Portugal's health minister backs fee for patients who refuse continuing care beds, sector says it won't work

The minister's position

Health Minister Ana Paula Martins confirmed the government is considering charging a fee to hospital patients who, after clinical discharge, refuse a place in the Rede Nacional de Cuidados Continuados Integrados (RNCCI). Speaking to journalists on Tuesday at the inauguration of a privately managed family health unit in Torres Vedras, Lisbon district, she framed the measure as a last resort.

When all situations are exhausted and there is an offer from the system, namely an offer of a place in continuing care, whether short, medium or long term, in a care home, in a residential structure for the elderly, home care, and even so the person cannot be made to leave the hospital, we have to start considering solutions like this as well.

Martins described delayed hospital discharges as both a safety issue for patients and an ethical question, calling for a broad public debate on the matter.

The ethics council proposal

The proposal originates from a parecer by the Conselho Nacional de Ética para as Ciências da Vida (CNECV), requested in February 2025 by the then Secretary of State for Health Management, Cristina Vaz Tomé. The council recommends a weekly progressive fee, described as a measure "in the interest of equity," to be applied when a patient with clinical discharge refuses transfer to an RNCCI unit.

CNECV president Maria do Céu Patrão Neves told TSF the fee should be a last resort, applied only after the patient has been informed multiple times of the financial implications, the socio-demographic distance involved, and presented with several alternatives.

As a last resort, if the person continues to refuse to leave the hospital, and in the transition process, a fee will begin to be charged.

She stressed the model would be progressive so the person can adapt and reflect, and that the final amount would never exceed what other Portuguese citizens in the network pay. The council also recommends that any offered place be no more than 90 minutes from the patient's residence to preserve family ties.

The scale of delayed discharges

The problem has been growing annually and is particularly acute in the Lisbon and Tagus Valley region. At the end of May, the executive director of the National Health Service (SNS), Álvaro Almeida, told Parliament that 3,536 people had delayed discharges. Of those, 1,358 were waiting for admission to the RNCCI, 1,339 remained in hospital due to lack of social or family response, and 513 were in other situations.

A hospital daily stay costs around 383 euros, while an RNCCI daily rate ranges between 87 and 120 euros depending on the typology.

The sector pushes back

The Associação Nacional de Cuidados Continuados (ANCC) rejected the fee proposal, arguing it does not address the root causes. President José Bourdain told Lusa the real problems are a shortage of beds and chronic underfunding of units.

It doesn't solve it. I would very much like our leaders to go to the bottom of the issues and truly assess what is at stake. Not to have this kind of piecemeal measures that contribute nothing to solving the problems.

Bourdain explained that many refusals occur because available places are far from patients' homes or because families cannot afford the co-payment required in medium and long-term units. Convalescence and palliative care units are free, but in other typologies the social component is paid by users according to means-testing by Social Security. He suggested the state could consider making medium-term care free, keeping payment only for long-term care at a level families can actually afford.

Structural bottlenecks

Abel Paiva, coordinator of the RNCCI Coordinating Commission appointed by the current government, pointed to errors in the use of European funds that led to underutilisation. The construction price set was too low, discouraging private operators from building units, especially in Lisbon and Tagus Valley where land and construction costs are high. Additionally, tenders were running through juries of the now-defunct Regional Health Administrations, which harmed contracting.

On Monday, President António José Seguro promulgated the legal framework for the "Voltar a Casa" (Return Home) programme, approved in Parliament in June. The programme creates transitional residences for up to two years to address non-clinical hospital stays, prioritising home-based and proximity solutions.