by Livio Garattini and Alessandro Nobili
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 also considering in a synergistic and integrated way the “new actors”, first and foremost nurses (graduates only from the end of last millennium in our country) and pharmacists
09 SET – The general practitioner (GP), otherwise known as a family doctor, historically represents the “first line” of primary care in health services throughout Europe, and Italy is no exception. With us, since the NHS was introduced in 1978, this role has also been joined by the more organizational role of “filter” of the most expensive specialist public health services, from visits to hospital admissions.
In recent decades, the role of the GP it has been increasingly severely tested by the progressive aging of the population, which has been superimposed on the continuing international economic crisis, which has put further pressure on all European health systems. Furthermore, in Europe there is a vocational crisis almost everywhere on the part of new medical graduates towards MG, which, moreover, is still not recognized as a medical specialty by us, unlike England and most other European states. Added to this is also a financial penalty during the three-year apprenticeship period, given that future GPs earn less than half the monthly salary of all other fellow trainees (approximately 800 vs 1,500 euros).
On the other hand, almost ignoring the generalized crisis of GPs, politics has not invested much in this strategic sector, even if it has (demagogically) continued with “effective messages” to capture the favor of voting citizens, arguing (paradoxically) the need to guarantee 24-hour availability of the MG during the entire week to guarantee full access to the population, both in our SSN and in the English NHS, without the minimum logistical and organizational requirements to do so (especially in Italy). This type of proposal has further widened the gap between the factual reality of MG and the expectations created in public opinion.
To remedy to such a situation, it is almost universally shared opinion that robust financial investments must be made in MG and the PNRR would seem to be the ideal opportunity in this very particular historical moment. In our opinion, however, it is necessary to create the right conditions to make a good investment, even more so if the money is a lot. First of all, it is necessary to radically redesign the organization of MG and put it in step with modern times, contextualizing it in an articulated system of primary care that truly (and not just words) puts the citizen at the center of the health system. To this end, regardless of the low recognition of the professional title of GP, it is necessary to make an intellectually honest analysis of the current weaknesses of the role, starting from the professional classification.
GPs are for historical reasons a category of non-employed doctors, “freelancers” also in the NHS and in the NHS, mainly paid on the basis of the number of citizens who choose them (so-called capital quota) in both systems. The substantial difference between our GPs and the English ones is that the latter have been used for decades to work in groups (on average six or seven together) sharing their patients, while here most of us still work individually in almost all regions, despite the various financial incentives implemented in the last twenty years to support teamwork. And in the end the fact remains that today every Italian citizen (unlike the English ones) is assigned to a single GP and this represents an obvious obstacle to group practice. A bit like it can happen in offices with groups of professionals (such as lawyers and accountants) with the same potential customers, you can also share the rental costs of the premises and the salaries of the switchboard operators, but in the end the main revenues of your customers remain however separate and therefore everyone keeps them tight.
Furthermore, as they are not employees, the GPs a considerable freedom of action regarding opening hours to the public is also granted according to the national collective agreement. Staying here in the north, according to our statistics from a few years ago, the clinics were open for a maximum of 20 hours a week on weekdays, a handful of hours a day scattered in morning or afternoon time slots rarely functional to needs (especially working ones ) of citizens.
On the other hand, it cannot even be argued that the SSN has encouraged forms of competition between GPs to favor those who decide to expand hourly access for the benefit of their patients, given the continuous decrease in the total number of GPs and therefore the ease of getting close to the threshold of the ceiling (still set at 1,500 patients) a little everywhere in the country.
Wanting to think in terms of the labor market, GPs basically enjoy almost all the advantages of the freelance profession without having to face the challenges related to the need to look for customers to maintain their turnover, as often maliciously commented also by their specialist colleagues. More generally, it is however necessary to underline that the problem of reduced opening hours also characterizes the various district primary care structures present in our NHS, see the case of vaccination centers just to name one, which confuses (and often makes us nervous) citizens, struggling with similar situations also for local administrative services. Just to continue with the comparison across the Channel, it should also be emphasized that in England the vaccinations of children are traditionally done by GPs and pediatricians of free choice do not exist as a separate category, as indeed in all other European countries.
In light of this general situation primary care, completely fragmented in the vast majority of regions at the local level, it seems to us 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 also considering synergistic and integrated the “new players”, first of all nurses (graduates only since the end of the last millennium in our country) and pharmacists, both categories already involved in various measures both in the NHS and in the NHS to compensate in some way the numerical shortcomings of GPs.
In a perspective truly oriented towards satisfying people’s health needs, in our opinion the real epochal change is to bring together all the operators in the area (including administrative ones) in unique district structures, with a local density that obviously takes into account the diversity of the population. in metropolitan areas compared to others.
Regardless of what you decide to call them (perhaps better “centers” than “homes”), we are firmly convinced that patient-oriented healthcare now has as an unavoidable premise to have facilities open to the public at least twelve hours of the day on weekdays, capable of providing all services, not only health, but also social and administrative. In order to do this, all the operators in the sector and the necessary infrastructures must obviously be concentrated there; in perspective, all public employees of the NHS, including GPs, in such a way as to guarantee the daily opening of all services with regular shifts.
By following this strategy, citizens would no longer have any problem even in understanding where and when to turn in case of need outside the hospitals. Even the distance to travel to go to these centers (by definition “less capillary”) is in our opinion a false problem. As the recent experience of consumer goods markets teaches us, accessibility is essential for everyone, including workers (often, as well as parents, also caregivers of elderly relatives and neighbors), which is why large shopping centers have had a great success all over the place.
As for frail patients who really need home care, not just health care in the strict sense if completely isolated, it seems to us that this type of center has all the credentials to be able to provide it adequately, as they have the necessary “critical working mass” to cope with the heavy social-health commitment induced by the management of these patients. Ultimately, even the inappropriate use of hospital emergency services should be drastically reduced for the most minor ailments, at most limited to night hours.
Given the presence of public pharmacists, it is not even clear why the already existing forms of direct dispensing of drugs could not be spread in these centers, in a complementary way to community pharmacies. Thus also systematically favoring the collaboration of pharmacists with GPs and nurses colleagues to improve the appropriateness of prescriptions and adherence to therapies and removing the disturbing spectrum of comparison from our NHS. Ultimately, all for the benefit of patients and caregivers, who could also derive further psychological benefits from direct contact with teams of health professionals.
In conclusion, we deliberately stop here, as we realize that we are unable to hypothesize anything but advantages thanks to this new type of multi-professional organization, with synergies that go well beyond individual roles, starting with GPs, on which it is focused this contribution. And who knows that, going beyond the self-referentiality of the individual professional categories, the strategy of optimizing the management of the workforce in a truly integrated primary care does not end up making realistic most of the expectations periodically raised by the promises of politicians to any faction in matters of territorial assistance.
Livio Garattini
Alessandro Nobili
Mario Negri Institute of Pharmacological Research IRCCS
09 September 2021
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