How to relaunch the National Health Service
The intervention Michele Poerio, Pietro Gonella and Stefano Biasioli
Over the past few months, we have become aware of several reports, drawn up by illustrious foundations and illustrious working groups, to revive social and health infrastructures in Italy, also in light of the Covid affair.
Like Feder.SPeV. and like Confedir, we have also contributed to sending Cnel a document of ideas relating to the reform of the National Health Service (dated 1978), taking into account the critical issues that emerged during the recent pandemic.
Quite recently, we have – by chance – come into possession of a draft report ("relaunching social infrastructures in Italy") promoted by the Astrid and Collegio Carlo Alberto Foundations (Compagnia San Paolo), as well as on the Prodi report (2018).
In the first report cited, the Health Working Group was coordinated by doctors Pietro Terna and Giuseppe Russo.
Below, we summarize the essential parts relating to Health, supplemented by our independent comments and ideas, the result of over forty years of work in Public Health.
THE THINK OF THE FEDER.SPeV AND THE CONFEDIR ON THE DRAFT OF THE "EXTRAORDINARY PLAN FOR SOCIAL INFRASTRUCTURE IN ITALY (HEALTHCARE AND RSA)" DRAWN UP BY THE ASTRID FOUNDATION
A. HEALTH
A.1. Fundamental premise
The Plan reserves spaces and perspectives for the construction of "social infrastructures", considering them also crucial for a radical reform and functional improvement of the health system.
Our personal history as Primary Doctors, Health Executives first and then as Managers, within the health world does not exempt us, rather it obliges us, for intellectual honesty, to clarify a basic concept for the functional organization of this sector.
In Healthcare, the hierarchies of the three factors in the field – in order of importance for its efficient and effective functioning – are the following:
human resources;
technological resources;
building resources.
So – on the basis of our professional experience – the “walls” are indeed important, but the first two factors are far more important than the third.
A.2. Fewer hospitals and more stand-alone territorial units
Hospital medicine
In light of what is envisaged by the Plan in question, the proposed reduction of ordinary hospital beds should not be considered negative (obviously with the exclusion of those intended for resuscitation, infectious diseases, pneumology, etc., beds that must be significantly enhanced. so as to bring them back to the standards of France and Germany), as the hospital of the future will increasingly be a high-tech Service Center as a necessary evolution of the Hospitalization Center that still characterizes it today, and this to obtain a high functional dynamism against current static nature of the hospital organization.
The Plan focuses on a no longer deferrable operation to rationalize and improve the real estate assets, so as to overcome the age of the hospital establishments.
It is a fair and acceptable proposal, even if it is not decisive for a citizen-friendly Healthcare, due to the fact that:
does not take into account, regardless, that in the future "pharmacogenomics" will make available advanced drugs that will offer the possibility of activating such targeted therapies that will allow treatment at home or at most in protected structures spread throughout the territory to monitor their effects for a few hours, replacement treatments of those currently provided in hospital; does not know / indicates the size / volume of "existing building spaces", an important knowledge because if redundant, as I think they are, they induce the consumption of considerable financial resources that could be more correctly channeled / used for direct assistance to the citizen (illustrative example: assuming that 80 million cubic meters of existing hospital spaces are compared to the 60 million actually sufficient = hospital building needs, we will see the consumption of 600-700 million euros to maintain "walls", resources otherwise destined to direct assistance applications, since each cubic meter costs 30-35 euros / year for maintenance, heating, cooling, cleaning and sanitizing, etc.). Every 1,000 cubic meters. in excess of its requirements it consumes 30,000-35,000 euros / year!
Compared to the stock of hospital investments made in the 24 years of the 1988-2012 period pursuant to article 20 of Law 20/1988, equal to 950 million euros / year, the investments simulated by the Plan for the period 2019-2045, to ensure the necessary availability of beds = hospital building needs, undergo an annual acceleration of 1.4 billion euros (1.99 billion euros in the first ten years): this is 47% more than in the previous 24 years and 0 , 8-0.9 per thousand of GDP!).
Furthermore, the Plan – it cannot be overlooked – has a significant deficiency: it deals with hospital investments without taking into account an existing situation which is variously articulated and which affects the rather diversified role and functions performed by the existing hospital complexes; it refers to the fact that the Plan should follow a necessary preliminary distinction relating to the so-called hierarchization = classification of hospitals in order to avoid unnecessary and costly duplication, and this to maximize the achievement of the improvement objectives of the overall hospital system.
Territorial medicine
As regards the outpatient structures, to be foreseen and established for a catchment area of about 20,000 inhabitants, a total specialist expenditure of 17.6-18.3 billion euros / year is estimated, equal to 15.4% -16% of the total public health expenditure.
The indication of such a catchment area, in my opinion, constitutes the first fundamental and inevitable change in the modus operandi, that is, in the approach of the so-called new citizen-friendly healthcare. And this because, beyond the nomen juris ("Community House" or "Initiative Health" experiment of the Tuscany Region in place since 2010), have 12-15 doctors united in aggregate studies located in a service / unitary / unique territorial structure, with the presence of 12-15 nurses, 6-8 rehabilitation therapists and 3-4 administrative units, means finally giving concrete implementation to the indispensable "continuity of care", a basic condition for successfully countering – even in terms of economic sustainability – the challenge of the next decades: “Long Term Care” (LTC).
With reference to 100,000 inhabitants, this change leads to the territorial availability / use of an adequate and organized target of resources, able to operate with the most advanced technologies and networked with the databases of both district and hospital structures:
60-75 doctors,
60-75 nurses,
30-40 rehabilitation therapists,
15-20 administrative units!
The second fundamental and inevitable change is to virtuously follow the path of "appropriateness" of the services (to ensure that the citizen-user stays in the structure – or follows the treatment – adequate in relation to their current health needs) as well as the " quality "of services (to ensure that the outcomes of treatment and the degree of individual satisfaction are the highest objectively possible), and this in order to implement a radical and effective change through two fundamental steps:
"Outside" hospitals, the treatment of chronic diseases,
Outpatient specialist assistance "outside" hospitals.
Fundamental steps which, for the first aspect, will find the more realization conditions the more the oupatient structures mentioned above are constituted, and which, for the second aspect, will find realization conditions in the activation of both the outpatient structures themselves, and of High-tech Regional Outpatient Clinics to be activated / built in the territory without further delay with a ratio of one every 300/400 thousand inhabitants, equipped with adequate and necessary medical health equipment, including large electro-medical equipment such as CT and MRI, and this to broaden and increase the response capacities with the aim of cutting down the waiting lists created by the funnel of the hospital structures involved, and it could not be otherwise, by the priority need to escape first of all the services due to hospitalized patients. In these outpatient clinics, where there are hospital doctors who also work there as a freelance company (ALPA), there is a guarantee – fundamental and indispensable importance – of quality and safety of the services on a par with what happens in hospitals.
The third fundamental and inevitable change (third certainly not in decreasing order of importance, on the contrary!) Concerns the strengthening of Integrated Home Care (ADI), a reality still in a state of backward implementation, since it treats an average of 47 patients for every 1,000 elderly residents> 65 years, a target that must be gradually increased, yes, but without further hesitation and delay, towards the insured levels in the two regions (Emilia Romagna and Tuscany) which express the most virtuous model with 101 and 103 cases per 1,000 elderly residents> 65 years.
B. RSA
The Plan, in addition to Health, also deals with investments in the field of assistance and care for elderly people who are not self-sufficient.
In the last 40 years, in correspondence with the progressive reduction of hospital beds, the number of beds in extra-hospital structures has increased – in line with the progressive aging of the population = Residential Health Care (RSA) for the provision of residential social and health assistance to non self-sufficient people who cannot be cared for and cared for at home. This process of transferring the treatment of non-acute pathologies to non-hospital settings has been and is correct both from the clinical-assistance point of view and from the point of view of economic sustainability, as – against an average hospital cost of 500 euros / day per hospitalized patient – an average extra-hospital cost of 120 euros / day per non self-sufficient guest (in the Veneto Region the hospital pls in 1982 were over 48,000, while in 2002 they were about 18,000, that is just over a third! it is obvious that the related costs – which are sustainable today – would no longer be so for an endowment almost three times higher!).
There are 21 nursing homes in Italy for every 1,000 people over the age of 65, against the target of 50 recommended by the European Commission.
The proposal of the Plan, regarding the adjustment of the average coverage from 21 to 25 beds, can be considered correct even in a perspective of a continuous and uninterrupted increase in the elderly population, given that there must and cannot be a corresponding and parallel growth = strengthening of Integrated Home Care (ADI), an organized-functional operating mode governed by outpatient structures to be set up for catchment areas of 20,000 inhabitants.
Since the management of RSAs in the hands of private individuals for 80%, the annual investment ceiling to increase the stock of the same is estimated in the order of 0.2-0.3 per thousand of GDP (a quarter of what is necessary for the stock of hospital investments!). This is an order of magnitude that can also be faced due to the objective advantage of being able to carry out faster and more decisive administrative procedures, due to the availability of financial resources consisting of private capital.
C. MENTAL HEALTH
The Plan, unfortunately, does not reserve spaces and perspectives for the thorniest problem of the NHS – mental health – to give an articulated and organic response to the needs of families who are affected, not to say upset, by the sometimes devastating presence of the disease, a community reality that must be faced both in adolescence and in adulthood:
for adolescence, widespread and extensive interventions are indispensable, in order to avoid / avoid that the deficiencies (preventive, diagnostic, therapeutic) of this phase are – as has been happening for some time, unfortunately in the indifference of institutions – transferred into the psychiatry of adulthood, with enormous health and social costs, in the sense of non-inclusion in the production circuit, with consequent failure / non-existence of individual human, economic, social dignity, etc .;
for adulthood, the provision of hospitals (SPDC / Psychiatric Diagnosis and Care Service), and extra-hospital facilities (CSM / Mental Health Center, DHT / Territorial Day Hospital, CTRP / Protected Residential Therapeutic Community is increasingly urgent , CA / Community Accommodation, COD / Day Employment Center, CLG / Guided Work Center) with particular attention to the "psychiatric" first aid / aid.
In this regard, it is necessary to ensure, in a catchment area of 100,000 inhabitants, the presence / availability of a team of psychiatrists, psychologists, social workers, nurses and professional educators in an adequate number, a team organized as a complex operational unit whose top manager, responsible for 'trend of the same, must relate to the managers of the individual outpatient structures to give their indispensable specialist support for the solution of the many forms of psychiatric distress present in specific territories.
We conclude by representing that it is on the issues of Mental Health and Non Self-Sufficiency that the level of "civilization" of a national community is and will be measured. And Italy cannot fail to take charge of the fact that the need for a structured response of a “universalistic” nature and character to be implemented with the establishment of the National Fund for Non-Self-Sufficiency (FNNA) is increasingly urgent.
So far, our observations on the Astrid report. However, we cannot conclude this article without asking an irrational question to Italian politics: will we access the Mes sanitary?
Ah, to know!
Nuisance as we are, for once we agree with a member of this government, Giovanni Amendola (minister for European affairs) who has confided to the newspapers (Repubblica) his concern about the possibility of seeing European funds arrive.
In the face of the optimists, today the path is difficult. In fact, the disbursement of the funds presupposes the ratification, within the year, by all the member states, and the vote of the European parliament on the new budget.
But, to date, there is opposition from 7 member states: the Netherlands, Austria, Denmark, Sweden, Finland, Poland and Hungary. For different reasons, but the substance is only one. “No to free loans to other states”.
The "real" situation is complicated. And, then, if the EU money does not arrive or arrive in installments, after the middle of 2021, what proposal, what concrete project will the Italian government implement to restart the economy?
In recent months, Cnel has suggested to Conte & C. some concrete and feasible projects.
We take the liberty of adding one, quietly.
Immediately request the activation of the Mes Sanitary (credit line of approximately 37 billion, with annual interest at 0.11%).
These money would be useful, without a doubt.
With these European moonshines, they would allow not only to fight better against Covid but also to modernize the NHS, with obvious benefits in terms of health quality, in favor of Italians (sick or not) and the quantity / quality of the response. health, using all the recent health technologies and the tide of "big data", with what follows.
Of this, we are sure.
But … is this government able to say – quickly – yes to the sanitary Mes ?
Yep, it's much easier to keep moving the lockdown to the full year 2021.
Prof. Michele POERIO – General Secretary of Confedir and President of FEDERSPeV
Dr. Stefano Biasioli, General Secretary of APS Leonida and Past President CONFEDIR
Dr. Pietro Gonella, former Coordinator of the General Directors of the Venetian ASL
This is a machine translation from Italian language of a post published on Start Magazine at the URL https://www.startmag.it/mondo/come-rilanciare-il-servizio-sanitario-nazionale/ on Sat, 10 Oct 2020 05:05:49 +0000.