by Claudio Maria Maffei
15 OTT – Dear Director,
I counted in the last month at least 30 interventions on QS on the transition or not to the dependence of general practitioners (Mmg) up to the recent report of the intervention of Minister Speranza at the Congress of the Italian Federation of General Practitioners. Speech during which the Minister declared that the transition of Mmg to addiction “is a topic to be discussed at a later time, it is not the heart of the story and those who insist on this issue just want to fuel a confrontation. I am interested in building a better NHS by valuing family doctors ”.
After all, the Minister could not say more to the Congress of the strongest union in general medicine, whose President Scotti in an interview with QS at the same Congress said about the transition to addiction: “If this project passes I will stop doing the doctor. It is my personal position. I don’t understand how medical professional autonomy can be reconciled with a subordinate role. “
This statement by Minister Speranza was followed by. always on QS. two interventions of different character which, however, both reminded the Minister of the need to immediately take on the problem of the choice between dependence and agreement.
With his usual authority, Antonio Panti highlighted three critical issues that in fact orient towards the maintenance of a conventional relationship: the contributory and therefore pension aspects (impossibility of paying the existing ENPAM pensions, if the contributions of the assets, paid to the INPS and no longer ENPAM), the question of the importance of maintaining the fiduciary relationship with the consequent possibility of changing doctors, the proximity and therefore the capillarity of the assistance that in many realities only the clinics of the single Mmg are able to guarantee.
In turn, the over 150 signatories of an open letter to Minister Speranza reaffirmed, but with a different sign, the urgency of the choice, proposing the transition to dependency in a “new Italian public NHS, fair and supportive for citizens, in which doctors of the hospital and of the territory will be able to operate with equal dignity and with all the protections and rights that every worker has the right to have “. In this case, the principle of fairness towards the operators of the NHS is oriented towards the choice of dependence.
This debate / clash that sees two very different positions opposed (for and against the transition to dependence) develops simultaneously with the progress of the process that will lead to the operational declination of the PNRR which with its Community Houses (CdC) and with the of territorial health care which certainly imposes a different general medicine within a different local medicine.
This coincidence between the renewal / evolution of the convention and the launch of the PNRR leads in turn to also question the PNRR and its indications.
On the one hand, for example Garattini and Nobili, they affirm that “the PNRR should be exploited above all to give a radical change to the territorial assistance of the NHS, starting from the classification of GPs” and on the other Belleri, among others, remembers that “In the CdC with the dimensions envisaged by the Pnrr, not even at the end of the five-year period all the primary care doctors currently in activity will be able to find accommodation, let alone in the event of an immediate and ope legis transition to addiction” and one wonders “what will become of the doctors that guarantee the capillarity and proximity of assistance in small municipalities scattered over large areas without CdC “and” who will guarantee the assistance of citizens residing in rural areas or in disadvantaged areas of the mountain, far from the CdC, already lacking assistance base for the lack of generational change “.
It is not surprising that in the face of such divergent positions in the presence of an emergency in the emergency such as the implementation of the PNRR, the Minister takes a position that he shares with all those, and not a few, who say that they are not passionate about the transition to the dependence of Mmg. And then postpone. In reality, I think that postponing the discussion on this issue is wrong, just as it is wrong to transform it into a sort of limit that some defend as insurmountable and others would like to remove as soon as possible.
Leaving the task of making detailed proposals to those who know more than me about general medicine, I limit myself to observing that many of the positions hosted here on QS about drug addiction are very precise when it comes to highlighting the supporting arguments. of one’s own thesis and very nuanced when it comes to arguing “against” the critical issues that one’s thesis leaves unresolved. Perhaps it would be useful to try to tackle the issue in all its complexity in order to build that path that leads to the one thing on which all positions converge: general medicine must change.
To those who argue that the transition to addiction is indispensable and urgent, I would ask you to specify how to resolve all the issues already mentioned that make it difficult and impossible for some: from the contribution and pension aspects to those on the capillarity and proximity that the Health Houses of the PNRR do not guarantee. To those who want the continuity of the conventional relationship, I would ask how to make it consistent with the cultural and organizational model that the response to chronicity requires and therefore with the needs of continuity, multidisciplinarity and multi-professionalism of teamwork, of sharing objectives between levels specialist and level of primary care and modification of professional roles.
Almost never in the debate has reference been made to concrete experiences of the evolution of general medicine in Italy and in other countries. By way of example, the microteams are considered by Scotti to be the most suitable solution (“We propose micro teams composed of 4-5 mmg with nurses and study staff who can become the spokes of the Community Houses and in connection with them”) , while for the signatories of the letter to Minister Speranza the microteams are a “linguistic restyling to define an old model because it has been applied for at least fifteen years with the ACN of General Medicine 2004-2005, passed off as” novelty “and already proved to be of limited usefulness for the ungovernability of the general system “.
Perhaps getting out of the trenches of the clash between Pro and No Dip to address the issue of convention / addiction in the open field, treating it as a complex public health problem on which there are already experiences and data could help.
Claudio Maria Maffei
Chronic-On Scientific Coordinator
October 15, 2021
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