4.2 Human resources
4.2.1 Planning and registration of human resources
The ACSS is responsible for planning and recruiting human resources for the NHS units, especially hospitals and primary care units (see section 2.3.1). Coordinated actions take place at central and regional levels to assess human resource needs and implement measures to streamline recruitment and placement of health care professionals (doctors and nurses). The RHAs analyse human resource needs of the NHS health care institutions within the respective region. Then, RHAs give an opinion that is analysed and decided at the central level. The ACSS launches tender procedures at the central level, taking into account needs foreseen by RHAs. These tender procedures may follow exceptional rules foreseen in the annual state budget: for example, financial and non-financial incentives for recently appointed doctors in needed areas; special regimen to recruit retired doctors for primary and hospital care (Decree-Law No. 89/2010, of 21 July 2010 and Law No. 7-A/2016, of 30 March 2016); temporary mobility regimen – for doctors only – for distances of less than 60 km (Law No. 66-B/2012, of 31 December 2012). Most NHS staff are civil servants and all new posts have to be approved by the Ministry of Finance. However, increasing numbers of workers are under individual contracts, which do not confer upon them the same rights as those of civil servant status. In addition, rules for civil servants are clearly becoming closer to those of private labour relations.
The numerus clausus for accessing medical schools varied in the last four decades between approximately 180 and 1800, but this significant increase in the number of new medical students was not guided by any planning of long-term need for physicians. Although there is a shortage of GPs (see section 4.2.2), there are strict limitations in terms of internship places, which depend on the reported capacity of NHS health care facilities (primary care centres and hospitals). Despite the existence of an active constraint on the number of postgraduate medical training places, the number of junior doctors increased from 6728 in 2011 to 8515 in 2014 (+27%), particularly in training programmes for GPs and family medicine (+70%), which shows the effort that is being made to address the limitations in primary care. It is widely recognized that there is a shortage of GPs and that this situation is likely to worsen in the future, as current GPs start to enter retirement. Recent decisions of the Ministry of Health regarding training vacancies indicate a willingness to deal with this issue.
In recent years, several frameworks of medical training (currently Ordinance No. 224-B/2015, of 29 July 2015), including new access rules, organization and governance, with a transitory period, were approved. Institutional cooperation with all entities involved in medical training led to an increase in the training capacity. The ACSS and the Portuguese Medical Association jointly decide on the number of specialized medical training places: the Medical Association is responsible for certifying each institution’s competence to receive a resident for postgraduate medical training and the ACSS is responsible for recruiting and placing the new doctors. Besides the accreditation of postgraduate medical training, the Medical Association is responsible for the accreditation and granting of licences to practise. There is no periodic relicensing of doctors, although the Medical Association has already indicated openness to do so in the future.
According to the EU Directive 2005/36/EC, of the European Parliament and Council, of 7 September 2005, which provided for the mutual recognition of professional qualifications in the EU Member States, there are seven professions whose recognition is automatic: doctors, dentists, nurses, midwives, pharmacists, veterinarians and architects. For all those where the Directive does not apply, they must request the recognition of their diploma from the Ministry of Science, Technology and Higher Education as well as the respective professional association.
The ACSS also plays a role in career development and training of health care professionals. For instance, in recent years collective labour negotiation with doctors’ unions took place to achieve a new salary scale and the reduction of supplementary work and external medical services, and to increase the doctors’ patient lists from 1550 up to 1900 patients.
4.2.2 Trends in the health workforce
According to the figures from the Portuguese Medical Association, the number of physicians (physicians registered, including retired physicians) per 1000 population is currently above the EU average (Portuguese Medical Association, 2016). The situation regarding nursing staff is quite different. The relative number of nurses in Portugal is well below the EU average. The definition of tasks that can be performed by nurses and by physicians probably contributes to this lower ratio. Still, recent years have witnessed a movement towards a rebalancing of this trend, with a greater increase of nurses than of physicians, and this is likely to continue in the future. One of the major challenges for the next decade, not yet translated into policy actions, is the redefinition of roles for health care professionals.
In 2015, there were 54 467 active members of the Portuguese Medical Association (Portuguese Medical Association, 2016), whereas in 2014 there were 25 246 physicians employed by the NHS – 816 more doctors (+3.3%) than those working in the NHS in 2013 (ACSS, 2015). GPs, working in primary care, accounted for 29.5% of the total number of physicians in the NHS, 69.0% were hospital physicians, and 1.5% were public health specialists. After witnessing a very rapid increase in the number of doctors during the 1970s and 1980s (from 95 doctors per 100 000 population in 1970 to 283 per 100 000 in 1990), since 1990 Portugal has maintained the increasing trend in the number of physicians but at a lower rate (Fig4.2). In 2014, there were 443 physicians per 100 000 population, higher than the EU average (350/100 000) (WHO Regional Office for Europe, 2016).
Fig4.3 shows that Portugal, like Spain, has steadily increased the ratio of nurses to inhabitants, but has one of the lowest ratios in Europe (638 per 100 000 population compared with the EU average of 864 per 100 000 population in 2014). The rise in the number of nurses reflects a policy adopted in 1998, with the creation of a four-year university training programme for nurses (licenciatura) and the opening of at least one publicly funded nursing school per district. Despite the increase in the number of nurses, the growth rate (compared with any previous year) has progressively decreased. Between 2012 and 2013, there was a negative growth in the number of practising nurses. In 2014, there were 66 340 nurses in Portugal, of which 39 316 (59%) were employed in the NHS (ACSS, 2015). Within the NHS, approximately 83% of nurses work in hospitals, while 17% work in primary care (ACSS, 2015).
The number of dentists has increased steadily since the early 1990s, reaching 85 per 100 000 population in 2013, more than in Italy, Spain and the United Kingdom (Fig4.4). Since the mid-1990s, in addition to three existing schools in the public system, several private schools for dental care medicine have opened. Training of new dentists increased sharply in the last two decades. Since the NHS does not offer extensive dental care coverage, dentists work almost exclusively in the private sector. According to the Portuguese Dental Association, there were 8933 active dentists in Portugal in 2015 (one dentist per 1161 inhabitants) (Portuguese Dental Association, 2016).
The number of pharmacists in Portugal has increased steadily in the last 15 years (Fig4.5). However, in 2013 Portugal still had a low ratio of pharmacists (77 per 100 000 population) compared with Spain (112/100 000) or the United Kingdom (80/100 000). According to the Pharmacists’ Association, in 2014 there were 14 668 active pharmacists in Portugal, of which 59% worked in community pharmacies, 9% worked at hospital pharmacies, 6% in clinical analyses and 5% in pharmaceutical industry (Portuguese Pharmacists’ Association, 2016).
See Box4.2 for the evaluation of the geographical distribution of health workers in Portugal.
4.2.3 Professional mobility of health workers
Between 2001 and 2015, the number of foreign health workers in the NHS has peaked in 2004 (4490) and has steadily decreased since then (ACSS, 2016b). The number of foreign doctors (mostly from Spain, Brazil, Ukraine and Angola) working in the Portuguese NHS increased until 2005 and has been decreasing ever since (ACSS, 2016b). However, in 2015 the number of foreign doctors in the NHS was still higher than in 2001 (Table4.6). Among foreign nurses, there was an increasing trend until 2003, and a strong decrease until 2015 (Table4.6). This was mainly due to changes in the Spanish nursing labour market, which was the main source of immigrant nurses in Portugal (ACSS, 2016b).
The economic crisis and deterioration of working conditions in the NHS are leading an increasing number of Portuguese doctors to leave the country (Table4.7). The Portuguese Medical Association holds records of doctors requesting the necessary documents to be able to practise medicine abroad. A survey was conducted in 2014 to follow up on those requesting the documents and reported that Brazil, Spain, the United Kingdom, Germany, Switzerland, France and Ireland are the main destinations (Público, 2014a). Reasons for leaving the country are mostly related to better working conditions and more attractive salaries paid abroad. Doctors emigrating are both specialists and junior doctors pursuing their postgraduate medical training abroad.
Portugal has become a source country for nursing migration. Many Portuguese nurses are seeking work opportunities abroad, in countries such as Spain and the United Kingdom. Several recruitment agencies are operating in Portugal (Público, 2014b), some of which try to recruit young nurses in nursing schools. Better salaries and benefits, having a new experience, and lack of job and career opportunities in Portugal are often pointed out as the main drivers for young nurses’ migration.
4.2.4 Training of health personnel
There are currently eight medical schools in Portugal (two in Lisbon, two in Oporto, one in Coimbra, one in Braga, one in Covilhã and one in Algarve). Medical training programmes at the medical schools of Lisbon, Oporto and Coimbra follow the same curriculum and, since the Bologna Process, are divided into two cycles of three years each, leading to a Master’s degree: a core programme covering the basic sciences and a clinical programme based on practice and specialized procedures. The two medical schools (opened in 1998) in Braga and Covilhã are developing innovative educational programmes characterized by problem-oriented lectures favouring a tutorial system, promotion of training that is closer to the communities and less hospital-focused, and with more multidisciplinary integration. In 2008, the first Master’s in Medicine was created at the University of Algarve, exclusively for people who have graduated in other areas and want to pursue a medical education. This Master’s degree differs from the previous programmes as it targets those who have already graduated, being more practical and based on problem-solving lectures. The length of the degree is four years, whereas the other faculties have a six-year programme.
In 2007, the Ministry of Health approved a law that regulated the creation of vacancies in Portuguese medical schools for applicants with a previous university degree (Decree-Law No. 40/2007, of 20 February 2007). This Decree-Law recognized that the scientific background of clinical practice and biomedical research was becoming more and more based on sciences not only physics, mathematics and biology, but also social sciences. For that reason, it was considered justifiable to widen the vacancies in medicine to candidates who had skills in these areas of knowledge. The existing medical schools were given the freedom to define the areas of knowledge of the prospective candidates, as well as the admission criteria by the Decree-Law No. 40/2007, of 20 February 2007. Between 2007 and 2011, each medical school was required to open at least 5% of the total vacancies for graduate applicants and, after 2011, 15%.
After concluding the medical degree, all graduates enrol in a national tender to pursue postgraduate medical training in the NHS. The government, through ACSS, is jointly responsible with the Portuguese Medical Association for the accreditation and certification of specialist training for medical graduates. That includes a national examination, which comprises 100 multiple-choice questions covering the digestive system, blood diseases, cardiology, nephrology and the respiratory system. After that examination (that usually takes place in November), graduates undertake a general internship for 12 months (Ano Comum), including three months of training in the primary care setting (general practice and public health), and nine months of training in the hospital setting (internal medicine, paediatrics, general surgery and an optional internship). On completion of the general internship, graduates are placed in their postgraduate training positions, according to the results that they achieved on the national examination: the results determine the order by which the positions – medical specialties and formative institutions – are taken. At the completion of the first year of training, junior doctors are free to practise without supervision. The duration of specialized training is determined by the specialist colleges of the Medical Association and varies according to different medical specialties: medical (i.e. hospital non-surgical) specialties: five years; surgical specialties: six years; general practice/family medicine and public health: four years. Specialists must be skilled in the diagnostic and treatment procedures of their own specialty and must be proficient in related techniques. They also have to carry out research and publish scientific articles, which are evaluated in curriculum analysis. After recognition of their aptitude, they can apply for a hospital position or go on to private practice.
In Portugal, there have been no nursing auxiliaries or equivalents since the 1980s. Currently, there are 31 public and 19 private nursing schools offering general nursing training, some of which offer two courses per year.
Nurses graduate after four years of university-level training as general nurses and are able to provide general nursing care in every health care context (hospital or primary care). In order to do that, they must register with the Portuguese Nursing Association. To become a specialist nurse, nurses have to enrol in at least two years of general nursing practice and must attend a specialization course (Cursos de Pós-Licenciatura de Especialização em Enfermagem) offered by nursing schools (Ordinance No. 268/2002, of 13 March 2002). This specialized training comprises theoretical and in-service training in the area of specialization and is of 900 hours duration (approximately three semesters). The only exception is midwifery training, which lasts at least 18 months full-time with the obligation of conducting at least 40 normal deliveries. The vacancies are determined by each nursing school offering the specialized training. Currently, there are seven areas of specialization:
- mental health and psychiatry
- community health
- children’s health
- medico–surgical nursing
- family nursing.
After specialized training, nurses are able to provide specialized care (defined generally by law) in their area of specialization. The practice of nursing is regulated by law and the Portuguese Nursing Association is responsible for its reinforcement and sanctioning (the Nurses Code of Practice came into law in 1998). Registration is mandatory for all nurses practising in Portugal.
Other health care professionals
Since 1986, several public and private dentistry schools have opened. The courses have had a 10-semester (approximately five years) duration since the Bologna Process changes (previously, it was six years of training), and consist typically of four areas of knowledge: basics, biomedics, clinical and multidisciplinary. Previously, physicians who undertook three years of dentist specialist training after their medical degree provided oral health care. Another nonmedical grade exists, that of orthodontist. The government introduced this grade at a time when there was a severe shortage of dentists, but it has been replaced by the degree in dental medicine awarded by higher education institutions.
There are also several allied medical professional degrees being offered, covering 18 specializations (such as physiotherapy and radiology).
In Portugal, there are several public and private pharmacy schools that offer degrees in pharmaceutical sciences. After the Bologna Process, the programme, previously a six-year degree, was renamed Integrated Master's Degree in Pharmaceutical Sciences, with a five-year length. Upon graduation and enrolment in the Pharmacists’ Association (Ordem dos Farmacêuticos), pharmacists may pursue a specialization. The specialization is a complementary training with variable duration, and is supervised by a Specialist Pharmacist. At the conclusion of the specialization, the pharmacist obtains the title of Specialist Pharmacist in a certain area of intervention: clinical analysis, hospital pharmacy, pharmaceutical industry, community pharmacy or regulatory affairs. The Pharmacists’ Association is responsible for the representation, supervision and regulation of pharmacists in Portugal.
There are also pharmacy technicians (graduates in pharmacy after a polytechnic programme of four years). The ACSS regulates the profession of pharmacy technician.
4.2.5 Physicians’ career paths
When medical doctors finish their graduate medical education after six years of undergraduate studies, the residency year and four–six years of specialty residency, they become an assistant physician, the lowest step in the NHS graduate physicians’ hierarchy (the others are graduate assistant physician and senior graduate assistant physician). Promotion within the NHS hospital hierarchy is based on both the number of years and the positions available in the structure. The hospital boards are responsible for these decisions.
4.2.6 Other health workers’ career paths
The majority of the health staff working for the NHS are civil servants, and have a standard civil servants’ career path, with some particular features. Those who are not civil servants have individual contracts, which are regulated by private labour market rules.
As for the physicians’ careers, a nursing career is considered to be a special career within the public service. In 2009, the nursing career was reviewed and two categories were created: nurse and principal nurse (enfermeiro principal). To be a principal nurse, it is mandatory to have a specialization and to have practised within the field of specialization for at least five years (Decree-Laws No. 247/2009 and 248/2009, of 22 September 2009). Access to both nurse and principal nurse positions is achieved by applying to competitive calls. In 2014, the Family Nurse was recognized as a preferred profession for the provision of nursing care in the community and primary care settings (Decree-Law No. 118/2014, of 5 August 2014), and 35 primary care units (both FHUs and PHCUs) were selected to pilot the inclusion of a Family Nurse in the practice (see section 5.3). However, this experience is yet to be piloted, so there is no evidence of the possible impact of Family Nurses on the NHS.
Unlike other health staff, dentists and most pharmacists do not work for the NHS, and they do not have a clearly defined career path.
Since 2010, there has been a tendency for health workers, mainly physicians, to both retire early and work for the private sector or to practise in both public and private sectors. Additionally, some professionals choose to practise abroad, where they can find higher salaries and better working conditions. The Ministry of Health is trying to overcome this trend by providing more attractive working conditions.