Feature

Healing by primary intention

While the UK argued about a primary care-led NHS, Cuba got on with it – and it worked, reports John Waller

Imagine a state-financed health service where the number of hospital admissions and A&E attendances is going down every year, or where the average wait to see a specialist is a week or two – and the patients complain if they have to wait a month.

No, it’s not fairytale land: welcome to Cuba. But how does it do it, and is Cuba’s approach transferable to Britain?

More doctors and nurses?

In Britain, the average GP has 1,900 patients, while in Cuba the number is about 600. Consequently, Cuban family doctors and their attached family nurses have the time to effectively do all the health promotion and chronic disease management that British GPs and practice nurses would like to be able to do.

The first Cuban family doctors and nurses were introduced in 1984, and today enough have been trained to cover the entire country. Annual admissions to hospital in Cuba peaked in 1985 at 16 per 100 people. Ever since there has been a slow but steady decline, down to 12.3 per 100 people in 1999.

This far higher level of supply is reflected throughout the service. Specialist provision is about two-and-a-half times British levels, for instance, leaving Cuba with a doctor to patient ratio of 1:170, compared with about 1:600 in the UK.

How can Cuba afford it? Partly because it spends, like many western European countries, about 8 per cent of its gross domestic product on its health service compared with Britain’s 6 per cent but principally because its social structure and organisation is so different. The social wage of free or highly subsidised goods and services that every Cuban receives is relatively very high, and the personal wages are extremely low.

Add to that the relatively narrow wage differentials in the state sector – currently about 5:1 between consultant and cleaner – and you have the cheapest doctors in the world. In fact, they’re so cheap that Cuba probably has an over-supply, although at any one time 2,000 – 3,000 are lending their services on internationalist missions in other developing countries.

Health workers with more dedication?

On such low wages Cuban health workers have to be dedicated to their work – and largely, they are. The emphasis in training is very much on being a servant of the people, and with private health care practice completely banned there is no conflict of interest for specialists. Though they might be dedicated, with far superior staffing levels they aren’t working under the degree of pressure experienced by many in the NHS.

A better organised system?

Cuban family doctors practice from individual consulting rooms but they are all attached to a neighbourhood polyclinic covering a population of about 30,000. The polyclinic provides many health and social services and is the base for nine specialists: three each in general medicine, paediatrics, and obstetrics and gynaecology. Increasingly, these specialists will have begun their careers as family doctors. In addition, consultants in many other specialties will visit the polyclinic on a weekly basis.

The emphasis is on dealing with problems in the community. If the family doctor can’t treat a problem, the patient will see a specialist in the polyclinic within two weeks. Sometimes the family doctor attends with the patient to learn from the specialist.

Many of the tests can be done in the polyclinic lab, and if the consultant feels an admission is required? With a surplus of doctors, and hospitals running at 70 per cent occupancy rates (down from 80 per cent in 1990 owing to fewer admissions), there generally won’t be much delay for admission or operation. The delays that do occur are usually the result of a shortage of spare parts for medical equipment that Cuba can’t easily obtain because of the US government’s economic blockade of the island.

A&E work is also handled somewhat differently. Every polyclinic provides a 24-hour emergency room staffed by family doctors on a rota, while selected polyclinics have in recent years been designated a wider role in emergency care (perhaps something akin to our minor injury units), with estate cars converted to basic ambulances. In 1980, hospitals handled 80 per cent of emergency consultations and polyclinics 20 per cent. By 1999, polyclinics were dealing with 55 per cent of cases, and the overall number of emergency consultations was 10 per cent below its 1985 peak.

Lessons for Britain

Britain can’t replicate Cuban wages and Cuban-style staffing levels, but all too often discussion of the need for service modernisation can obscure the central NHS problem of a lack of skilled personnel.

In addition, Britain does not have the political will or the consensus to dispense with private practice. Cuba, at least, shows what can be done with a high-quality health service that is 100 per cent state provided.

Perhaps most relevant in the short and medium term is what the NHS can learn about how to organise the system. When the Cuban health service set about its modernisation agenda in the mid-1980s the key was making primary care central to the provision – not purchasing – of health care. All Cuban medical students are now trained to be family doctors, to practise what they call ‘integral general medicine’. Only as mature doctors can they specialise for hospital or polyclinic work.

‘Integral’ perhaps defines the Cuban approach in two senses. The approach to the patient integrates individual pathology with an understanding of the economic, social and family determinants of ill health, while primary and secondary care integrate seamlessly – with the polyclinic as the literal meeting point.