Since 2011, I’ve worked as a locum GP in Portugal’s national health service, where patients pay five euros for each appointment with a GP. Many people are exempt from paying, for exemple pregnant women, children up to 12 years of age, unemployed people receiving benefits, and patients who have had transplants.
The co-payment to see a GP was 2.25 euros until 2011, but this figure increased the following year to five euros as part of austerity measures implemented by the then Conservative government.
As a health professional, I have mixed feelings about people having to pay five euros every time they need to see a GP. Five euros may not seem like a lot, but it is important to realize that salaries are very low in Portugal compared to Western European standards. The minimum wage is currently set at 530 euros per month. Approximately 13% of the Portuguese population earn the minimum wage. Considering that patients also pay co-payments for drugs and even higher co-payments to attend the emergency department (20.6 euros) and hospital outpatient consultations (7.75 euros), out-of-pocket expenses for even non-serious complaints can become considerable for the average citizen using the country’s national health service.
Personally I’ve found that co-payments often cause delays to consultations, as patients have to make a payment to administrative staff before seeing the doctor, and there are often long lines of people waiting their turn to pay, particularly during peak times such as the early morning. This means that I often lose precious time when I could be seeing patients, and may only see the first patient of the day at 08h15 rather than at 08h00, thus creating delays downstream (consultations are booked every 15 to 20 minutes depending on the GP practice) as well as frustrations for both me and my patients.
I also feel that the introduction of higher co-payments drove a lot of people to purchase private health insurance, as co-payments to see private GP’s and private hospital doctors are often less than five euros. This makes private medicine extremely competitive with the public system. Moreover, patients who use the private health system for most of their healthcare needs only resort to state GPs for certain things that only they can do and which are not so clinical, like issuing sick leave. This can generate additional frustrations and a lack of professional satisfaction as challenging clinical problems are being transferred to private doctors, which leaves us with far less interesting tasks. This has implications, for instance, in terms of attracting more doctors to primary care if they perceive it as being mostly about carrying out menial tasks.
From my experience, patients also feel a certain sense of entitlement when they make a co-payment to see the GP. When you pay for a service, you’re more likely to feel you have more negotiating power to demand something, even if the patient’s expectations may seem unreasonable for a GP (e.g. patient requesting expensive tests which the GP may not feel are clinically indicated). Moreover, patients often try to get their money’s worth by using the consultation to sort out multiple rather than a single problems, which can frequently lead to lenghty consultations as I explained above. It is therefore not easy to balance the patient’s expectations with the limitations of a public system where there’s very limited time and resources.
Co-payments in Portugal are called “moderating fees,” meaning they’re aimed at moderating the use of healthcare services. And even though this may be the case in certain situations, where one will think twice before seeing the doctor for self-limited illness for exemple, it may shift demand for health care towards those that have less need but more ability to pay. In other words, co-payments may foster the inverse care law.
The current liberal (socialist) Government has said it wants to lower these co-payments this year, which would be good news for most Portuguese citizens, who have already withstood very tough austerity measures since 2011. Austerity measures have generated a lot of unemployment and emigration, which has led to an increasingly aged, multi-morbid population staying behind, while a substantial proportion of the working-age population, who fund the national health service through their taxes, has left.
Although deep down I wish co-payments didn’t exist and patients were able to access truly free and high-quality publically funded healthcare, the system has to remain sustainable (it seems increasingly unsustainable to me) and therefore I am aware that is very unlikely to happen anytime soon.
See also: Should patients pay to see the GP?
Tiago Villanueva is assistant editor, The BMJ, and a locum GP in the Portuguese national health service.