President of the Portuguese Association of Hospital Administrators criticizes the ministry's lack of planning and transparency. “Ten years later, going back to asking a foreigner for help because of our fault is humiliating”, he says.

The government this week admitted asking for international help. Are hospitals on edge?

What we've always said is that it takes timely planning. Realize what resources were available to respond to the pandemic, in the public sector, in the private sector, in the social sector, in the military sector. There could even be a political decision to only use the NHS, but that planning should accompany the decisions. If we have a thousand infected per day and we know that 10% need hospitalization, and there is an average hospitalization delay of 10 days, after ten days we have a thousand hospitalized. If we have 10,000 cases a day, we are talking about 10,000 hospitalized after ten days. The decision to confine or toughen pandemic mitigation measures depends solely on the capacity of the system. Hospitals in September handed in their contingency plans. What was the capacity indicated by the hospitals? Were these values taken into account to confine? At some point it seems that people forgot about it and let it go.

Are you talking about relaxing measurements at Christmas?

Even before Christmas, in some regions of the country, the contingency plans made in September had already been exceeded. This was the case with Penafiel. All that planning that was done in September is what should inform the decision to confine or not. And from the moment the measures are no longer tightened because it is known that this penalizes society, the economy, employment, it is known that hospitals will have to give more. And so instead of having 100 beds, you have to have 300. We can then arrange back structures and we have more slack to have more infections per day. We didn't see any of this being planned in a structured way. It didn't come out of the paper. The minister was asked a few days ago if this scenario was ever foreseen. The answer is no. The scenario of rupture in a situation like this must always be on the table, with the planning of the different resources that can be activated and in what way, whether in the private, social or military sectors. We reach a certain level of effort and this means is activated. It was the plan that should have been made in September and already contemplating the international aid scenario. This has to happen before the collapse, because if it happens after the collapse it means that we are going to have people dying in an avoidable way. So I don't know what limit we had, the point at which it was said that it was no longer possible.

Are we in this collapse situation?

The disruption of the system happened before the second wave. The system has been in deficit since April. When we got to November and we have 120,000 fewer patients operated on, more than 10 million face-to-face consultations to be carried out and recovery was not possible, there was a collapse. The system broke down a long time ago.

Hospitals on the outskirts of Lisbon complained this week of an uneven distribution of patients and unequal effort rates. Do you understand this criticism?

Everyone had to be involved in the planning and understand the rate of effort required of each. We have been talking for months about the need to improve coordination, initially the concern was to have a common management of intensive care beds, also recommended by the intensive care committee and which was never structured. On a daily basis, doctors continue to work with groups on Whatsapp, saying “please stay with this patient”. What the hospital administrators' letter shows above all is the total disarticulation of the network. They note that there is a greater effort in some hospitals than in others, but I don't know and I don't know if everyone knows if this was predictable or not, because there may be more differentiated hospitals that have to maintain more critical services, a neurosurgery that cannot close, etc.

Or to envisage a strategic reserve of beds in a hospital in the event of an accident, a natural catastrophe?

Precisely, but it would be something everyone should know if they had gathered and planned. At this moment, they see the effort of each other and feel that it is unequal, but this may or may not be real.

Going back to the beginning, was the request for international help unavoidable at this time?

Ten years ago I participated in the implementation of the economic and financial adjustment program. I confess that it was one of the most difficult moments of my professional life and that I had many hardships when having to be accountable to foreign countries. Ten years later, having to ask for foreign aid again because of our fault – because this situation is our organizational and planning fault – is humiliating. Now, of course, between putting the lives of Portuguese people at risk and passing humiliation, naturally we pass the humiliation to save lives.

What kind of help is needed?

I think essentially human resources that can be made available, especially to open up back structures. It is not in the transport of patients (to abroad) that we are going to solve the problem, it is a structural issue. At this moment, our projections point to around a thousand patients who may leave hospitals for backup structures. These structures have to be activated and need human resources.

Are you talking about social cases, patients who could have already been discharged?

I'm not even including social cases anymore. They are patients with moderate covid-19 who can be treated in low intensity structures.

One thousand of the 6,000 inpatients could not be in hospitals?

Yes. And so we need people to activate these structures so that hospitals can concentrate on the most seriously ill, namely those who need oxygen therapy, and also seriously ill patients who are not covid.

This week the Amadora-Sintra oxygen network went into overload. Can the same happen in other hospitals?

One of the concerns we've had since March, when we developed a tool for planning the resources needed to respond to the epidemic, then adopted by the WHO, was to be able to predict intensive care and oxygen therapy needs, this more with a view to developing countries that depend more on cylinders and they don't have as many channeled oxygen structures. So it was a variable that we followed. In the projections we made last week for this one, given the evolution, I made this alert: we are at a pressure level that advises checking the oxygen supply networks. I was far from imagining what happened in Amadora-Sintra, but right now all institutions have to review their infrastructure. It's not lacking oxygen, but realizing the capacity that exists. And just as we made that alert last week, we have to think the same for fans. We may reach a limit situation in some institutions in terms of available fans. There may even be 200 fans to use, but they have to be in the right place.

When can this limit reach?

At this time, our projections indicate that this week, in terms of mechanical ventilation, we can reach 844 ventilated patients until Friday in the best scenario and 987 in the least optimistic scenario. Yesterday we reached the most optimistic scenario, in non-ventilated patients. But the point is that we have to be prepared for the worst-case scenario and there has to be an agile management of the fan base, because a patient who needs to be ventilated cannot wait a day.

In addition to human resources, what other support can be provided by other countries?

I think that will be the essential. We need resources that we have not been able to hire in the last ten months and we have been above safety ratios for a long time, with professionals working consecutive shifts and in great exhaustion and ethical suffering. There, too, we could have had strategies to attract Portuguese professionals who are abroad, but for that we had to have attractive conditions and not four-month contracts, which naturally would not make people return to their country.

Yesterday it was learned that a team of German doctors was already in Portugal carrying out the needs assessment. Are you aware of this mission?

No, but I confess that it seems a little strange to me that foreign countries are coming to carry out a needs assessment. We should know what we need and ask for that help. We went back to the need for transparency: we had to have known what the limits were and what price the country was willing to pay to control the pandemic and know what is needed now. Now I don't think we're in a situation where we can't say what we need to. The human resource planning tool for the response to covid-19 is Portuguese. It was delivered to the Ministry of Health in March. We have planning capacity in the country. The Portuguese hospital administration does not need lessons in hospital management neither from the Spaniards, nor from the French nor from the Germans. You know how to plan. And it must be said that many alerts were made in time. What we showed is that some people didn't know how to plan and didn't know how to do it.

Is it a criticism that you direct to the Ministry?
Obviously.

The health minister said this week that it is criminal to say there was no planning. Wasn't there enough?

The minister said that it was criminal in front of the people who were working every day on that planning. The point is that we all have to be subject to peer scrutiny and understand what planning was done and how. I am not talking about political evaluation. It is a technical question that has to be answered by the Government: what was the planned breaking point of the NHS. It's not enough to say you're on the edge.

Interview conducted by Marta Reis and published in Jornal I on January 28, 2021. The original text can be consulted on here