Margherita Miotto and Fulvio Lonati
The lesson of the pandemic was not useful. The Meloni Government has blocked the process of renewal and strengthening of primary care and local services triggered by the PNRR and Ministerial Decree 77: serious damage to the health of citizens. The complaint of the Alliance for the Reform of Primary Care in Italy.
It’s as if the pandemic had never happened! And it seems that political decision-makers have forgotten the clear lesson of Covid-19: “We need an adequately organised, equipped and financed National Health Service, in particular in its territorial and primary care component”[1]. With the PNRR, and in cascade with Ministerial Decree 77[2] which defined the reference models and standards for the territorial network, a radical process of renewal and strengthening had been activated of local health services. Unfortunately, after this significant start, we are here losing the innovative spirit and we record one worrying stagnation; moreover, in the face of the worsening crisis of the entire National Health Service, which is making the fundamental principles of universality, equality, equity and gratuitousness increasingly less demanding.
L’Alliance for the Reform of Primary Care in Italy[3]born just over a year ago with the aim of rethinking, enhancing and redesigning the so-called “territorial medicine”, adopting the proposals of the Blue Book[4] promoted by Campagna Primary Health Care Now or Never[5], launches his complaint e asks the Regions to implement rapid access to local health services and urges the Government to allocate the necessary funding. Many others – organisations, unions, research centres, operators, citizens – are denouncing and asking loudly to intervene; the Alliance joins these many voices, asking that particular attention be paid to local health services.
Upon its establishment, the Alliance presented an organic series of proposals, partly already outlined by the legislation:
define a single institutional-organizational framework for Primary Care, identified in the Social and Healthcare District coinciding with the Social Territorial Area, organize the work of Primary Care in interdisciplinary teams and in a network with the territory and hospitals, with structured working methods multi-professional and multi-sectoral, equipping Primary Care with adequate numbers and types of professionals,
but also with strong new elements:
support local communities so that they generate health and well-being, territorialize (not decentralize) the Social and Health Service, adopt methodologies that make services constantly and dynamically adapted to the context and demand for health, equip Primary Care with adequately trained professionals with a congruent contractual form.
When DM77 was adopted, the Alliance demonstrated the presence of important positive elements: it dictated uniform national implementation criteria, which had been awaited for many years; oriented towards a systemic, collaborative and participatory approach of community health promotion and generative welfare “according to a one health approach”; included in a single act all the Primary Care services linked to the District and the Community House (CdC). Above all, it gave a mandate to the Regions to take action quickly and in a defined manner.
AIn light of this assessment, in July 2022, the Alliance publicly stated that the strategic objectives could be implemented within 3-6 months (therefore by 2022):
identification of territories of approximately 100,000 inhabitants and activation of all the Districts coinciding with the Social Territorial Area; start of the unitary planning of social and health actions; implementation of the Territorial Operations Centers – COT; activation of the essential Operational Units envisaged by Ministerial Decree 77 in each District and, in particular, of the Single Access Point in the logic of welcoming and listening; launch of multi-professional teams starting from the necessary involvement of the structured forms of association of General Practitioners and Free Choice Paediatricians.
Deeming it important to monitor its progressive implementation at a national level and the effective assignment of additional dedicated staff to the local services by way of derogation, the Alliance had therefore committed itself, since then, to implementing independent multi-year monitoring.
Unfortunately, just over a year after the adoption of Ministerial Decree 77, the outcome of this monitoring leads to a completely disheartening finding: also the recent AGENAS monitoring[6]which however presents numerous inconsistencies[7]shows that the implementation path of CdC, Community Hospitals and COT has significantly slowed down or, in many regions, even stopped. Not only that: in Lombardy, a region that appears to be the most advanced in the opening of these structures, according to the evaluation carried out by the Mario Negri Institute[8] it clearly emerges that “few fully meet national and regional standards” e “generally they were placed in existing structures, especially former outpatient clinics, and are the result of a reorganization of already available services rather than the creation and implementation of new organizational models aimed at an interdisciplinary approach and working in multi-professional teams”.
The progressive dilution of the objectives of the PNRR-DM77, the emptying of innovative contents capable of giving impetus to the reform of primary care, the alignment on the conservative positions of the trade union representation of General Medicinepersevering in the performance-commercial logic to the detriment of the orientation towards taking care of the health problems of individuals and communities, have led the Alliance to transmit the following press release to the press and to the Regional Health Councillors.
“Dangerous negligence towards the care and assistance needs of citizens: risk of weakening the territorial health services provided for by the PNRR”
The pandemic has made evident the weaknesses – which pre-existed – of the territorial socio-health network for which the advent of the PNRR and in particular Mission 6 – Component 1 represented a decisive novelty to infrastructure the territory with Community Houses, Community Hospitals , Territorial Operations Centers, etc.
The stages of the journey outline the different level of conviction in the project:
15 January 2021 proposal by the Conte II Government; 30 April 2021 the PNRR is transmitted by the Draghi Government to the European Commission which approves it on 13 July 2021; Governance takes off: Control Room, the Unit for rationalization and improvement of effectiveness of regulation, Permanent table for the economic – social – territorial partnership, Central Service for the PNRR, Mission Unit at the State General Accounting Office, ReGis platform for programming and monitoring support; 7 November 2021 the Regions present the regional implementation plans of the PNRR Mission 6; 23 May 2022, Ministerial Decree 77 is approved which identifies models and standards of the territorial network; 31 May 2022, the Government-Regions Institutional Development Contracts are signed.
25 September 2022, once the Chambers have been dissolved, early voting can take place.
On 22 October 2022, the Meloni government is sworn in and presents the programmatic lines to the Chambers, ignoring healthcare. Pressed by Parliament, the Prime Minister cites General Practitioners and Pharmacies but not the Community Houses, subsequently defined as “cathedrals in the desert” (30 May 2023); 31 July 2023 the Government revises the PNRR and reduces the objectives of the Mission 6 – Component 1, i.e. reduces the Community Houses from 1,350 to 936 and the Community Hospitals from 400 to 304, promising to find additional resources to complete the initial program by resorting to the funds of the former art. 20 law 67/88 on hospital construction as well as the Development and Cohesion Fund; 17 October 2023 the budget law ignores or strongly underestimates both the additional funding essential to continue the construction of the structures and the economic support for the hiring plan for health workers which will gradually have to be guaranteed.
In summary:
In 17 months (January 2021 – 31 May 2022) the program was built, the resources identified and contracts signed with the implementing bodies; In 12 months (October 2022-2023) the objectives were scaled down.
We express great concern for the lack of attention surrounding territorial social and health assistance and ask the Regions for maximum commitment in the rapid implementation of the programs covered by the Institutional Development Contracts and the Government for the financial integration essential for the creation of the structures contained in Component 1 of Mission 6 .
The Alliance for the Reform of Primary Care in Italy
which they join:
Primary Health Care Campaign Now or NeverACLI – Christian Associations of Italian WorkersAICP – Italian Academy of Primary CareAsIQuAS – Italian Association for the Quality of Health and Social CareAIFeC – Association of Family and Community NursesAPRIRE Association – Online Primary CareAssociation of Solidarity Community ParmaLa Bottega del Possibile AssociationPrima Association the CommunityFundamental Health AssociationInternational Health AssociationCARD – Confederation of Regional District AssociationsCommittee to Promote Community Houses in Parma and the ProvinceEURIPA Italy – European Rural and Isolated Practitioners AssociationMario Negri Pharmacological Research Institute – IRCCSMovimento GiottoSItI – Italian Society of Hygiene, Preventive Medicine and Public HealthSlow Medicine ETS
Margherita Miotto and Fulvio Lonati – Alliance for the Reform of Primary Care in Italy
Bibliography
[1] In defense of the NHS and territorial welfare – International Health – https://www.saluteinternazionale.info/2023/06/in-difesa-del-ssn-e-del-welfare-territoriale/
[2] Decree 23 May 2022 n. 77 – Regulation establishing the definition of models and standards for the development of territorial assistance in the National Health Service
[3] Alliance for the Reform of Primary Care in Italy – https://sites.google.com/view/il-libro-azzurro-della-phc/alleanza-per-le-cure-primarie-in-italia
[4] Blue Book for the reform of Primary Care https://sites.google.com/view/il-libro-azzurro-della-phc/home
[5] Campagna Primary Health Care Now or Never – https://2018phc.wordpress.com/
[6] AGENAS, Monitoring phase 2 concerning the implementation of Ministerial Decree n. 77 of 2022 – https://www.agenas.gov.it/images/2023/primo-piano/monitoraggio-dm77/Monitoraggio_DM_77_sintesi_fase_2_v2__finale.pdf
[7] PNRR monitoring. The numbers still don’t add up – Quotidiano Sanità – https://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=116756
[8] Community houses and territorial assistance reform: where we are in Lombardy –
International health systems, temp Alliance for the Reform of Primary Care in Italy, Social Territorial Area, Primary Health Care Now or Never Campaign, Community homes, Primary care, District, DM77, Meloni Government, Blue Book, General practitioners, GPs , community hospitals, Free Choice Paediatricians, PNRR, national health service