The progressive weakening of hospital care in our country is in the numbers: in ten years, between 2010 and 2019, care institutions decreased from 1,165 to 1,054, with a cut of about 25 thousand ordinary hospital beds (from 215 thousand to 190 thousand). Not only that: the employees of the National Health Service (NHS) decreased by 42,380 units (from 646,236 to 603,856) and the definition of health care reached 37 billion. This is what the ‘Forum of scientific societies of Italian hospital and university clinicians’ (Fossc) denounces, which – today in an online press conference – highlighted the ‘inadequacies’ of some reforms underway, starting with that of territorial medicine, making requests concrete and underlining the need for a common table to address all the serious problems of the NHS.
The pandemic – according to scientific societies – has shown the weakness of the system and the current crisis in the emergency room is nothing more than the result of years of cuts and the tip of the iceberg of a hospital system in trouble. And the proposals for the reform of territorial medicine (Ministerial Decree 71) are insufficient to fill the serious and increasingly evident gaps, which risk compromising the quality of care. The need to bring treatments closer to the patients’ living environment cannot be satisfied simply – they denounce – with the creation of new structures, the so-called community houses (one for every 50 thousand inhabitants) or, worse, the health districts (one for every 100 thousand inhabitants. ). For this – argues Fossc – we need a new model, in which the territory and the hospital are interconnected. Starting with an ‘adequate’ hospital, which is extended to the territory, redefining the parameters that have characterized its organization so far and that date back to 1968.
“We agree on the need to strengthen local medicine – says Francesco Cognetti, coordinator of the Forum – but we believe that it is not enough to solve the problems of the hospital, starting from the waiting lists and the collapse of the emergency rooms”. And according to Cognetti “the solutions to be envisaged must not take place in isolation, but in a systemic logic. The historical duality between hospital and territory must be overcome, in favor of a single interconnected, continuous and complementary system of services in which the idea of hospital extended to the territory and adapted to the needs of the population, bearing in mind its scientific, clinical and organizational complexity. For this reason, the organizational parameters of the hospitals sanctioned by Ministerial Decree 70 (Ministerial Decree 70 of 2 April 2015), of which we look forward to a profound and radical revision “.
“We ask that the hospital – explains the coordinator of the Forum – be rethought due to the epidemiological needs that have clearly changed in recent years, whose responses require both quantitative and qualitative measures. It is necessary that the number of ordinary hospital beds grows well over 350 per 100,000 inhabitants today to reach at least the European average of 500. The number of intensive care beds must also exceed 14 beds, which have remained on paper and never reached, to reach at least 25 per 100,000 inhabitants”. Learning from the lesson of the pandemic it is also necessary to provide for semi-intensive care areas in both the Medical Department and the Emergency Department.
The Fossc also fears the “real risk that the activation of territorial structures in the absence of adequate medical personnel compromises the system of primary care, carried out through the general practitioner with the taking in charge of all citizens who are really close to their threshold. Primary care in fact has nothing or little to do with local services, on the other hand they represent the first opportunity for individuals and families to come into contact with the NHS and constitute the first element of a continuous process of health care, a sector well defined to be preserved and indeed to be strengthened.
“Furthermore, there is a progressive prerogative of services in favor of the private sector compared to the public which is thus depleted – denounces Cognetti -. As Pope Francis reiterated in the recent audience with the Federsanità executives, ‘it is necessary to confirm the importance of public health system and to reduce health inequalities we must work to ensure that everyone has access to care, the public health system is supported and promoted, and continues to be free. Cutting health resources is a real outrage ‘to humanity’. These are the harsh and solemn affirmations of the Holy Father which represent a warning to all “.
And again: health workers are inadequate in relation to the population of our country. There are about 130,000 hospital specialists, 60,000 less than Germany and 43,000 less than France. In Italy, as highlighted in a recent article published in the Lancet, the bleeding of white coats also affects general practitioners: there are about 40,700, but every year 3000 retire. And we are witnessing a consistent exodus of newly graduated and postgraduate doctors, because abroad salaries and working conditions are much better.
The new articulation of territorial care outlined by Ministerial Decree 71, although highly desirable, presents a structure and a model corresponding to a community philosophy or rather a population philosophy (50,000 / 100,000 citizens users) which flattens the diversity and complexity of the modern demand for health and it seems – argues Fossc – completely disconnected from the hospital environment with which it should structurally collaborate. The feeling, or rather the conviction confirmed by the facts, is that we want to invest in structures rather than people. In reality, the system is close to collapse, the scientific societies denounce.
The Forum defines “worrying” initiatives such as that of the Lombardy Region, which has announced an experiment to favor the ‘organizational’ replacement of nurses in relation to general practitioners. This is a confused, wrong and almost desperate answer to the problem of severe staff shortages. We appeal to the legislator to consider at the same time the reform of territorial and hospital assistance. Moreover – the experts underline – the hoped-for decrease in low priority access to the emergency rooms is not obtained only with the strengthening of the territory, on which the less acute clinical needs must be redistributed. We need a cultural change. What is territorial must be considered pre and post-hospital, in an integrated vision of the two realities.
And again: the parameter of the beds must no longer be considered static, but dynamic in relation to the needs: the beds must be assigned to the individual medical and surgical disciplines and calculated on the basis of the prevalence data of the various pathologies. Fossc is also asking for an investment in medical disciplines, a substantial increase in the number of hospital specialists, such as to reach the standards of other Western European countries, and an increase of the same amount of nursing staff.
The overall system – this is the proposal – will have to configure a sort of departmental logic with the idea of the real hospital (general or specialist classically understood), which functionally extends to the territorial health realities as well. We realize that revising the Ministerial Decree 70, as per our proposals, implies an increase in expenditure for the health fund. In fact, it is impossible to rethink hospitals, increase their functionality and increase their degree of adequacy with the need for care of the population at an unchanged cost. If you enter the logic of re-hospitalization, it is necessary to move from saving to investment. We demand a reasonable refinancing of hospital spending, but at the same time we make ourselves available to seek a sustainability agreement with the institutions to eliminate diseconomies, overcome disorganizations, reduce waste still largely existing at the local level, in a word to find solutions that allow, following an increase in spending, to ensure added value.
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