As the Pact for Health is being discussed, it is urgent to rethink the role of care providers and their management model.

Along with other European countries, such as Italy, Greece and Spain, Portugal only started the development of a universal health system in the late 70s of the last century. This foundational period has been characterized as “the absence of a management culture appropriate to the specificity of health”. Thus, it was soon understood that the development of the National Health Service (SNS) would involve training intermediate and senior staff.

The specialization in Hospital Administration, given by the National School of Public Health, and the admission of its graduates to a career in Hospital Administration corresponded to this option of the health policy. The good contribution of the Hospital Administration to the creation, organization and qualification of public (and private) hospitals is irrefutable, as it is also in the exercise of management in other health units and bodies of the Ministry of Health.

However, in the last decade, Portuguese hospitals have undergone a process of entrepreneurialization and deregulation, with the hospital administration matrix having been reduced in favor of a discretionary model of admission to middle and top management positions without taking care to ensure the necessary knowledge, capabilities and skills. However, it is important to understand that this option only had room to be implemented due to the weakness of the current matrix. On the one hand, the high degree of centralization of decision in central bodies impeded the development of organizations. On the other hand, the growing complexity of the provision of care was not accompanied by the sophistication of continuing education programs, nor by the demand in the recruitment, selection and progression of graduates in hospital administration.

Thus, this weakness and inability to reform paved the way for a politicized management model, full of professionals without adequate training or specialization in health and, consequently, incompetent. Today, many of the health organizations are managed by curious people at the most varied hierarchical levels, who are not held responsible for the results of their (in)action. This fact has been recognized by the Court of Auditors, and even by CRESAP, associating the insufficient performance of hospitals and health center groups to the poor preparation of management and managers. The results of this process are well known, with the Central Administration having been compelled to “administer” health care providers as “its offices”. In other words, after more than a decade, entrepreneurship, associated with professional deregulation and mediocre and unprepared management, resulted in the return to square one of autonomy.

If more than ten years ago, the model did not satisfy, today the model is obsolete and unable to respond to the challenges that our organizations face (eg digital transformation of society; demographic evolution; potential changes in political and social values; new management models and health leadership; stagnant public spending on health; impact of new technologies on knowledge management; transformation of the treatment paradigm for various diseases with increased focus on prevention, personalized medicine and patient experience). In this framework, it is not possible to develop and/or innovate the service model according to the needs and demands of the community and health professionals, such as improving the quality and efficiency of health institutions.

These challenges can only be responded to with clear strategic options. Note that it is not just by optimizing the operation that we will be able to advance to the health system of tomorrow. Entrepreneurship without a vision of health and innovation will only perpetuate the current model. To reinvent healthcare provision, it is necessary to prepare healthcare professionals and healthcare management for increasingly complex challenges. Only with highly prepared professionals and supported by a competent leadership will it be possible to develop the NHS.

In this context, what is the role of Hospital Administration?

The progress of the NHS and its institutions requires coherent leadership and capable management. It is all too evident that health management has specificities that should be taken into account and that are difficult to acquire through a generic academic training in management or through training in the areas of healthcare provision.

The health system, and particularly hospitals, has been recognized as one of the most complex areas of management. Gone are the days when it was believed that healthcare organizations were so simple to manage that they could easily be led by unprepared professionals.

Let's see: the system does not need partial health care producers solely focused on immediate efficiency. The system needs managers who know the whole operation and who promote a collaborative network of providers that ensure health care centered on the needs of the citizen. Likewise, it is not possible for the administration to be performed by politicians, curious people or health professionals without a thorough knowledge of management methods and instruments.

As for more than 35 years, it is necessary to decide on the capacity of middle and senior management of clusters of health centres, hospitals and local health units. There should be no doubt that the quality of managers and leaders depends on their training and the knowledge, skills and competences they have.

The hospital administration career deserves to be restructured, becoming a healthcare administration and management career, in which access should be limited to those who have specialized training in health administration and management and the necessary skills.

Firstly, it is necessary to ensure the quality of the complementary training program in health management, comprising a solid theoretical component, but also the knowledge and skills acquired through internships and work accompanying the daily management of organizations. Given that access to the health management training program should allow recognition of skills, competences and professional experience and, necessarily, adapt the program to the need for additional training. The National School of Public Health has the potential to ensure these functions by restructuring the Specialization Course in Hospital Administration and by a greater participation of health organizations in the preparation and operation of the course.

Secondly, once the necessary training has been validated, as in the hospital administration career, it is essential to ensure access to the supervised exercise of the profession for a minimum period necessary to acquire autonomy to manage the health organization. After this period, there should be an evaluation of that exercise and transparent and competitive access to a career in healthcare management regulated through an appropriate legal instrument (eg collective bargaining agreement) should be triggered.

Thirdly, investment in a management body with specific training must be accompanied by a program of continuous training and performance assessment, without which professional practice must be limited and career progression impeded. Even the change in the areas of health management will merit the requirement to attend certified training programs.

More than three decades after the creation of the NHS, while the Pact for Health is being discussed, it is urgent to rethink the role of care providers and their management model, namely at the level of middle management and top management. Hospital administrators are part of the history of the NHS and will be part of its future. At first, we did not hesitate and said we were present to the most outstanding construction in the history of our Democracy. We were and are the cement that unites the parts of our hospitals, combining public health and management knowledge. We, by right, do not need to ask permission to continue learning and working, contributing to a NHS with better results for patients and the population.

Article published in the Jornal Público on April 20, 2016. The original article can be read on here