“Health Thermometer – 2nd Healthcare System Report.” Eurispes and Enpam present the results

The research Il Termometro della Salute (The Health Thermometer), promoted by the Eurispes-Enpam Health, Legality and Social Security Observatory, returns to propose, almost five years after its first issue, an attempt at an overall reading of the reality and prospects of the National Healthcare System.

As the President of Eurispes, Gian Maria Fara, emphasises: «This study seeks to address what the impact of Covid-19 has generated in the perception of the National Healthcare System and its planning in the post-Covid period. In our country, as well as in the rest of the world, health issues have in fact leapt to the top of citizens’ and governments’ attention, transcending the traditional contours of sector policies and imposing itself as a central junction of the economic policies themselves. One only has to think of the ‘revolution’ in the EU represented by the partial sharing of the debt of the acceding countries, which led to the launch of the Next Generation EU and national resilience plans.

The Eurispes-Enpam Observatory believes that it is now possible to go beyond the specific issues related to the pandemic to address the reform of the National Healthcare System, which, precisely from the limits shown in the recent past and the measures in response to Covid-19, is taking the starting point for an ambitious reform. Ambitious, but problematic and fraught with contradictions and unknowns. If the country has held up, if public healthcare has fulfilled its decisive and recognised function, if the role of health in the more general framework of a democratic and advanced society has returned to the front page, it would be a serious mistake not to concentrate now the maximum effort on putting healthcare, through reform, back definitively at the centre of policies aimed at the growth of the country».

«The National Recovery and Resilience Plan – states Enpam President, Alberto Oliveti – intervenes on Health with the first component of Mission 6, redefining the cornerstones for relaunching territorial healthcare with an organisational model centred on proximity networks, facilities and telemedicine. To this end, significant resources are invested in Community Homes and in supporting home care, on the assumption that the ‘patient’s home’ is the first place of care. It is evident, however, that the 1,400 Community Homes envisaged by the Plan will not fulfil the same function as the tens of thousands of medical practices currently operating in Italy.

Between the Citizen’s Home and the planned Community Homes (one for every 42,000 inhabitants), in fact, a care gap will be created if a project to revitalise the current network of general practitioner practices is not set up at the same time.

In this regard, Enpam is implementing a project that will enable general practitioners to join together in more structured, organised and equipped practices, while continuing to guarantee a truly capillary and flexible presence throughout the territory (“spoke” practices). These practices will have to be fitted out with advanced equipment to take advantage of telemedicine solutions. This initiative is quickly achievable and consensual, since it is promoted by the same category that is to implement it. We believe that once implemented, it can be highly effective in improving territorial healthcare according to the objectives of the NRRP».

Finally, the President of the Eurispes-Enpam Observatory on Health, Legality and Social Security, Carlo Ricozzi, explains: «The Working Table has conducted permanent monitoring of the sector, not neglecting to assessing the extraordinary implications of Covid-19. The issues addressed in this Report are among the strengths and weaknesses of our National Healthcare System: the political choices, the relationship between public and private healthcare, human capital and university education.

In addition, we wanted to dedicate a space, in interview form, to the considerations of authoritative scholars and the point of view of health workers, doctors and nurses working in hospitals outpatient clinics and general practices.

The issue of combating health offences was instead addressed in two documents specially drawn up by the Guardia di Finanza and the Carabinieri, which describe monitoring and control methodologies and the reporting of operational results.

In the Observatory’s intentions, the publication of this research work is aimed at fuelling the debate, which has never really died down, on one of the key aspects of social justice: access to care regardless of wealth».

The weakening of the NHS. GDP invested in healthcare over a third less than in Germany and France

For at least 15 years, the National Healthcare Fund has undergone successive cuts in the spirit of the spending review to balance the public accounts. This has resulted in a progressive depletion of performance capacities and the downgrading of our country in world rankings of the ratio of investment in public health to GDP. In 2019, a watershed year because it had not yet been affected by the pandemic, the share of GDP reserved for healthcare had fallen to 6.2%, to which citizens added 2.2% in direct spending. The average in the EU-27 was 6.4% and 2.2% respectively, but in Germany 9.9% and 1.7%, in France 9.4% and 1.8%, in Sweden 9.3% and 1.6%. This means that public investment in healthcare in Germany and France is more than a third higher than in Italy. Therefore, after the “extraordinary” three-year period, which saw the allocation of the necessary resources to deal with the pandemic and the vaccination campaign (by the way, only some of which have been disbursed to date), with the last Stability Law the share of GDP reserved for the NHS has gone back down, tending to that historical minimum of around 6%.

Over a decade, more than 37 billion euros have been subtracted from public healthcare, of which about 25 billion in the period 2010-2015, as a consequence of “cuts” in various financial manoeuvres, and over 12 billion in the period 2015-2019, as a consequence of the “defunding” that, for public finance objectives, has allocated fewer resources to the NHS than planned levels (Gimbe Foundation data).

The ageing of human capital and precariousness: a problem that is about to explode

For doctors, nurses and other professionals supporting the NHS, the lack of turnover and the repeated recruitment freeze have also produced pockets of precariousness irreconcilable with continuity of care. But, first of all, it has generated the strong ageing of human capital that has led to a high number of retirements. This phenomenon, which has already eroded the number of professionals, is set to explode in the coming years and also affects the area of private healthcare.

In 2019, there were 4.05 doctors per 1,000 inhabitants in Italy; a figure that is slightly lower than Spain (4.4) and Germany (4.39), and higher than France (3.17). The share of nurses (approximately 6.16 per 1,000 inhabitants; with 1.4 nurses for every doctor) places Italy at the bottom of the places in the ranking of OECD countries. The “registry” of the medical class speaks for itself: many professionals often elderly, and very few young people. More than half of the entire medical class of doctors (56%), the majority of whom are aged between 55 and 75, will no longer be operational in five years’ time. “Young” doctors, i.e. under the age of 35, are only 8.8% in Italy, compared to percentages of over 30% in Great Britain, the Netherlands and Ireland, or over 20% in Germany, Spain and in Hungary. France, which for the under-35s shows a figure less distant from ours, nevertheless presents 15.7% of under 35s: almost twice as many as Italy.

The ageing of doctors has a particular impact on primary care medicine. Without turnover, in 10 years there will be a serious shortage of nurses

If there are, for example, 10 specialised physicians working in a hospital, and one of these retires without being replaced, there will be a partial reduction in activity and/or an extension of the time that the citizen-patient will have to wait for the provision of a given medical service. But when, on the other hand, the ratio is 1 to 1, – as in the case of the relationship between general practitioner and patient –, and this doctor retires, his colleagues having already been saturated by the maximum number of patients, what looms is the practical impossibility of providing a service. Analysing Agenas data, it emerges that in the three-year period 2019-2021, 2,178 general practitioners and 386 free-choice paediatricians were “lost” in Italy: in percentage terms, more than 5%. Given that each general practitioner assists an average of more than 1,000 citizens and that senior doctors often come close to or even exceed the maximum of 1,500 patients, this has meant that around 3,000,000 citizens have been left without a general practitioner.

Even for the nursing professions, the average age of current active nurses is about 47 years, but every six months this average age rises by one year. Within a decade, therefore, unless there is a strong turn-over, the already reported shortage would turn into a real famine.

For public healthcare workers, the freeze on turnover in the regions with recovery plans and the measures to contain recruitment have led to a decrease in permanent staff. As of December 31, 2018, it was lower than in 2012 by about 25,000 workers (about 41,400 compared to 2008). Between 2012 and 2017, the number of staff (healthcare, technical, professional and administrative) employed on a permanent basis at local health units, hospital trusts, university trusts and public IRCCSs fell from 653,000 to 626,000, representing a decrease of just under 27,000 (4%). Over the same period, the use of staff with a flexible employment profile increased by 11,500, managing only partly to offset this decline.

Healthcare provision, the country is split

The average annual turnover rates are very different between the northern and central-southern regions. Tuscany, Emilia-Romagna and Veneto, even in the hard years of the spending-review, were able to fully replace staff who had retired and even increase them. Lombardy substantially maintained its staff numbers. Piedmont decreased them slightly. All the other regions are united by the fact that they are still under a rehabilitation plan and had an average turnover rate, between 2012 and 2017, of less than 70%.

From 2022 to 2027, the public healthcare system will lose an average of 5,866 salaried doctors each year, and an average of 2,373 general practitioners. For the entire five-year period, the exits of 29,331 employed physicians and 11,865 general practitioners must be calculated. Compared to the current staffing levels, these are losses of slightly less than 30% for both departments. The 21,050 most senior nurses in the public service are also set to leave their jobs empty in the next five years ‘due to age limits’. It should also be considered that in many cases this is a wearing job and that it cannot be ruled out that there will be many early retirements, which would add up to the loss of almost 10% of the workforce.

Moreover, data on the remuneration of specialist doctors and hospital nurses in relation to per capita GDP indicate that the Italian doctor has an income equal to 2.4 times the country’s average, while in Great Britain the ratio rises to 3.6, in Germany to 3.4, in Spain to 3.0, and in Belgium to 2.8.

Regional differences and waiting lists. Healthcare mobility affects almost 1.5 million citizens

Italians spend “out of their own pocket” on healthcare for services and medicines in whole or in part (payment of a co-payment) not covered by the NHS annually almost 40 billion euro, amounting to a share of GDP in excess of 2%. To this must be added the intensification of “healthcare mobility”, generated by the need to turn to public facilities in other regions to obtain NHS services that cannot in fact be provided in the territory of residence due to the structural deficits of the regional health service to which they belong. This “healthcare mobility” in the three-year period of the Covid has contracted, due to the restrictions on free movement and the overburdening of most public healthcare facilities; but looking at the 2018 data, strong territorial imbalances emerge in relation to patients “entering” and “leaving” between the different regional healthcare facilities.

The Regions with a surplus balance are Lombardy, Veneto, Emilia-Romagna and Tuscany, and those that instead deplete their healthcare budget are almost all the remaining central-southern Regions. Moreover, the amounts paid by the Regions that ‘give up’ patients to those that are able to provide the services, cause a further difficulty in healthcare budgets that are already compressed by the Deficit Recovery Plans. On the contrary, the Regions that provide many services to non-residents can count on an over-budget that makes it possible to invest in facilities and personnel, from which resident citizens benefit in the first place. In terms of efficiency, the “gap” between some northern and central-southern regions inevitably widens. At the two extremes, in 2018 the Region of Lombardy had a positive balance of almost €809 million, while the Region of Calabria had a deficit of almost €320 million and the Region of Campania more than €302 million. This also gives rise to impacts such as that of the lack of turnover of medical and nursing staff In addition to the burden on the “economic accounts” of the individual regional health authorities, “healthcare mobility” brings to light the seriousness of the phenomenon represented by almost 1.5 million citizens who, in 2018, had to go outside their region of residence for treatment.

The time series of the Eurispes sample surveys show a trend from which it emerges that a quarter of Italian households report economic difficulties in relation to healthcare services. In 2022 this difficulty is confirmed to be greater especially for citizens in the southern regions (28.5%) and the Islands (30.5%). Moreover, one third of citizens (33.3%) state that they have had to forego healthcare services and/or operations due to the unavailability of healthcare facilities. Data for 2023 confirm this trend and indicate it is on the rise.

Comparison between Italy and Germany

The comparison between Italy and Germany in terms of the reaction to the first wave of the pandemic is important because of the territorial proximity and interdependence between the two countries, but above all because of the different approach adopted by the two countries in dealing with the health emergency. The data show that the use of hospitalisation in Italy was far more widespread than in Germany. Italy has favoured the expansion of the private system, thus sustaining a high level of quality of services, while at the same time promoting an increasing centrality of hospital care to the detriment of more integrated care at territorial level. The German one cannot be taken as a model, but in some important areas, especially with reference to community medicine, it can offer some important indications for the Italian system as well.

Public health and territory: a comparison between Veneto, Lombardy and Emilia Romagna

The healthcare systems of Lombardy, Veneto and Emilia Romagna are to be considered among the best in Italy and in the entire European Union. These have been taken as a model in the Report to identify the differences, including structural differences, that led them to adopt different strategies that were variously effective in containing the spread of infection during the pandemic. The healthcare system in Lombardy dealt with the spread of the disease by favouring assistance centred on hospitalisation, and less on a network of territorial assistance that allowed patients to be maintained and followed at home. On the contrary, Veneto and Emilia Romagna maintained stable integration between the three types of assistance (Intensive Care, Ordinary Hospitalisation, Home Hospitalisation), which indicates that these two systems structurally have a better balanced health policy between the different types of assistance. This different orientation is particularly evident when comparing the number of cases treated through home care pathways in the different regions. Veneto demonstrates that treating patients at home is a basic principle of its healthcare provision. The more than 3,500 cases treated (2017 data) indicate how the integration policies advanced over the years have then manifested themselves in what today generates a particular proactivity of the territory, in contrast to Lombardy, for which the centrality of the hospital system has strongly contained its growth. Lombardy’s 1,500 cases are significantly lower not only in comparison with Veneto, but also Molise, Tuscany and Emilia Romagna.

The critical aspects of the reform project

The goal set in Ministerial Decree 77 of opening around 1,350 Community Homes in a few years entails a huge logistical effort that most regional healthcare facilities are unlikely to be able to cope with. During 2022 there were many “openings” of Community Homes, but in reality they were pre-existing facilities (outpatient clinics, health homes). If the National Healthcare System is not put in a position to plan and then absorb the necessary professionalism, the Community Homes and Hospitals will remain empty; while the crisis of the decisive sector of general medicine will spiral further, hospitals will continue to deteriorate, the universality of public healthcare will continue to decay, more highways will open up for private healthcare, and caring will become a matter of census. Also from a ‘cultural’ point of view, the attention that Ministerial Decree No. 77 devotes to telemedicine and to the optimisation of communication networks in the health sphere clashes with the reality of many regions for which the Electronic Health File is still an essentially unknown tool.

The Observatory’s commitment to monitor the progress of the reform

Mission 6 of the PNRR and the full implementation of Ministerial Decree 77 on territorial medicine envisage time steps that have already been set from today to 2026, on the respect of which the disbursement of the subsequent tranches of the Next Generation EU depends. Hence the commitment of the Eurispes-Enpam Observatory to follow the entire implementation process of the reform over the next few years, analysing the steps in the progress of what is envisaged by the PNRR and the reorganisation of territorial medicine, especially in terms of the quality of the interventions. In this way it will be possible to assess the levels of implementation, point out any needs for fine-tuning and, on the whole, verify its adherence to Article 32 of the Constitution on which a public and universalist health service is based that realises the right to health for all: a health service that must continue to represent, as in the past, an essential pillar of social coexistence.

The summary of the Report can be downloaded at the link https://eurispes.eu/wp-content/uploads/2023/06/sintesi-eurispes_enpam-rapporto-sanita.pdf

The full Report is available for viewing online after registering on our website at the link https://eurispes.eu/ricerca-rapporto/termometro-della-salute-2-rapporto-sul-sistema-sanitario-eurispes-ed-enpam/

 

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