NHS Performance in 2023

Non-technical Summary

In 2023, the Portuguese National Health Service (NHS) hospital activity increased, but to an insufficient extent to meet demand. In primary care, the number of medical consultations fell. Within the scope of the National Integrated Continuing Care Network, the greater number of users cared for in 2023 was not enough to respond to the increase in the number of users referenced that year. Thus, it is possible to conclude that the level of activity of the SNS was insufficient to meet the (growing) needs of the population.

Regarding unmet health needs, in 2019 (the last year with information published by Eurostat), Portugal had the highest level of "population with health care needs who reported unmet health needs" among the countries of the European Union and European Economic Area. The main cause of unmet needs was waiting lists. The persistence of unmet needs and the other indicators presented in the text point to efficiency problems in the SNS. 

From a budgetary point of view, the NHS deficit was reduced in 2023, but arrears increased. In this respect, there is an urgent need to institute the regular publication of the consolidated financial accounts of the SNS, to allow a transparent assessment of its financial position, the evolution of its liabilities and, not least, the state of its assets and their consequences on the provision of public goods and services.

Assistance activity

In 2023, the number of registered NHS users rose to 10.6 million, of which 1.7 million users (16%) had not been assigned a general practitioner (GP). This is an additional 230,000 users than in 2022 without a GP.

The total number of medical consultations carried out in primary care fell for the second year running, despite the increase in the number of NHS users. This reduction was due to the lower volume of non-face-to-face consultations (-6.3%), although there was a slight increase in face-to-face consultations (+0.8%). As a result, the usage rate for medical consultations was lower than in 2022, indicating a reduction in the adequacy of the volume of consultations to users' needs. Consequently, a significant gap remains between the activity provided in primary care and what is required to meet the needs of the population.

In hospital activity, the higher number of hospital medical consultations compared to 2022 (by 3.9%) and surgeries (by 7.7%) was not enough to prevent a significant increase in the number of users on the waiting list for their first consultation in 2023 (by 46% compared to the previous year), as well as the number of users on the "Surgery Registration List" (by 13%).

The emergency and hospitalization services continued to experience various constraints. In emergency episodes, triage times were only met in 60% of cases (61% in 2022). In hospitalisation care, there was an average occupancy rate of 91%, higher than the 86% rate recorded in 2022 and the highest in the last 10 years - it should be noted, however, that this occupancy rate includes situations that are quite different in the various regions of the country.

Within the scope of the National Integrated Continued Care Network, the higher number of users assisted in 2023 was not enough to respond to the increase in the number of users referenced that year. Although 1,585 more users were assisted compared to the previous year, the number of users on the waiting list at the end of 2023 was higher than the previous year, standing at 1,804. The increase of 317 vacancies in the National Network for Integrated Continued Care in 2023 was the result of the increase in home-based care, as the number of institutionalised patients decreased this year, with 17 fewer inpatient beds compared to 2022. 

Budget outturn

The NHS ran a deficit of 435.1 million euros (million €) in 2023, an improvement of 631.5 million € compared to 2022. This evolution is explained by an increase in revenue (+1 524 million € compared to 2022) greater than the increase in expenditure (+892 million €). In recent years, NHS expenditure has systematically exceeded revenue, and the deficit is assumed from the outset when the budget is proposed, resulting in a level of revenue lower than expenditure. In 2023, the deficit was 62.4 million € lower than initially implicit in the State Budget for 2023 SB/2023.

According to the provisional consolidated account drawn up by the ACSS, in 2023 total NHS revenue totalled 13 626 million €, representing an increase of 1523 million € compared to 2022 (+12.6%). Current NHS revenue totalled 13,525 million €, corresponding to 99.3% of total revenue (+12.4%). In turn, capital revenue accounted for just 0.7% of the total, i.e. 101 million € (+39.6%). In terms of structure, the predominance of current transfers and subsidies (funds from the State Budget) stands out, accounting for 95.3% of total NHS revenue in 2023 (12 987 million €). Given the low diversification of revenue sources, among other measures, it is important to improve the invoicing process for the provision of services, particularly to insurance companies, and to third countries for healthcare services provided to foreign citizens.

NHS expenditure totalled 14 061 million €, an increase of 6.8% on the previous year (+ 892.3 million €). This increase was essentially due to the 761.8 million € growth in current expenditure compared to 2022. In fact, current expenditure has a predominant weight in NHS expenditure, accounting for 97.4% of the total and essentially concentrated in three headings: staff costs, external supplies and services and inventory purchases. Capital expenditure continued to represent a low percentage of total NHS expenditure in 2023 (2.6%), reflecting the low priority given to investment in the NHS in recent years. Between 2014 and 2023, capital expenditure represented an average of 1.7% of total NHS expenditure, especially in 2023, when capital expenditure was 460.2 million € lower than forecast in the SB/2023. According to the General State Account for 2023, the low capital expenditure in 2023 is partly due to payments associated with investment within the Recovery and Resilience Plan (RRP) funding, related, for example, to the digital transition in health, primary health care and hospital equipment, which have not been made.

Debt and average payment terms

In 2023, the NHS recorded a decrease of 387 million € in debt to external suppliers, totalling 1.2 billion €, the first reduction after three years of consecutive increases. This decrease was reflected in the reduction of both the maturing debt and the overdue debt of the SOEs and ARS. However, arrears rose to 141 million €, a 122 million € increase when compared to 2022, which reflects the financial deterioration of the SOEs and the need for better management and more agile payment processes. Despite a capital injection of 1.1 billion € in 2023, mostly to cover losses, the structural debt of the NHS was not significantly reduced. The average payment period fell to 96 days, but only 26% of NHS entities managed to meet the legal obligation to pay within 60 days.

Risks and uncertainties

The NHS faces risks and uncertainties that condition its short and medium-term performance, as well as its future sustainability. These risks are transversal to the care plan and budget execution, and the following stand out:

On the assistance side:

(i) the constraints on primary care activity as the first point of contact with the NHS, in particular the higher proportion of users not enrolled in Family Health Units and the growing number of users without a family doctor, which are factors that condition access to the NHS and may put pressure on emergency and inpatient services, sometimes forcing hospitals to redirect resources from scheduled activity to deal with emergency episodes;

(ii) the saturation of access to public healthcare, which has as a consequence for users who need healthcare the risk of an increase in their unmet health needs, reported by 40% of the Portuguese population in 2019, according to the OECD, the highest figure in the EU. In Portugal, the main reasons given for the existence of unmet health needs are: 1) waiting lists (which increased in 2023 for the first consultation, for those registered for surgery and for access to the National Network of Integrated Continuing Care); and 2) financial reasons, reflected in the worsening of direct payments from users ("out-of-pocket"), due to the greater need to use private providers, a situation that is especially serious for families with lower incomes;

On the budgetary side: 

(i) the low level of diversification of NHS funding sources, in a context of growing public spending on health and the growing needs of an ageing population, can create significant sustainability challenges for the system. The almost exclusive dependence on the State Budget to fund the NHS can limit its ability to respond to emerging crises or unforeseen needs;

(ii) the sharp growth in NHS spending in areas such as staff costs and hospital medicines requires maximising efficiency and predictability in the use of resources. It is essential to improve the planning of NHS resources and strengthen the mechanisms for controlling and evaluating services and teams, promoting more effective management and the accountability of all those involved;

(iii) the need to implement public financial management instruments to support efficient management and adequate budgeting in order to identify strategic and operational objectives, while also establishing the link between the expected evolution of care activity and the resources needed to realise it;

(iv) the need to adopt measures to bring forward the publication of the NHS consolidated accounts, both budgetary and financial. This will allow for greater transparency and better preparation of managers and stakeholders, facilitating a more detailed and informed analysis of the NHS financial and operational situation; and

(v) ensuring that the funds from the RRP are fully used and that the reforms and investments provided for in the RRP are implemented on time. Making full use of the RRP funds and maximising the impact of investments is essential to correct existing weaknesses and move forward with the proposed reforms.

Date of last update: 26/06/2024