3rd Eurispes-Enpam Health and the Health System Report
3rd Report
on Health and the Health System
PRESS RELEASE
The picture painted by the 3rd Report on Health and the Healthcare System presented this morning at the Nymphaeum Museum in Rome is not encouraging. It tells us of tired, frustrated operators looking for ways out, of a NHS that seems to have lost its way, forgetting the priorities for which it was set up, neglecting its beating force, namely its staff. At the same time, the Public Health Service is going through a change that is taking place within it, in generational and gender terms, and perhaps it is from these issues that we can start to imagine a different future for healthcare.
The President of Eurispes, Gian Maria Fara, emphasised that: ‘dealing with health requires a holistic, intersectoral, dynamic, national and international approach, but it also requires the ability to immerse oneself, from time to time, in precise disciplinary areas or specific problems, in order to observe them, analyse them and formulate observations and proposals.
The Report we are presenting today develops precisely along these lines and the message that emerges is clear: health, more than ever at the centre of public debate, is an issue that involves all levels of decision-making and requires the participation of different sectors, from urban planning to environmental policies, from education to technology. Only through an integrated and sustainable approach will it be possible to develop policies that are not limited to the management of the health system, but promote the overall wellbeing of people and communities. This means proposing new organisational models, innovative approaches to public health, and advanced paradigms that consider prevention, lifestyles, and social conditions as central to the protection of health, fundamental elements on which to start working, together, in a serious and concrete manner’.
The President of the Enpam Foundation, Alberto Oliveti, pointed out that: ‘In the changes taking place – demographic, generational, values, technological – the medical profession must regain social relevance and authority. From this perspective, therefore, the role and the medical act must be re-evaluated. This is the crux of the problem. To regain possession of the ars medica, we must start again from its definition and thus from: science, conscience and wisdom, well aware that Artificial Intelligence, in its pervasiveness, will change practices, policies and ethics.
Without prejudice to the need to prevent aggression, by increasing controls in places of care, and to prosecute violence even in deferred flagrante delicto, the doctor-patient relationship must become a subject of study in search of the best approach.
The relationship is characterised by stress: the doctor is busy, the patient is worried, often uncaring. The management of the relationship with the patient under stress must be studied considering that the other actor, the physician, is also under stress. The competence and commitment of doctors (who in litigations that end up in court are directly called upon in only 3 out of 10 cases) are not in doubt.
The need is to teach the importance of speech and different non-verbal approaches to interpret the patient’s relational need and expectation. Because it is only in the relationship that care potential is realised’.
Below are some of the elements that emerged from the Report:
Professions in transition
Since 2008, the expansive dynamic of the figure for medical and nursing staff in the NHS, recorded between 1978 and 2007, has undergone a downturn linked to political and economic choices.
The loss of staff is gradual and constant: in 2014, 80 employees are hired for every 100 who leave, in 2015 the ratio is 70 for every 100, and in 2017, 98 employees are replaced for every 100. In addition, between 2014 and 2017, the ratio of NHS staff expenditure to total healthcare expenditure fell from 31.4% to 30.1%. One consequence of the low turnover of health personnel is the increase in the average age of NHS employees.
The decrease in stable staff is matched by an increase in flexible work: in 2018, the health sector accounted for 45% of the use of fixed-term annual units of the entire PA (35,481 out of 79,620). In addition to the reduction in the number of employees, there is a deterioration in working conditions for the same gross average wages.
As of 31 December 2022, the number of employees in the NHS amounted to 625,282, an increase of 1.3% over the previous year (+8,083). But in the meantime, precarious employment is also on the rise: between 2019 and 2022, the use of temporary staff increases by 44.6% (Fnomceo Report, 2024).
Staffing has been one of the main aspects of the policies to contain and reduce public spending on health. This has contributed to the explosion of problems related to employee disaffection and above all to the emptying of the value and meaning of work in and for the National Health Service. The blockage of turnover, and thus the chronic shortage of staff within healthcare facilities, has been for decades forcing workers to prolonged, continuous and highly physically and psychologically demanding efforts. A survey conducted by the Federation of Hospital Internists shows that one doctor out of two is experiencing burnout (52%), and for nurses just under one out of two (45%); for both professions, the incidence is more than double among women, where there are still difficulties in reconciling work and family life.
Adding to the discomfort experienced by healthcare personnel is the increase in the aggressiveness of users, who are increasingly responsible for episodes of violence, with about 18,000 operators involved. Two thirds of the aggressions are reported by female professionals; the profession most affected is nursing, followed by doctors and social and health workers. The most at-risk settings are Accident and Emergency departments and the aggressors are mainly users/patients. These factors have contributed to reducing the attractiveness of the NHS by making it extremely difficult to recruit new workers and retain those already in service. Those who leave the NHS go abroad or to the private sector in search of more flexible working hours, greater professional autonomy, and less bureaucracy.
The generational change also seems to have led to differences in the way of living and practising the medical profession. There is a rather pronounced gap between the first generation (Baby Boomers), composed almost exclusively of men, and the second two (Gen X and Millennials), which are highly feminised. The latter, finally, seem to differ in turn from Generation Z, the digital natives, who are even more flexible and mobile than their colleagues.
Staff expenditure and salaries in Italian healthcare
A comparison with the countries of the OECD area shows that the annual income of specialist doctors in Italy is almost 22% lower than the average, with very strong penalisations compared to Switzerland, Holland, Germany, Ireland and also relevant with Denmark and the United Kingdom. Even for the average annual income of hospital nurses Italy is more than 22% below the OECD average. We have 1.8 doctors per thousand inhabitants, with an average age of 50.5 years, where the 60-64 age group is still the most numerous. For the nursing staff, on the other hand, the average age is 46.9 years, with a ratio of 4.71 per thousand resident population, which rises to 5.04 if we also consider hospitals equated with the public sector.
New technologies and work in healthcare
Many technological innovations lead to time savings and greater efficiency in the work of doctors and nurses, with positive or very positive effects on productivity. We think first of all of well-established systems such as remote reporting, digital medical records, and various telemedicine applications. The increasing use of robots in surgery not only makes it possible to perform particular sequences of operations more precisely, thus improving the quality of performance, but also often guarantees faster execution. In a totally different field, reference can be made to the development of specialised software and sophisticated systems for analysing and processing data in diagnostics.
The greatest risks of job loss are present for some ‘lower’ level occupations with predominantly manual skills, such as auxiliaries. Similarly, the low or medium-low levels of occupational stratifications are swollen by the growth of primary care workers, with tasks with a strongly relational content that still seem to be fairly sheltered from technological innovations of a replacement type.
The National Health Service is impoverished in perhaps its most important resource: the human one. On the one hand, the great challenge is to reaffirm the importance of work in the public sector as a value in itself: the NHS conceived as a common good capable of serving the collective well-being. On the other hand, it is essential to use economic leverage first of all in order to attract new forces, adjusting salaries to the roles held and to European salaries. However, economic leverage does not seem to be sufficient to improve the recruitment and retention of medical and health personnel in the NHS: the well-being to which young people aspire refers to decent working conditions with regard to workloads and shifts, the physical environment in which they exercise their profession, and the reconciliation of the professional and private spheres.
An increasingly female, but not equal, SSN
Another major challenge concerns the governance of women in healthcare, where the presence of women has grown steadily over the years, to the point that two thirds of workers in the sector today are women. However, managerial and top positions are still predominantly occupied by men; and shift work, organisational difficulties, and the lack of work-life balance services place a particular burden on female professionals. As of December 2021, there are 450,066 women working with permanent contracts in NHS facilities, a trend that has been growing steadily in recent years. More than one doctor in two is a woman (51.3%), a percentage that is destined to grow, given the prevalence of women in the younger age groups.
Strong imbalances of power also persist: in 2022, of the 106 presidents of the provincial professional associations, only 11 are women (10%), and only 19.2% of primary doctors are female. A similar situation emerges when analysing the data on teaching and research staff in the medical sciences at Italian universities: female professors make up just 19.3% of the total and, to see their presence increase, it is necessary to move down to the lowest positions in the academic hierarchy. This gender disproportion is strongly linked to the age composition and age pyramid structure of doctors.
PNRR Mission 6.
Mission 6 called “Health” has economic resources of 15.62 billion euros, or 8.03 percent of the entire PNRR. The investments are aimed at overcoming critical issues in the NHS – waiting times, poor digitalization, lack of synergy between facilities, territorial gap – to prepare the sector for current demographic, epidemiological and social trends.
The available resources will be divided as follows: a first Component in Proximity Networks, Facilities and Telemedicine for Territorial Health Care for 7 billion euros; a second Component in Innovation, Research and Digitization for 8.62 billion euros.
To date, territorial medicine relies on primary care physicians and emergency units, which are insufficient to meet the needs of the community. The implementation of territorial medicine through Neighborhood Networks coincides with the implementation of Community Homes for 2 billion euros, Patient Living Homes for 4 billion euros, Community Hospitals for 1 billion euros. If Community Homes will be the single point of access to health care services in the territory – 1 per 40,000/50,000 inhabitants is expected – the House of Housing focuses on the needs arising from the aging population and the resulting chronic diseases that affect 40 percent of the population, including through telemedicine and home care. Community Hospitals, on the other hand, will have the function of enhancing intermediate health care through the creation of facilities designed for short stays – less than 30 days – and medium/low clinical intensity health interventions, with 20 beds per 100,000 population, and 24/7 care.
The second Component of the Health Mission, on the other hand, provides for investments in the modernization of the technology and digital park (4.05 billion), safety and sustainability of buildings (1.64 billion), strengthening of ICT and tools for data collection, processing, and analysis (1.67 billion), strengthening of biomedical research (0.52 billion), and implantation of technical-professional, digital, and managerial skills (0.74 billion). The Reform also consists of the reorganization of the network of Scientific Hospitalization and Treatment Institutes (IRCCS) with increasingly strategic and research-oriented corporate governance.
While the regulatory and procedural implementation of the Components of Mission 6 – for the most part entrusted to the Ministry of Health – has so far taken place in compliance with the timetable set in the NRP, their concrete implementation – left to the Regions and Local Authorities – is suffering from slowdowns and delays capable of casting doubt on the conclusion of the related interventions, scheduled by June 2026. This is the case both for the new territorial medicine, where the creation of the new Community Homes and Community Hospitals is a long way from actual completion and commissioning; and for ICT enhancement within the SSN. The number and technical-administrative capacity of the same personnel have so far been unable, even within the Health Mission, to make the Regions and Local Authorities fully capable of actually implementing the interventions entrusted to these levels of government.
Digital health and digitized SSN
In the clinical sphere, AI has already shown its potential: in diagnostic activity; in data analysis and predictive medicine; in patient care, enabling advanced telemedicine projects; and could reduce by 17 percent the time physicians spend on administrative tasks, which currently corresponds to 50 percent of their work time. The de-bureaucratization of medical activity may result in more time and attention to be invested in the doctor-patient relationship. The NRP represents a concrete opportunity (the last one?) for a revitalization of the NHS through digitization.
One of the main challenges identified by Eurispes for the SSN concerns the level of digital skills of staff, which is still too low. Italy ranks 18th in the degree of digitization among the 27 EU countries, highlighting the systemic rather than particular nature of the issue. Secondly, there is the need to digitize infrastructure throughout the country, in accordance with what Mission 6 of the NRP indicates. The risk, in healthcare, is that the well-known inequalities of the “analog” NHS, which have never been remedied, could be compounded by those specific to the digitized SSN.
Telemedicine
Artificial intelligence promises to revolutionize the health care system, multiplying the possibilities of care and redefining all the relational dimensions of which it is composed: health care professional-patient, health care professional-structure, patient-health care structure. But regulatory uncertainty is a very significant obstacle to the spread of AI. The EU AI Act identifies precisely health as one of the primary interests to be protected. On the clinical activity front, however, relevant implications will come from including software as medical device (SAMD), that is, software used in the context of healthcare activity, among the high-risk systems. The special caution in the use of data obviously applies even more in the health care setting because of the nature of the data produced, stored, transmitted and processed.
In Italy, a DDL is under consideration that recognizes the use of Artificial Intelligence systems in the health care setting, as long as this is done with respect for the rights, freedoms and interests of the individual, including with regard to the protection of personal data, perhaps the most complex aspect and one that involves communication between doctor and patient.
Generative Artificial Intelligence and cybersecurity
Generative Artificial Intelligence has the potential to generate, globally, $2.6 trillion to $4.4 trillion in value across all sectors of the economy. The pharmaceutical and medical products sector, along with the healthcare sector, is also poised to experience significant economic growth through the adoption of generative AI. Specifically, the healthcare sector could see its revenues increase from 1.80 percent to 3.20 percent, corresponding to an additional $150-260 billion. Generative AI will give rise to increasingly personalized treatments and better health outcomes for patients. Currently, several biotechnology companies are trying to develop personalized drugs based on each individual’s genetic profile by combining generative AI and digital twins technologies together.
Drug discovery is certainly an area where generative AI can reach its full potential in large part because it can increase productivity by speeding up the process of identifying compounds for possible new drugs, accelerate development and approval processes, and improve the way drugs are marketed. Generative AI is also making great strides in imaging, where it enables accurate reading of medical images and early detection of abnormalities.
After clinical productivity, engagement as well as improving the patient care experience is the second area where generative AI is expressing high potential. In the United States, more than 70 percent of healthcare organizations are already using generative AI tools or testing them. The World Health Organization itself supports the use of technologies such as Artificial Intelligence to reduce the harm from medical errors in prescribing drugs, which are a serious problem considering that in 2023 alone they caused the deaths of about 163 thousand people in Europe (ENPAM, 2024).
The pervasive growth of Artificial Intelligence solutions including generative intelligence suggests a reconsideration of the roles and professions to be integrated into healthcare. Many new job profiles will require science, math, and computer science graduates to fill roles in all medical and scientific specialties, from computational genomics to bioinformatics.
In addition, there will be a need for professionals who will perform “hybrid” roles based on the intersection of medical and computer science skills. In this regard, the education system, and universities in particular, must play their part by offering interdisciplinary courses of study that can adequately train future healthcare professionals.
The propensity of generative AI models to present incorrect or completely fabricated information as real facts is one of the main obstacles to their dissemination. Generative AI results may reflect biases in the underlying data, and this can give rise to inaccurate assessments that can have serious consequences. Some studies have also shown that such models can produce results that discriminate against certain social groups.
Cyber attacks in healthcare
The healthcare sector, globally, appears to be among those most affected by cyber attacks. In 2023, there were 396 cyber attacks globally: the highest number recorded since 2018 (Clusit Healthcare Report). More than 80% of the cyber attacks that occurred in 2023 had serious or very serious consequences on the healthcare facilities involved, leading to real paralysis of activities with serious repercussions also on patients’ health. Studies have found a positive correlation between cyber attacks and increased mortality in affected hospitals.
In 35 per cent of cyber attacks, cyber criminals used malware, especially the ransomware variant, through which they encrypt patient data and demand a ransom to unlock it, causing disruptions in healthcare services.
In Europe, between January 2021 and March 2023, the most affected countries were France, Spain, Germany, the Netherlands and Italy, whose healthcare systems recorded more than 60 per cent of cyber attacks. European hospitals were confirmed as the favourite target of cyber criminals, with 42% of total incidents followed at a distance by health authorities, agencies and bodies (14%) and pharmaceutical industries (9%). This is because attacks on hospitals, in addition to the media hype, can provide cyber criminals with a hefty loot. Data contained in medical records are, in fact, among the most coveted data on the dark web, with buyers willing to pay hundreds of dollars for a single record (Digital Agenda, 2022).
Given the devastating consequences of a cyber-attack, employee training as well as investment in advanced security systems and specialised personnel should be a key point in countering cybercrime.
Growing cyber threats therefore suggest that best practices should be adopted in order to increase cyber resilience. Public-private collaboration is essential to build cyber resilience that goes beyond the boundaries of the individual organisation and affects the system as a whole. It is also crucial to increase cybersecurity awareness by investing in the continuous training of all medical, administrative and technical staff.
According to the European NIS2 Directive, companies in the healthcare sector are required to implement and adopt a risk analysis methodology and security measures to mitigate cyber threats, implementing specific controls to ensure the security of their IT systems. Examples of these controls are backup, access control, Multi Factor Authentication (MFA), encryption, good IT hygiene practices, and human resources security. Companies are also called upon to constantly evaluate the effectiveness of the security measures taken.
The compass for the future: the multidisciplinary One Health approach
According to the One Health approach, the health of humans, animals and the environment are closely interconnected and interdependent. In order to mitigate and/or remove harmful factors and contribute to global health, a collaboration between the different disciplines is required that aims at sustainable development for our ecosystems. The One Health approach is therefore based on three fundamental pillars: Medicine, Veterinary and Environmental Sustainability. The principle was summarised at a Wildlife Conservation Society conference in 2004 as ‘One Planet-One Health’.
The One Health approach is particularly important for preventing global health threats such as the Covid-19 pandemic, for food and water security, nutrition, zoonoses control, pollution management and combating antimicrobial resistance, which threatens the sustainability of the public health response to many communicable diseases, including tuberculosis, malaria and HIV/AIDS. Recent data show that global deaths associated with antimicrobial resistance reached almost 5 million in 2019.
Over the years, emerging infectious diseases have caused epidemics and considerable damage to the global economy. Among the pathogens involved, RNA viruses have been responsible for about 44% of emerging infectious diseases many of which are zoonotic in origin.
The emergence of antimicrobial resistance in foodborne bacteria is mainly due to the incorrect use of antibiotics in animals for human consumption. The prolonged use of antibiotics at subtherapeutic doses in farm animals to promote their growth and prevent disease has led to the selection of multiresistant bacteria that can pass from animal to human and vice versa. In addition, these multiresistant bacteria can be released into the environment and contaminate it through manure used as fertilizer. Food production systems, therefore, need profound changes to make them increasingly sustainable and safe.
Chemical contamination of water is another major public health problem. It is estimated that about 80 percent of urban wastewater is released untreated, while industry releases numerous toxic compounds including heavy metals, sludge, and solvents into the environment, and agriculture is a source of pollution through the release of wastewater from irrigation and livestock farms. Physical contaminants include microplastics which are plastic particles <5mm produced by human industrial activities.
The concepts of sanitation and health have long undergone an inherent transformation. Health, first of all. Understood as the set of activities, facilities, resources and services that aim to ensure the protection of individual and collective health, health care has always been based on standardized approaches to diagnosis and treatment, the well-known gold standards. Thanks to increasingly advanced diagnostic methods, the development of genomics, and technological advancement in general, however, it is now associated with the idea that care should be increasingly personalized and “tailored.”
Expressions such as precision medicine, gene therapies, gender medicine, theranostics have become quite popular even among laypeople, and, it is now not uncommon for patients and family members to come before health care providers invoking, if not even hypothesizing, advanced solutions specific to their situation. The cultural push toward the expectation of personalized treatment has elevated the degree of awareness toward care but, at the same time, this awareness has grown spotty, mainly among certain generations and among those with even minimal digital literacy, in a haphazard and mostly online fashion. The outcome of this process, in its negative manifestation, is that inappropriate, economically unaffordable or unjustified diagnoses or treatments are often invoked, and that people react very badly when they are not accommodated. The issue of assaults on health care workers is only partly attributable to overcrowding or long waits. The advent of ChatGPT and other similar Artificial Intelligence models has accentuated the phenomenon, further redefining the relationship between patients and health information: old search engine searches have given way to articulate interactions. While offering new opportunities, these generative platforms nevertheless raise numerous questions as to reliability, security and the role of health care providers, whose centrality-as this Report points out-remains and should continue to be so.
The second concept that is progressively changing is that of health. Until a few decades ago, health was perceived, in a sense, as a “matter of luck.”
Today there is a paradigm shift, and the passive attitude that preceded the state of illness is (fortunately) changing direction: the awareness of having to actively and individually take care of one’s health before getting sick is slowly making its way.
You have to think about it first, and you have to think about it yourself. Many see this as a real paradigm shift: a shift from the Sick Care model to the Healthcare model, where the former is reactive and focuses on treating symptoms and illnesses after they occur. In contrast, the Healthcare model is proactive and focuses on preventing diseases before they occur. Scientific research, moreover, goes even further, hypothesizing the possibility of performing “true ‘systemic resets’ that allow the human body to remain relatively young, functional” (V. Longo).
How important, in this light, are the genetic make-up and family predisposition to certain diseases? Far less than was claimed not so many years ago. The hope (and rush) towards genetic tests – some 80,000 available on the market – has been, and still is, a real trend, as well as a flourishing business. For a time, there was the illusion that a simple blood sample could once and for all rule out the suspicion of a genetic disease, determine the risk of developing a certain disorder or calculate the probability of transmitting it. This approach led to an underestimation of the value of the most common laboratory investigations – e.g. cholesterol and blood sugar – which instead offer a snapshot of precise risk factors.
Evidence-based medicine, in particular, has confirmed the link between environment, diet and non-communicable chronic degenerative diseases, identifying lifestyle, with a 50% incidence, as the main determinant of individual health. Genetic and socio-economic factors, each weighing in at 20%, come next. Finally, there is health care, which is worth 10%.
In this debate, the concept of the exposome, a holistic concept that further broadens the perspective on the determinants of health and takes into account all exposures from various sources, both external and internal, from the moment of conception to the end of life, has been gaining ground in recent years.
Two strategies to implement
If those just described are the evolutions of the concepts of health and health, then there seem to be two main strategies to implement: to make individuals aware that as much as 50% of the chances of staying healthy lie in their lifestyle choices; to stimulate governments and policy makers to develop health policies based on a deep and integrated understanding of all exposures that influence health: genetics, climate, urban and natural environments, work, education, psychological stress and, of course, the health system. And since, just to name a few, climate, air pollution, waterways, and the food production chain are phenomena that cross state borders, it is imperative that we proceed with an international logic.
The interviews
The Report closes with 15 interviews with opinion leaders: Micaela Arfò Guarrasi, psychologist, Specialist in Neuropsychology Director Psychologist ASL Roma 3, UOC – SPDC Ospedale G.B. Grassi; Marco Baccanti, Director General of the Innovation and Technology Transfer Foundation; Ilaria Capua, Professor – DVM, PhD Senior Fellow of Global Health, Johns Hopkins University, School of Advanced International Studies – SAIS Europe; Nino Cartabellotta, President of the GIMBE Foundation Nunzia Ciardi, Deputy Director General National Cybersecurity Agency (ACN); Francesco Cognetti, President of the Confederation of Oncologists, Cardiologists, Haematologists (FOCE), Professor of Oncology at the International Medical University UniCamillus; Stefano da Empoli, President of the Institute for Competitiveness (I-Com); Valter Longo, Professor of Biogerontology and Director of the Institute on Longevity University of Southern California – Davis School of Gerontology, Los Angeles, Director of the Longevity and Cancer Research Programme IFOM Institute of Molecular Oncology, Milan Beatrice Mazzoleni, National Secretary FNOPI; Donatella Morana, Professor of Constitutional and Public Law, University of Rome Tor Vergata; Francesco Perrone, President AIOM – National Cancer Institute IRCCS ‘Fondazione G. Pascale”, Naples; Lorenzo Pregliasco, Expert in political communication and public opinion, he is Founding Partner of Quorum and Youtrend and member of the European Society for Opinion and Marketing Research; Giosy Romano, Coordinator ZES Unica del Mezzogiorno; Raffaella Rumiati, Director Neuroscience and Society Lab, SISSA Scuola Superiore di Studi Avanzati; Antonella Viola, Scientist, Professor of General Pathology at the University of Padua and science popularizer.