General medicine. It all depends on the union …

by Giuseppe Belleri

04 MAR – Dear Director,

on QS Proia and Polillo fear the risk that Mission 6 of the PNRR will end the Balduzzi reform, which was to introduce the aggregations of MG doctors throughout the national territory, that is to say functional monoprofessional ones and complex multiprofessional units. In reality, only a minority of the regions have activated the AFT while the situation of the UCCP is even more lacking.

Before addressing the issue, a conceptual premise is needed about the application of public policies. There are two “standard” models for implementing policy decisions: that of a “top down” reform with rules applied in an “instructive” way (top down) and the solution of change promoted from below on the initiative of the actors concerned ( bottom-up).

Usually the two models are considered alternative. In reality, a reform to be successful must trigger a virtuous interaction between the regulatory device and the social system of implementation, made up of the implementers and beneficiaries of the reform. The botanical metaphor of sowing, perhaps a little taken for granted, can give the idea: even the best seed cannot take root on arid or not very sunny soil and if the roots do not find in the soil the necessary for the growth of the plant.

The Balduzzi story is an example of the limitations of the top down model, which refers to a still prevailing legal-formal conception, based on the idea that to induce change it is enough to produce a legislative device, applied in a timely manner by the “executors”, like a musical score. In reality, without the promotion of the cognitive and organizational resources of the base, without sharing the path with implementers and stakeholders and without adequate funding, the reform risks producing unsatisfactory results, for what is called the implementation gap between objectives and empirical results.

This is the case of Balduzzi, which claimed at no cost to change the territorial organization without an articulated program of implementation and ad hoc incentives. To tell the truth, AFTs are combinations at practically no cost but with potentially high returns as a tool for promoting the professional community and good practices. Nevertheless, the resources of the AFT, in the programmatic “philosophy” of Balduzzi, have been underused in many regions. Similar is the case of UCCPs, structures that require public governance to coordinate the inter-professional network that can hardly arise spontaneously.

Now the Pnrr guarantees the infrastructures where the Balduzzi aggregations will be able to express their potential which has remained clipped due to the lack of interest of many administrations. However, the walls are not enough, as demonstrated by the sinking of other public investments, but they can be an opportunity to activate processes of change that involve local doctors, especially young people, motivated and willing to change, to experiment with new practices and collaborations. professional. The technical regulatory device without a social implementation system is condemned to ineffectiveness, as demonstrated by the ten-year impasse of Balduzzi and the experience of the PiC in Lombardy. The other lever of change may come from the ACN 2016-2018 which finally implemented the aggregations of the reform in a perspective of organizational professionalism.

In short, the NRP lays the infrastructural foundations to implement the “re-foundation” of the MG promised at the time, even if the demographic standard of the CoC seems to discourage effective participation which is essential for the success of the initiative. This is the problematic node and the main criticality that could affect the success of Mission 6. However, the UCCP will be able to bridge the gap between the houses of the hub community and the isolated studios of GPs in small municipalities, making up for the spoke houses not the realization is foreseen shortly due to lack of funding, if not in the regions already endowed with a solid territorial network.

It is up to the trade union to take the opportunity and not remain anchored to defensive logic and to the counterpart to propose programs shared at a territorial level and not imposed in a bureaucratic or hierarchical way by the center, which pay more attention to the control of the card than to the quality of care and the results of health.
Dr. Giuseppe Belleri

04 March 2022
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