Equal opportunities and dignity for dependent people
In December 2023, the Budget Law for 2024 will be approved: the Government will be called upon to decide whether and how many economic resources to devote to the reform of policies in favor of non self-sufficient people, which currently do not have them. Alessandra's speech Servants
On 21 March, Parliament definitively approved the Draft Delegated Law on non-self-sufficiency.
In the history of our country this is the first reform of the sector and it has been awaited since the 90s, when it began to be discussed in a technical and political context. In the meantime, similar reforms have taken place in numerous states, everywhere with the same aim: to structurally modify the welfare systems, designed when there were very few elderly people who were not self-sufficient, to put them in a position to respond to their increasingly widespread presence. The Government included the reform in the final version of the Pnrr (April 2021).
At the beginning of 2022 the Draghi Government started preparing the Delegation Bill and in October that Government approved the Delegation Bill. In January 2023, the Meloni Government in turn approved the Delegation Bill, substantially confirming that of the previous legislature with further contributions. In December 2023 the Budget Law for 2024 will be approved: the Government will be called to decide whether and how many economic resources to devote to the reform, which currently does not have any, since the Delegated Law contains the overall structure of the reform and the translation in precise indications it will have to be implemented by the Government in Legislative Decrees, to be promulgated by January 2024.
The Delegation pursues two macro objectives which, considered jointly, should address the underlying criticalities of this area of welfare. In fact, it is a question of building a unitary and specific welfare sector, to overcome the current chaotic fragmentation of measures and to recognize the importance of this area for Italian society; define new intervention models, designed starting from the conditions of the elderly and families and, between the social and health care sector and therefore, able to respond appropriately to their complex and changing needs.
The objectives are important for the whole country, while their relevance varies between the different local realities. Consequently, for each of the planned interventions, the State indicates only a few qualifying elements and each territory takes the necessary steps to adapt. In this way no changes are requested to the contexts which, in whole or in part, already possess the required requisites.
Overall, with the introduction of the National Assistance System for the Elderly-SNAA, shared action is envisaged by the various government bodies involved, the State, Regions, Municipalities in respect of the different responsibilities and at the level of the elderly and families, simplifying the evaluation framework to be done in order to receive public responses and making the path to be followed continuous and not fragmented like today.
The SNAA has the objective of building a system: all publicly owned measures for the assistance of non self-sufficient elderly people are governed and implemented jointly by the various responsible bodies. Today, however, fragmentation prevails. State, Regions and Municipalities jointly plan and manage the interventions but retain their respective ownership. Envisaging the change of competences would be unrealistic and conflicting.
At central, regional and local level, the set of different services and interventions aimed at the non self-sufficient elderly population will have to be programmed in an integrated and simplified way with the transition from the current 5-6 assessments of the conditions of the elderly required to define the interventions disburse to two, one state and one regional. The two planned evaluations are linked to each other, contrary to what is the case today. There is provision for a new national assessment tool, much more complete and precise than the current ones. This improves the ability to understand the situation of the elderly and, therefore, to determine the appropriate responses. Public home services are introduced specifically designed for elderly people who are not self-sufficient. Today those existing in Italy are not designed for them. For this it will be necessary to organize services of adequate duration for the condition of non-self-sufficiency, which can extend for years. Currently they are mainly paid for 2-3 months.
To respond to the many needs of non-self-sufficiency, there must be the possibility of benefiting from a plurality of medical-nursing-rehabilitative interventions, support in the fundamental activities of the elderly's daily life and support for family members. The indemnity is transformed into the Universal Benefit for Non-Self-sufficiency (the current carer's allowance). The possibility of receiving it continues to depend exclusively on the need for assistance of the elderly, regardless of their economic conditions.
Today all recipients of the allowance receive the same amount (527 euros per month) which will represent the minimum level of the Benefit. Its amount, in fact, will be graduated so as to be higher for those who need more assistance. The beneficiaries will be able to choose between two options: a) an economic contribution with no constraints on use, b) the use of personal services (provided by private operators, public bodies or by carers regularly hired).
On residential services, but not only on them, the Delegated Law discounts a certain vagueness of intent and barely touches on a crucial issue: the effort to equip the structures at a territorial level, which today sees abysmal differences between one region and another moreover, it is linked to the implementation of the Pnrr. The law envisages an adequate supply of personnel commensurate with the needs of elderly residents: today, on the contrary, there is an evidently insufficient number of operators in Italian residential structures.
Then there is the issue of skills, i.e. the presence of professionalism with skills suited to the profiles of the elderly hosted. The resident population, in fact, is increasingly problematic, both due to functional impairment and (in particular) due to the high number of guests with dementia. The aim is to guarantee the quality of living environments, thanks to structures with friendly environments, familiar, safe, facilitating normal life relationships and ensuring the privacy and continuity of residents' relationships with the local community.
We are moving towards the definition of training standards for carers through specific national guidelines, specifying the skills required and indicating the methods for recognizing previous skills, however acquired. The reorganization of tax and social security benefits concerning the work of family carers is essential to support the regularization and quality of care work carried out at home.
Obviously there are some obvious critical points. In fact, to issue all the legislative decrees that this Delegated Law prefigures, there are not even 8 months of time.
The Delegation addresses all the problematic issues of care for the elderly as a whole. The ways to make the indications of the Delegation concrete can count on analyzes and numbers produced and experts in the sector. But they certainly still require a lot of work, because it is evident that a great deal of interdisciplinary and inter-ministerial elaboration of the indications of the Delegation is needed, in many points rather generic and only hinted at. Without consistent dedicated resources, little will be achieved.
Public spending on care for the elderly remains decidedly inadequate in our country.
This is demonstrated by studies and data that analyze the unsatisfied needs present in Italy and as shown by comparisons with other countries. To translate the reform into practice, therefore, it is necessary to significantly increase funding, otherwise there will only be a series of good intentions on paper but the truth is that it does not provide for new appropriations.
The rules of the PNRR and its reforms cannot have structural increases in current expenditure and the reform should initially start by rationalizing the current expenditure items and without additional funds. We know that it is a very weak sector politically, and until now the political forces have devoted little political attention to reform. But there is also another cause for concern: non self-sufficiency. It is not only the prerogative of the elderly and on this the Law discovers all its limits.
Non self-sufficiency is always consequent to the loss of health due to irreversible disabling chronic diseases or their outcomes. Therefore, the assessment of the chronically ill person who is not self-sufficient must necessarily be "health and clinical health", a competence that falls fully under the ownership of the NHS and the right to health and social health care guaranteed by law 833/1978 and subsequent amendments and by the Lea of the dpcm January 12, 2017. The bill, on the contrary, shifts the competence of long-term social and health care to the social and welfare sector. This is only for elderly sick people who are not self-sufficient: the resources of the NHS will therefore be those limited to integrated home assistance (ADI, doctor and nurse) wholly insufficient to meet the protection services they need 24 hours a day.
It is certainly extremely important to consider the so-called "social needs" of non self-sufficient people (defining them more precisely as "relational", "economic", "housing"…), but it is advisable that they be taken into account in the formulation of individualized plans, not to select users in accessing the evaluation and in the use of contributions or social security, health and social health services (home, semi-residential and residential) of an essential level, which are unconditional individual rights.
Anyone who assures that there are resources within the framework of the bill also knows that the text reaffirmed nine times that the services are provided with the resources provided "under current legislation". If the reference is to the Inps funds of the accompanying allowance that the bill proposes to use as a "universal graduated benefit", it is necessary to specify that for its disbursement the criteria of social services will be applied and therefore the evaluation of the family nucleus, as well as of the sick elderly person who is not self-sufficient.
With these assumptions, a selection system will be defined in the implementing decrees or, worse, in the regional resolutions on multidimensional evaluation which will affect the allowance for those who exceed a certain Isee threshold.
The resources envisaged by the bill in question are not enough if we want to counter institutionalisation, while keeping as a reference the healthcare sharing model envisaged by the Lea for residential services, and to take care of the elderly who are not self-sufficient at home. In fact, the provision of a universal contribution for home care services for non self-sufficient patients and people with disabilities and very limited autonomy by the NHS is not envisaged – as it would be dutiful and as requested by the families of the sick. The contribution should be recognized so that the interested party or whoever represents him (family member, support administrator, guardian) is put in a position to be able to make use of the help of "personal assistants" and/or "social-health workers" (hired directly and/or made available by suppliers accredited by the Health Authorities) to ensure, 24 hours a day, the necessary and non-deferable services for the protection, in the broadest sense, of health. The financing without the ISEE bond of the care allowance for these services could be quantified in double the accompanying allowance (which would instead be safeguarded as it is), a sum which the National Health Fund, therefore the Ministry of Health, should bear , with corresponding transfers to the Regions and Local Health Authorities.
The latter would be required to prepare, in collaboration with the general practitioner in charge of coordinating it, an individualized project of health and social care and assistance, signed by the person concerned or by whoever represents him and against the availability and suitability of the joint to carry out the function of care with the support of operators with a regular employment relationship.
Finally, the question of the legal recognition of family caregivers. We as a nation Italy have been subject to a sanction by the UN Commission for Human Rights since the Fund established in 2017, with law 205, does not have a legal match in the profile of the family caregiver and the resources must not be distributed (90 million) generally on territorial budgets.
We as an inter-ministerial and associative group have prepared a track of the DDL which we attach in PDF and we hope that Parliament will wisely pay due attention to it.
This is a machine translation from Italian language of a post published on Start Magazine at the URL https://www.startmag.it/sanita/pari-opportunita-e-dignita-per-le-persone-non-autosufficienti/ on Sun, 09 Apr 2023 09:03:36 +0000.