How to make the national health system more efficient
Advice and wishes to make the National Health System more efficient. The intervention of Stefano Biasoli, a retired hospital doctor
Where to start to efficiently reform the Italian health system? From the code of clinical exemptions and prescriptions.
In health care, few things haunt chronic patients in daily practice:
– pathology exemptions;
– recipes for radiological and laboratory tests;
– recipes for specialist visits;
– the supply of medicines for daily use.
THE EXEMPTIONS FOR PATHOLOGY
They are one of the paradoxes of Italian medicine. In fact, they are entrusted exclusively to dependent specialists and not to contracted specialists, due to an atavistic distrust towards the latter. As if only the "first" to be strictly attentive to the rules of the NHS and in health spending and "second" instead of cicadas were spendthrift.
The simple proposal is that of a single form (national and regional) that can be filled in by each specialist, for each specialty and easily identifiable.
The population is aging and it is no longer acceptable to force the Fr, who must renew the exemption, to a specific specialist visit by exemption, at a 100% public hospital (therefore not affiliated) already overloaded with long waiting lists, for medical and non-bureaucratic reasons.
An unnecessary workload, which could be avoided by allowing the affiliated specialists to fill in the exempt forms, with adequate rates and personal responsibility. This would be an "essential task" for the "health poace", a task that could also be entrusted to retired specialists, similarly to those that "controllers" should do on behalf of INPS.
RECIPES FOR PHARMACEUTICALS
Another aspect, essential for citizens and doctors. Each Region has dealt with it differently, including “dematerializing the red recipe” and sending the “dematerialized white recipe” directly to the pharmacy.
However, it all assumes that:
– the patient realizes that "he is running out of that drug";
-the patient calls the Mmg and asks him the problem (or uses the computer, if he is capable and if he has the Internet);
– the Mmg check your database and then send the dematerialized prescription to the pharmacy;
– the pharmacist informs the patient that the prescription is ready;
– the patient withdraws the drugs.
5 steps, difficult if the subject is elderly, alone, not very mobile.
Alternative solutions? The neighborhood or family nurse? Not very credible, as a solution, if he were to take care of about 1000 families (2/3 of the patients of a maximum Mmg). Anglo-Saxon system? Insertion, by the pharmacist, of the pills necessary for 2-3 months, in personalized glass bottles with a label relating to the patient and the drug. Empty bottles to be returned at the end of the supply period. In this way the pharmacist would check the correct consumption of the drug, communicating any anomalies to the doctor (Mmg).
Another alternative? Simultaneously with the "Irpef unloading of the drug" the pharmacist should perform an "automatic unloading of the tablets / packs delivered", with tracking of the same.
Alternative solution? For chronic “superspecialist pathologies (transplants, severe heart failure, BPCO, oncological diseases, chronic infections) direct supply of the material to patients by the hospital / district, similarly to what happens for patients on home dialysis.
THE RECIPES FOR DIAGNOSTICS
In this case the problem has some peculiarities. The diagnosis is requested by the Mmg or by the specialist, after due consideration, ie after a medical examination. On the basis of the regional rules, only the Mmg or both (Mmg / specialist) can fill in and justify the single specific request. In any case, once the request has been completed, both have to do with the Cup (single booking center), with the organization of the Cup and with the operational difficulties of the Cup. A fundamental phase, which must be analyzed in detail because it is a "sanitary funnel".
THE CUP (SINGLE BOOKING CENTER)
As written, it is currently the funnel of the NHS. Today, it can be structured "by hospital" or "by province", rarely "by Region". Within the same Region, the Cups do not talk to each other, except occasionally.
Here, it is necessary to modify the Cup, organizing it (at least) on a provincial basis, with a structure similar to that of 118. Timetable 8-20, at least 4 stations per shift, entrusted to expert and ad hoc professional nurses (IP), with the supervision of a doctor / shift. Doctor, even retired! The telephone requests of users must be structured, with the preparation of a series of questions that the operator must ask the caller.
For example: personal data / residence of the subject; requesting doctor; required performance; diagnostic hypothesis; required timing; date of the last similar examination carried out; structure that performed it.
In the event of an incomplete / unclear request, direct contact between Cup and Mmg for clarification, closure of the procedure, with further contact between Cup and the patient, with establishment of the site and date of the examination.
NB: It is clear that, if the Health Microchip / USB key were already active in the Region – as I proposed in a previous article -, this procedure could be simplified: microchip / key-Reader / computer-connection with the Cup-interview telephone to complete the necessary information or computer reservation, with subsequent telephone interview, case by case.
Annotations. Today, access to the Cup is problematic, both for doctors and for patients, with a huge waste of time for both and with heavy dissatisfaction for both. "The lists are closed, call back!". "Closed lists, please ask elsewhere". “We have placed in 6 months”. And we could continue …
In a polyclinic facility, the medical request could be initiated by the Secretariat staff, in direct connection with the Cup and with a direct interview, in case of doubts.
In the individual clinics of Mmg and specialist doctors, the request for the service (filled in) should be entrusted to the patient, with a direct conversation with the Cup or through a special pharmacy service (for a fee?) Or with the neighborhood nurse.
Pharmacy = new place for health services!
Neighborhood nurse: new figure for health services, with duties not only of medication but also of tutoring.
The proposed approach would be fundamental for radiological, interventional diagnostics (colonoscopies, gastroscopies, biopsies, fine needle aspirations, etc.) and various instrumental diagnostics (ECG, EMG, HOLTER, Uroflowmetry…). Instead, laboratory diagnostics (on blood, urine, saliva …) could be direct (individual and computerized), regardless of the Cups, or take place through a pharmacy.
PATIENTS WITH SEVERE CHRONICLES / MULTIPATHOLOGIES
A specific analysis must be made for all of them. Oncological patients, transplanted, immunosuppressed, with heart failure in stage 3 ° -4 °, directly or in Irc in stage 4 ° -5 °, with severe COPD, with unstable DM should always be managed by the reference department (Uoc).
Eliminating unnecessary steps, both diagnostic and therapeutic, as much as possible. Direct supply of all essential drugs included. All of them should be given a priority code for accessing the PS (First Aid) and a dedicated telephone line for home interventions.
The Covid-19 experience has shown that all of them cannot be abandoned at home and cannot be entrusted "in full" to the GP. Not only that, but the use of the most effective drugs with fewer complications, even if expensive for the NHS, must be guaranteed to all of them.
An example? The use of Coumadin and similar drugs (dicumarolics) must be reduced in favor of more modern anticoagulants and less associated with complications (for example apixaban or similar), without waiting for these to occur and are dangerous for the patient and expensive for the Ssn, for the costs deriving from the necessary interventions.
TERRITORIAL POLYAMBULATORS
The Covid-19 experience has also taught that, for outpatients, access to the hospital must always be reduced, indeed it must be drastically reduced in the presence of virosis. This should lead to a new regional / national health organization, as we have uselessly proposed for at least 10 years. We will talk about it again, in detail. For now we limit ourselves to writing that, in the area, there should be some new aggregations / cases.
AGGREGATE STUDIES BY MMG
At least 1 for every 9,000 inhabitants, with 6 doctors, 3 IPs, a secretary.
Working hours (shift): 9-13; 14.30-20, then 9.30 hours / day for 6 days / week, in order to allow access to the clinic for everyone.
In practice, 56 hours of weekly clinic guaranteed by 6 doctors, with 8.30 hours / doctor / week in the clinic and the remaining individual hourly debt to be used in a more rational way today.
Alternatively, a total of 100 hours / week, for the 6 doctors with 16-17 hours / doctor / week in the aggregate outpatient clinic and with the remaining contractual hours to be used for personal clinics, home visits and office procedures not delegable.
The 3 professional nurses would be used for dressings, catheters, the usual nursing practices, telephone calls to the CUP, keeping the nursing records. The Secretary would carry out the bureaucratic activities, the forms, the connection with the district.
SPECIALIST TERRITORIAL POLYAMBULATORS (FORMER HOSPITALS)
Specialist outpatient clinics, at least 1 / 35,000 inhabitants (for example, 140 in Veneto), must be built in spaces outside the hospitals, to be implemented both from scratch and using the already existing affiliated or private clinics in the region.
They are all to be networked and organized with the presence of both hospital specialists in corporate freelance (extra institutional working hours) and specialists with special agreements.
If they were put online, this would allow their classification / hierarchization: from those with basic specialties (internal medicine, cardiology, general surgery, orthopedics, geriatrics, neurology, physiatry, dermatology) to those with more complex specialties (endocrinology, maxillary surgery -facial, nephrology, diabetology, neurosurgery, pulmonology, infectious diseases, sports medicine, ophthalmology …).
Outpatient radiological diagnostics should also be networked, to avoid duplication of equipment and to allow for correct planning of modernization of the same.
A similar program should be set up for outpatient and out-of-hospital laboratory diagnostics.
In this logic, some innovations should be favored:
-the carrying out of blood / urinary samples throughout the day (with a few exceptions);
– correct information to users before some particular tests (hormonal, 24-hour urine collection, load curves, stimulation / suppression tests);
– the identification of 1-2 regional laboratories where to concentrate the performance of particular hormonal investigations and / or "delicate" dosages.
Examples? Hypothalamic, pituitary hormones; free radicals; Cat-SOD- GHPX; amino acids; cellular and humoral immunity; Hdl fractions; genetics; trace elements essential for hormonal functioning (copper, selenium, cadmium ..); various pollutants (arsenic, Pfoa, Pfas); immunomodulating drugs …
Also in this field, the organizational support structure should be similar to that of the top private clinics, with obvious links with the provincial Cups, for an optimization of the response to clinical requests.
Once again, the health card with Microchip is fundamental and the possibility of booking in different ways (in person, telephone, computer …), with immediate payment (prepaid card, pharmacy, tobacconist) upon confirmation of the date and of the hour, to avoid queues for payment on the day of the exam) or "sudden holes" for defection of the subject to be examined.
The delivery of the reports could take place either on-site or electronically, either at the patient's home or in the usual pharmacy (pharmaceutical service) and / or to the "general practitioner", to whom – in any case – a copy of the reports should be sent.
Those who think that these are marginal aspects of the Italian health problem do not know what is happening in health care in recent years and especially in the time of Covid:
– they ask the Mmg for clarification;
– involve other medical professionals, in the presence of "examinations with asterisks" or with "danger warnings" (gray areas or similar);
– they look for (and often do not find) specialists in the sector;
– send "desperate" e-mails to medical friends;
– they obtain – via the web – more or less qualified health responses, often superficial (therefore dangerous) because they are hastily evaluated and because they are free (therefore, “wasting time”).
All this IT consultancy should be regulated – at least minimally – to avoid possible medico-legal disputes, with few documentary elements "in defense".
In the Veneto Region the problem is the subject of a discussion table.
However, we remind you that, already today, there is a company able to optimize the reports, reduce the risks associated with incomplete diagnostics, while optimizing the use of any additional analyzes, to complete the initial diagnostics itself.
THE TIMING OF CHECKS
In each Region, the individual medical specialist associations should elaborate a rough timeline for the specialty outpatient checks, with an official ratification, also through Bur.
This timing could be applied in 90-95% of stabilized chronic conditions, obviously being able / having to be waived in the presence of significant clinical news for the individual as well as in case of important therapeutic variations, to be monitored closely.
This timing (timing) would allow to:
– contain the abuse of performance;
– avoid the overwork of the Cups, at least of that linked to the forgetfulness of patients;
-fostering patient loyalty towards that "certain" outpatient clinic;
– to facilitate the identification of useful days for chronic patients;
– activate a "network of alerts" to patients, in the days preceding the scheduled checks (SMS, phone calls, etc.);
We do not intend to go into detail here, but limit ourselves to a few rhetorical questions.
RHETORICAL QUESTIONS, WHICH REQUIRE CONCRETE ANSWERS
– How often is SCC (heart failure) checked in stages 3 -4?
– With what criteria is the therapy with dicumarolics abandoned in favor of the more modern anticoagulant drugs, that is, with fewer side effects and without the obligation of periodic monitoring?
– How many months is COPD (chronic obstructive pulmonary disease) checked / monitored?
– How many months do you check a DM2 (diabetes mellitus 2) or, better, the potential complications of a DM2?
– How many months do you check for 3rd degree obesity?
– How many months are the motor / cognitive conditions of a disabled person or a resident of an RSA checked?
-How many months should disabled people be reclassified (and not just for accompanying practices)?
-How many months should pathology exemptions be evaluated?
-How many months should income exemptions be re-evaluated?
– How many months should a reasoned review of the current therapy and the interrelationships between drugs be made?
– How many months should an adequate assessment of the nutritional status of chronic patients be carried out?
– In times of Covid, what is the optimal timing for influenza and pneumococcal vaccinations, pending the specific vaccine?
(Third and last part of a speech by Stefano Biasoli; here respectively the first and the second )
This is a machine translation from Italian language of a post published on Start Magazine at the URL https://www.startmag.it/innovazione/sistema-sanitario-nazionale-ecco-cosa-e-come-possiamo-rendere-piu-efficiente/ on Mon, 24 Aug 2020 05:20:02 +0000.