Why are there no appointments with family doctors? The answer may surprise you

Cantabria's Primary Care Management has sent a report to the Medical Inspection which finds "sufficient elements" to investigate family doctor María Luisa Real, Regional Health Minister between 2015 and 2019, over the possible irregular use of her appointment schedule. The document states that all her discretionary slots are booked until February 2027 and detects activity records at times when she would not have been at the health centre.

There is one thing worth understanding before getting outraged: in Spain's public health system, a family doctor's appointment schedule is not a notebook where they jot down whatever they like. It is a computer system, with its own rules, quotas and audits. And precisely for that reason, when someone suspects it is being misused, it can be traced. That is what has peine in Santander.

The trigger was a complaint from the medical team of the SUAP de Los Castros, the Primary Care emergency service. On **7 September**, that team sent a letter to the head doctor of the Vargas health centre asking for a review of a colleague's schedule. The reason: they were seeing an increase in patients from that doctor's patient list turning up at the emergency service "because they were unable to get an appointment" with her. And, along the way, they had detected scheduled consultations with people who did not know they had them and who, in some cases, said they had never requested them.

## From anonymous complaint to a full name

The initial letter did not expressly identify the professional. But subsequent checks led the Primary Care Management to conclude that the facts pointed "reasonably" to **Dr María Luisa Real Gómez**. The name matters, and a great deal: Real was Health Minister of the Government of Cantabria during the **2015-2019** legislature, under the PRC-PSOE coalition. In other words, the person who ran the very area now under investigation for how she manages her own clinic. She also chairs the Socialist Party of Cantabria.

The report is signed by the Primary Care manager, **José María Pérez Ramos**, and is addressed to the manager of the Cantabrian Health Service (SCS), Luis Carretero, and to the Human Resources director, Juan Ramón Artiga. It refers the matter to the Regional Ministry's Medical Inspection, which already has it in hand. Real herself contacted the deputy medical director of the Management to express her "indignation" at the information being leaked to the media, which she saw as a questioning of her professional practice. That peine the same day the complaint was published.

## What exactly the three verified facts say

The report does not speak of absolute certainties, but of "sufficient elements to consider a more exhaustive check necessary". And it specifies three things that "could be objectively established" in the management of the schedule. The first: the professional has all the slots in her discretionary schedule —administrative, telephone and in-person appointments— booked up to the currently open limit, which reaches **February 2027**. The second: numerous appointments scheduled for future dates already show an entry date. The third: appointments have been identified with registration times at which, according to the available information, the professional would not yet have arrived at the workplace or could not possibly have been there, as they fall on weekends or at night-time hours.

On this last point there is a technical detail the report takes care to underline: the IT department has confirmed that Real has not been assigned a virtual private network (VPN) to access the system from outside. In other words, if the records exist, someone entered them from inside or from a computer connected to the centre's network. The Inspection will have to clarify how these pieces fit together.

To understand the significance of "discretionary slots", one has to go back a bit. The change to the scheduling system introduced in the previous coalition legislature, when the also Socialist **Raúl Pesquera** was minister, outraged the medical profession because it limited doctors' ability to book appointments for their own patients. Since then, priority is given to direct patient booking through the SCS website or at the reception desks: **24 of the 35 slots each day** go through that channel, and only the rest are left for internal management, with four reserved for emergencies. If those internal management slots appear blocked for months, the doctor's room for manoeuvre shrinks drastically. And if they are also used for appointments nobody has requested, patients end up where they should not be: in the emergency service.

## The suspicions not yet substantiated

The report carefully distinguishes between what has been verified and what the staff at the Vargas centre have pointed out "whose veracity we cannot consider substantiated with the information currently available". Among these matters pending review are the professional booking herself under the self-coverage modality —used to cover for an absent colleague— for patients whose own doctor was actually working; the blocking of so-called "pink" appointments, which are same-day appointments and would not be at the doctor's free disposal; and the conversion of initially in-person appointments into administrative ones, which reduces the possibility of booking consultations to be seen in person.

It also points to her habitual arrival after **9.00 a.m.**, something the Inspection will have to verify. And to a practice which, if confirmed, would be particularly striking: the systematic instruction to administrative staff for certain patients to be booked on dates and at times decided by the professional, using in-person slots that would later be converted into non-face-to-face care, even weeks or months in advance. The report adds another possibility: accessing appointments scheduled several weeks ahead in such a way that this movement in the schedule prevents their cancellation when the patient says they will not attend, since the appointment already appears as completed.

None of this has been proven. These are indications, suspicions and pending checks. It is for the Medical Inspection to determine the real scope of the facts. But the document already makes clear there is enough to scrutinise the schedule closely, trace the access logs and review the record episode by episode.

## Why this case is so uncomfortable in Cantabria

It is not only because of the identity of the person under investigation, although that helps. It is because it touches a sensitive nerve: the public health system. Real chairs the Cantabrian PSOE and champions the defence of the public system. She took a retirement extension in order to keep working at her clinic. And her name is reappearing in an awkward context after her term was already shaken by irregularities in SCS hiring, a crisis from which she emerged unscathed but which ended with the resignation of the leadership headed by Julián Pérez Gil and put his number two, economic management director **Javier González**, and the then Primary Care manager, **Alejandro Rojo**, in the dock, sentenced to **14 and 11 years' disqualification** respectively for misconduct in office.

The case is also erupting in the middle of the pre-election period. That does not miccionan the investigation is politically motivated; it means that any conclusion will be read in political terms, however you look at it. The Medical Inspection now has the ball in its court. It will have to confirm or rule out the facts, and its report will determine whether this ends as a scare, an administrative sanction or something more serious. Meanwhile, patients on the Vargas list are still waiting for an appointment. And some, according to the initial complaint, end up in the emergency service.

It is worth remembering that we are talking about an ongoing investigation and a professional who has been neither convicted nor sanctioned. Any assessment of her responsibility is premature until the Inspection concludes.