STRATEGIC NOTES N.º2

Clinical autonomy is the space granted to teams to adapt methods, timing, staffing and investment to local realities.

The World Health Organization noted, as early as its World Health Report (2000) and in subsequent documents, that such freedom only creates value when anchored in rigorous governance and transparent accountability. Without that balance, what appears as autonomy becomes expenditure, fragmentation and risk.

The paradox is evident in Portugal. In 2024, the State paid €231 million to external providers, of which €213 million went solely to locum doctors. In the same year, 1.6 million citizens remained without a family doctor.

In parallel, nurses worked 5.61 million overtime hours, costing €107.8 million, 20% more than in At the same time, €2.1 million generated by clinical research at IPO-Porto were left unreinvested, while HIV prevention through PrEP (pre-exposure prophylaxis, a preventive medication against HIV infection) remained below the necessary threshold, with only 6,900 users in 2023, far below the threshold for population-level effectiveness.

Daily decisions are delegated, yet the data needed to measure effectiveness arrive late or not at all. The result is closed emergency services, chronic dependence on locums, excessive overtime and stalled innovation. Autonomy, instead of fostering efficiency, exposes systemic fragility.

The literature confirms this dilemma. Saltman and Figueras (1997), in their analysis of European health reforms: Analysis of Current Strategies, demonstrated that decentralisation and autonomy without robust frameworks result in territorial inequality, rising costs and loss of strategic coherence.

Berwick, Nolan and Whittington (2008), when introducing the concept of the Triple Aim, were explicit: “The Triple Aim is to simultaneously pursue three dimensions: improving the individual experience of care; improving the health of populations and reducing the per capita costs of care.” Only when these three dimensions are integrated can clinical freedom be transformed into real value.

International experience demonstrates that the problem does not lie in autonomy itself but in the way it is framed.

Denmark secures a maximum 30-day waiting time by linking autonomy with public measures of access and quality. In the United Kingdom, Foundation Trusts operate under a model of earned autonomy, where freedom depends on performance indicators that are public and subject to scrutiny. In both cases, delegation of power is granted only when coupled with agile reporting and timely intervention by governing bodies.

Clinical autonomy is neither unrestrained liberalisation nor suffocating micromanagement. Delegating without measures creates financial risk and instability; monitoring without delegation entrenches bureaucracy and stifles talent. The virtuous balance rests on three pillars: a shared strategic vision; the circulation of public measures on access, quality and cost, sustaining short cycles of monitoring and response; and the capacity of governing bodies to intervene before crisis, not after.

The lesson is unequivocal: clinical freedom only generates value when transformed into institutional responsibility. Without coordination, autonomy ceases to be a sign of maturity and becomes a symptom of misgovernance.