You may not know who Donald Berwick is, or why I mention him in the title of the article. The same is true, it is evident, for most of those who are participating in the current Health Pact. They don’t know what Berwick’s Triple Objective is, much less the Quadruple Objective that has replaced this model. You may not know what is at stake behind these words: the sustainability of the public health system and, with it, one of the pillars of your well-being. Perhaps that is why you have lost it from the beginning, because the future of our public health system is based on an inappropriate paradigm. And if you argue in a wrong paradigm, know that you have lost the debate, the game, and everything in advance. The Osakidetza did it, if we continue like this.

Berwick’s model, i.e. the Triple Objective, advocated first of all the improvement of the health of the population, that is, the achievement of good health results. Second, to improve the experience of patients, that is, to ensure that the appropriate care they have received is courteous and timely, to meet their expectations in some way. Finally, the long-term economic sustainability of the health system. Berwick’s model is not bad in itself and, at first glance, it seems acceptable to all of us. Perhaps that is why all the participants in the Health Pact have endorsed it.

Everything, however, has an expiration period, and the Berwick model can be said to have already expired. The Quadruple Objective has been prioritized in its place by many, including myself, or at least in our country today by myself, in view of the situation. The Quadruple Objective considers the people who are essential to the provision and delivery of health care: the workers. Because without cleaners, without nurses, without doctors, without administrators... there is no health care. The exception, perhaps, would be the directors, since without a medical director the hospital works. The Quadruple Objective defends Berwick’s goals, of course, but it also considers the well-being of the workers to ensure them and aligns them with others.

The exact opposite is what is happening today. With the hat on your head, it’s important to recognize that it doesn’t just happen here. Bodenheimer and Sinsky found that 46% of physicians in the United States have burnout syndrome. In a study conducted by Kane and collaborators, 73% of internal doctors and 68% of family doctors would not do their specialty again if they had the opportunity; preferring another specialty. We are no exception: 246 residents’ places for the specialty of family medicine remained vacant in 2024 throughout Spain. At present, family medicine at the UPV/EHU is not offered as a subject in medical school, and most students do not even know what it is. It is of little interest; almost no one wants to be a family doctor. There are not enough doctors, at least in primary care, and in this regard we are studying Basque geography: Zaldibar, Zumaia, Aulestia, Izurtza, Mañaria... Especially in the Basque villages on the outskirts, in the Basque breathing spaces, the attention in Basque is over. Attacks against Osakidetza professionals have increased by 12% in the last year, 1,176 notifications precisely in 2024, knowing that many are not reported and therefore there will be many more. Temporary work disabilities have doubled in the last ten years, and 10.3 per cent of workers are not at work at the moment. I think the situation is going to get worse: more harassment, more attacks, a higher workload and increasingly older workers. Because the counselor wants us to work until we're 72, if we're alive by then.

Priority should be given to the Quadruple Objective and, as such, to improving the working conditions of staff. Because in the area of health, where the most intimate and important aspects of life are taken care of, there are the worst working conditions of the Basque administration. Unfortunately, the Berwick model, which has already expired in the Health Pact, has been prioritized with the approval of political parties, unions and social actors. Maybe because they don’t know what Berwick’s model is, or they don’t want to know it, as they don’t know the situation of the workers. We are supposed to want quality and equitable health care, but for that, as the Irish say, we must first take action. There is no doctor, and there is no Basque care because you don’t want it, you don’t want to see it.

Aitor Montes, family doctor from Osakidetza