Hospital administration and working conditions reform proposed

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A public debate has begun in Portugal about the privatisation of public hospitals. Medical, paramedical and nursing unions have reacted largely negatively to proposed changes in the regulation of industrial relations, employment contracts and working conditions, and strikes were due in August-September 1997.

Two strikes in the health service were planned at the beginning of August 1997.

  1. The public health service announced a strike which is to take place in the second half of September (this is the first time that the 115,000 workers are proposing to strike together as a sector). There is a widespread reaction against the proposal to alter conditions in the health service (relating to the legal status of hospitals and the organisation of health centres), a reaction which is being backed by five trade unions, namely: the Portuguese Nursing Union (Sindicato dos Enfermeiros Portugueses), the National Federation of Doctors (Federação Nacional dos Médicos- FNAM), the Independent Union of Doctors (Sindicato Independente dos Médicos- SIM), the Nursing Union of Madeira (Sindicato dos Enfermeiros da Madeira), the National Federation of Public-Sector Unions (Federação Nacional dos Sindicatos da Função Pública) and the Paramedical Union (Sindicato dos Técnicos Paramédicos). Both SIM and FNAM are requesting the Doctors' Association (Ordem dos Médicos) to establish a medical forum to discuss the professional implications of the proposals, which is a matter contained within its remit. Furthermore, the unions are also going to present their case to the Prime Minister, the President and the Chair of the Legislature.
  2. The Portuguese Nursing Union is threatening to go on strike over negotiations for the collective agreement covering the private hospitals sector.

Issues at stake

At present there are two issues under discussion:

  1. the new proposed administrative structure of the health services, in particular with respect to hospitals; and
  2. the repercussions for industrial relations.

The Ministry of Health has released the text of a proposal to restructure the administration of hospital health services and health centres following meetings with doctors' and consumers' associations. Public debate over this plan is expected to intensify in September. A recent inquiry revealed poor functioning and failures in various aspects of healthcare services.

The Independent Union of Doctors gave the proposal a very negative reception. Furthermore, the SIM is standing alongside the National Federation of Doctors against the Ministry of Health's intention to transform hospitals into trusts "with a liberal managerial ethos" run by managers who, according to the unions, are not always appointed according to the efficiency criteria prescribed by FNAM. They claim that this is a project similar to that implemented in the United Kingdom by Margaret Thatcher, which had negative results.

The Doctor's Association, on the other hand, broadly accepts the proposals, but advocates certain amendments. In the main, they are striving for the autonomy of the medical board (the professionals) from the boards of directors.

According to the trade unions, the administration of the hospitals is going to be based on an annual budget, which will condition staff numbers and the care of patients. Hospital managers would be able to indicate lack of financial means as the grounds to dismiss employees, who would then lose their contractual rights. According to the General Confederation of Portuguese Workers (CGTP), this proposal will make working conditions more precarious and will not improve, in any way, patients' access to healthcare, nor will it rationalise the resources of the national health service.

Alterations to working conditions

Discussions about amendments to the legal status and restructuring of the health services are related to certain changes to be introduced in working conditions and career prospects, some - but not all - of which result directly from the present proposals. Where there is a link, the unions are maintaining the following.

  • One of the basic arguments being used by the Ministry of Health is that an obstacle to the efficient functioning of hospital units is related to career progression in this sector. This is, however, seen as an attempt to pull apart and destroy professional careers which are already very problematic. In fact, some workers are currently permanent public service employees whilst others are contracted on "atypical" conditions. One of the most contested matters is the introduction of individual employment contracts, temporary or otherwise. This would introduce a third category of employment contract (terceira categoria de contrato) alongside existing public service and "atypical" work contracts. On the other hand, those with permanent contracts are not necessarily well placed either. There are, for example, doctors still working as assistants after employment by the state for over five years and others who, after 15 years, have made no progress at all in their career and do not even belong to the hospital staff board where they work. These situations often result from a lack of new vacancies in their speciality, no open competition for jobs or from the fact that the number of candidates is too high and discrimination too frequent. Length of service and medical experience, it is claimed, are no longer considered important.
  • Individual contracts are going to worsen precarious employment in the health service. By putting an end to public open competition for recruitment, medical career progression, according to SIM, is going to be placed purely in the hands of managers. Open competition, by contrast, helps to prevent arbitrariness. FNAM argues that the existence of a career and the chance to develop technical and scientific competence are the main guarantees of quality service.
  • Fixed and equal pay for work of equal value for everybody is going to disappear.
  • If workers have to discuss their employment conditions individually with hospital management, then unions will no longer have a say in them. FNAM maintains that reducing the influence unions have in such matters will adversely affect rights and dignity at work.

The Ministry of Health replies as follows.

  • In the case of contractual employment, it expects collective bargaining to take place at hospital level in the future.
  • Insecure employment will be replaced by individual working contracts which, it believes, will make the contractual link with the institution a lot safer.
  • Where assistant doctors are concerned, the personnel management of the Ministry of Health says that immediate and direct integration into health units will always prove difficult because open competition takes place at national level and so the filling of vacancies is also carried out at that level. However, there are doctors who do not wish to apply for posts outside the hospitals where they are currently working. There are many different cases and, therefore, there cannot be one overriding solution but several. The interests of the national health service will always take precedence over private interests and furthermore, they say, within a flexible geographic perspective doctors must be located where they are needed.

In the meantime, new working conditions in the health service for various professions such as doctors and nurses have been established.

  1. The decree of the Ministry of Health published at the beginning of August 1997 covered the salary scales of doctors in general practice and allowed for a certain flexibility; teams of three doctors have been set up jointly to administer lists of patients; and health centre timetables have been extended to midnight from 22.00 and a weekend service has been introduced, in spite of the additional payment for that extra service being very low. It is important to note that in Portugal, even though discussions are held, collective bargaining for public sector employees does not officially exist and, therefore, working conditions are regulated by the state. SIM does not accept these new working conditions as it views them as regressive in terms of welfare and as a means for making doctors work extra hours without being paid.
  2. The joint committee of the Portuguese Nursing Union and the Portuguese Association of Private Hospitals (Associação Portuguesa da Hospitalização Privada) has negotiated pay scales for 1997-8. Wage increases are fixed at 2.8% (theSocial and Economic Council advised an increase of 3.1% for 1997). The union initially claimed 3.1% and the employers' association offered 2.5%. Demands concerning reductions in working hours remain to be discussed (they are currently 40 hours a week while in the public sector they are 35 or 38 hours). In addition, aspects of work organisation, such as establishing the number of professionals per work unit and the role of unqualified staff in performing tasks, and additional remuneration were not negotiated. The union threatened to call a strike in the second half of August if an agreement had not been reached.

Commentary

Strikes or the threat of strikes remain an important element in industrial relations systems. When health service unions consider certain working conditions as non-negotiable, they allege that the Minister will give in only if faced with strike threats. As is well known, strikes in the health service always have a big impact on the public. On the other hand, there is obviously a labyrinth of regulations governing industrial relations in Portugal. Working conditions in the private sector are worse than in the public health service.

The structure of the process of collective bargaining in the health service is undergoing a process of change in which centralisation and state regulation of certain areas like career progression and promotion are taking place. At the same time, however, that process is also moving towards decentralisation of negotiations at local level. As has become apparent, the unions are concerned about an excessive individualisation of industrial relations that could adversely affect collective bargaining and their relationship with other unions. (Maria Luisa Cristóvam, UAL)

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