The bill on differentiated autonomy approved in the Senate marks a point of no return for the National Health Service. The alarm comes from the Italian Association of Medical Oncology (Aiom) which expresses strong concerns and presents a scenario that is anything but rosy: assistance for cancer patients reduced to a simple service, limits to weaker scientific research and at different speeds, increase in inequalities territorial access to care, progressive privatization of healthcare in some Regions, competition even between public structures, to the detriment of both patients and healthcare workers.
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The possible tightening of regionalism
In 2001, with the reform of Title V of the Constitution, many powers in health management were delegated to the Regions, with the aim of reducing territorial differences in health outcomes and improving the level of care. “The objective, many sources say, was not achieved – he recalls Francesco Perrone, President Aiom – On the contrary, the establishment of 21 different regional health systems has worsened disparities in care. Now differentiated autonomy constitutes, in fact, an intensification of the healthcare regionalism introduced in 2001, which has already caused too much damage to cancer patients. And we fear that it could worsen inequalities instead of decreasing them”. The lesson comes from the world of oncology: “If a treatment against cancer does not work – Perrone exemplifies – it is a rule of clinical practice to change therapy: insisting, intensifying the doses, increases side effects without any benefit”.
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Perplexities about Essential Performance Levels
Over twenty years ago, the scientific society recalls, the Essential Levels of Assistance (LEA) were introduced precisely to define what care should be guaranteed to everyone. “The LEAs should have represented a parameter for understanding where to invest more resources, but they have become criteria for judging the efficiency of regional health services and for establishing sanctioning measures. In this way, they have been transformed into a tool aimed at quantifying the distribution of National Health Fund – explains the AIOM President -. The Regions in difficulty in reaching the ‘threshold criteria’ defined by the LEAs, instead of being supported, have been damaged with the further reduction in funding, thus determining a vicious circle, because without resources it is difficult to guarantee good care.”
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If the LEA system has not worked, the Essential Performance Levels (LEP), which would be introduced with the law on differentiated autonomy, cannot be the solution to the problem according to the Aiom: “The LEP constitute a debasement and an excessive simplification of the LEAs. From the concept of assistance we move on to that of the single service. But the care of cancer patients is 360 degrees and cannot be reduced to a sum of services: just the administration of drugs or the possibility of promptly accessing a surgery. It is a complex set of elements, which contribute to important results, such as survival and quality of life of patients”, underlines the president.
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Fears for scientific research
Also of concern are the possible difficulties for scientific research as a consequence of regionalism: “In scientific research – continues Perrone – there must be no barriers: only collaboration and cohesion without obstacles allow the quality of care to be improved. This is a key principle of our professional ethics, both in assistance and research”.
The risk of dangerous competition between hospitals
Aiom’s position is clear: for too long the management of the Health Service at central level has lost propulsive capacity and management skills, which have not been promptly replaced. On the other hand, many professional figures have distinguished themselves in some Regions which have therefore required greater autonomy. But in this way territorial disparities have worsened. “Differentiated autonomy would increase the already existing gap – explains Perrone – Today there is already strong competition between the public and private systems, but, with the creation of differentiated regionalism, there is a real risk that the same public structures will compete with each other and that richer regions offer professionals better contracts and higher salaries”.
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Centralization and regional oncology networks
In Italy, in 2023, 395,000 new cases of cancer have been estimated. Approximately 60% of patients are alive 5 years after diagnosis. “The National Health Service is one of the best in the world, but it needs ‘maintenance’ and to be defended in its main characteristic, that is, the universalism of care – states President Aiom -. Scientific progress loses much of its beauty’ if it does not reach everyone. Indeed, it takes on the unpleasant appearance of wasted opportunities, of rights told but not guaranteed. The way forward does not go towards an even stronger healthcare regionalism, but in the direction of strengthening the system at central level , which need more skills and resources. On the other hand, regional oncology networks must be created throughout the territory. As made known in the recent Agenas report, there are still disparities in the state of progress and efficiency of the regional networks and those still far from achieving the organizational objectives, they must be supported, more than has been done up to now. Aiom – he concludes – is at the complete disposal of the Institutions to reduce the disparities that still exist and continue to guarantee patients the universality of care”.