential services is the only way to slow down depopulation. The survival of their villages is at stake, but the discussion is much more profound. It is about the health system and the territorial distribution the country wants for the future.

Surrounded by vineyards and guarded by the greatness of the Montsant mountain chain, the Catalan villages of Ulldemolins and Poboleda seem unaware of the uncertainties of modern life.

The Catalan region of Priorat has world-famous wines, good restaurants, and an astonishing landscape. It is the perfect place to go on holiday, but daily life is not so easy. Curvy roads, distances that double when it snows, and the remoteness make it difficult for these villages to keep a minimum number of GPs. The staff is so tight that any unforeseen event causes anxiety, say Sergi Méndez and Josep Maria Díaz, mayors of Ulldemolins and Poboleda.

“Some of our neighbours are old people with chronic illnesses. When a doctor is off sick, and the medical practice cannot open, there are concerns and worries.”

Finding substitutes is almost impossible. When one of the doctors is on holiday or sick, the rest of the team has more patients to attend. The worst moment is in summer when population triples while the number of physicians declines for holiday shifts.

“Despite the pressure, we try to paper over the cracks”, says Doctor Elena Taverna, manager of the Health Care Centre in the villages of Cornudella de Montsant and Les Borges del Camp.

But just muddling along will be unsustainable in the long run. In the next 10 years, more than 8,000 doctors are expected to retire, some of them in the Priorat region, as Doctor Taverna warns:

“Three doctors retired in the last two years, and we expect three more retirements in the next three years. The problem is that nobody wants to come here.”

Where are the doctors?

Catalonia had 476 doctors per 100,000 population in 2018, behind the Spanish regions of Aragon, the Basque Country, Navarra, Cantabria, Asturias, and Castile and León. Madrid had the highest number, but its particularity – a big city with fewer square kilometers – would not make it entirely comparable with the other regions.

This graph shows the evolution of the number of doctors per 100,000 population between 2007 and 2018. Every Spanish region has increased its staff, but they have done so at different speeds, as the percentage change shows.

Madrid, Aragon and the Basque Country had the highest numbers, whereas Castilla-La Mancha and the autonomous cities of Ceuta and Melilla had the lowest. In 2007 Catalonia had more doctors than the Spanish average, but in 2018 it had the same.  

The Catalan government was one of the first to cut expenses in health care at the beginning of the financial crisis. Years went by, but resources never came back. Tired of the situation, last year GPs went on strike. The Catalan government recognized some of their demands and increased the number of doctors by almost 300. Unions consider these measures “bread for today and hunger for tomorrow” because they do nothing to solve the widespread lack of GPs in the country. 

The solution might seem simple: You need doctors, you hire them. The problem is that there are not enough GPs to fill the vacancies.

Family medicine is unattractive for medical students as the data shows: In 2018, only one in ten chose this field. 

Verónica Cusati is a junior doctor and she is part of the minority that wants to work as a GP. Family Medicine is extremely important, but it is discredited, she says. Apart from vocation and prestige, money is another key factor, she admits. 

“Areas such as cosmetic surgery are better paid. Performing a mammaplasty in a private clinic is not the same as being on duty in a public hospital.”

Around 8,000 doctors are expected to retire in the next decade in Catalonia alone. In theory, there are enough doctors to fill the vacancies. Spain is the second country in the world with more medical schools per number of people. Only South Korea has more. 

However, data show huge imbalances. Although Catalonia is one of the regions with more medical schools, it is the one that lost more registered doctors between 1997 and 2017, according to Organización Médica Colegial, an organisation that represents Spanish Colleges of physicians.  

Metges de Catalunya, the biggest doctors’ union, says data makes clear that the Catalan government is not able to retain and attract talent. Thirty percent of all doctors trained in Catalonia work in Valencia and the Balearic Islands. Aragon is another popular destination because, even though it has an income per capita lower than Catalonia, doctors there earn between 300 and 500 euros more per month.

In a TV interview, the Catalan Health Minister Alba Vergés acknowledged the salary gap and the problems that arose from the lack of doctors, especially outside the cities. “The government is working on a 20-year plan to solve the issue”, she pointed out.

How to make rural medicine more attractive

Professionals and unions agree that economic incentives may help. Doctors working in the county of Priorat already receive a bonus, but “the amount of money is so low that it does not even help to pay for the petrol”, says doctor Elena Taverna.

Being a rural doctor means working alone most of the time and inexperienced physicians don’t feel prepared, claims Carles Garcia, who has worked as a rural doctor for more than 30 years. 

“Junior doctors learn in a hospital or a health centre and they always work in teams. In a village, the doctor or the nurse have to know how to respond quickly and alone. This responsibility scares a lot of people.”

The intensive care unit is far away. In serious emergencies, Ulldemolins and Poboleda residents have to go to the Sant Joan de Reus Hospital. It is 40 kilometers away, but the road is so curvy that they need 45 minutes by car to reach the hospital. 

If there are no ambulances available, Priorat GPs have to handle emergencies but they only have basic training in cardiopulmonary resuscitation, says doctor Elena Taverna: 

“Every year, doctors in rural and urban areas are trained in cardiopulmonary resuscitation and basic support with a defibrillator. It is useful but too basic. We can only react the same way as any person in the street could do. We should receive advanced training”. 

More GPs for better service

In spite of the increase of chronic diseases and an ageing population, the number of GPs has stayed the same for years. To tackle the challenge and plan future needs, the Catalan Ministry of Health created a new role in 2018: the General Director of Health Professionals. 

Unions say this is better than nothing, but it is not enough. The measures arrive late. The lack of doctors is generalised in rural areas, but other Spanish regions took action earlier than Catalonia. Doctors in Aragon and the Basque Country have higher salaries, and Castile and León offers three-year contracts to the best junior doctors.

The strength of rural and family medicine has to do with the kind of health system we want. Do we want a more expensive model with the hospital as the centre, or do we prefer a more sustainable model with primary health care as the backbone? The choice will also determine the kind of country we will become. 

First published on Catalunya Ràdio website