by Carlo Palermo and Giammaria Liuzzi
26 OTT –
Dear Director,
there was much discussion, during the election campaign and even afterwards, on the alleged lack of specialist and non-specialist medical professionals. The analyzes advanced regarding this criticality turned out to be very distant from each other, even divergent: from the recognition of the problem with the proposal of the elimination of the number programmed for access to the degree course in medicine in order to give a solution in perspective (but only in 11/12 years !!) up to the denial of the problem itself at least as far as hospital specialists are concerned, in our opinion basing the analysis on numerous inconsistencies, omissions and errors in the evaluation of the data.
In particular, reference was made to an alleged dominance of our country in the European rankings relating to the number of doctors in relation to the population who actively practice the profession.
According to the statistical data referring to the year 2020, in reality, Italy (4.1 doctors per thousand inhabitants) in the OECD ranking, considering only the European countries, is in 12th place, just above the average of the countries EU (3.8 per thousand inhabitants, with an average of OECD countries estimated at 3.6 ‰) and far from the top positions: Greece (6.2 ‰, Austria (5.3 ‰), Portugal (5 ‰), Norway (5 ‰).
Italy, on the other hand, definitely dominates over other nations in relation to the aging of doctors still in business. In fact, as many as 56% of these are over 55 and close to retirement, while in Great Britain the over 55s are just 14% of active doctors (Oecd; Health Statistic, 2021). In short, we have the oldest medical population in the world, certainly endowed with great clinical experience, but it is clear that without adequate turnover in the coming years Italy risks falling into the ranking of active doctors per thousand inhabitants, becoming a country with an important shortage compared to European averages of health professionals (therefore not only nurses but also doctors) precisely in the midst of a demographic and epidemiological transition that would require the strengthening of health services.
A figure that is not considered in the various comments is that relating to the trend in the supply of hospital doctors in the decade from 2009 to 2019, in practice from the year of maximum expansion of the staffing staff in the NHS, close to the economic crisis of 2008, to the one prior to the pandemic crisis.
While in Italy, due to the spending review, in this period there was a contraction of about 5,000 units of medical personnel, in France and Germany there was an increase of 20-30%. Yet, precisely the shortage of personnel was one of the main reasons why our NHS arrived weakened and vulnerable to the appointment with COVID-19, penalized by years of reduced funding, cuts in beds, staff reduction and policies that negatively affected the performance of services. The ability of the NHS to respond to people’s needs has been progressively undermined to such an extent that the fundamental right to health enshrined in Article 32 of the Constitution has been questioned.
The estimate made by many institutions of doctors leaving the NHS due to retirement limits reached in the coming years is very variable: Fiaso indicates retirements in 35,000 in the period 2020/2024, the Centro Studi Sumai identifies the number in 28,125 in the period 2021/2025, Agenas calculates in the period 2022/2027 and with an average age of 65 years, 29,000 units will be released.
A figure far higher than that of nurses (about 21,000), although these professionals are globally more numerous in the NHS (260,000 versus 103,000 doctors) but with a less problematic average age. However, the criteria for retirement in the public sector are very complex (quota 100/102; woman option; “Fornero” rules for “early” retirement; “old age” at 67, which can be postponed to 70 years, without considering “totalizations” and ” cumuli “with regard to social security contributions) and it is very difficult to identify a reliable average age of leaving work due to the extreme variability of individual choices, so we prefer to indicate a more prudential estimate referring to an average age of 67 years and calculating in approximately 25.000 releases in the period 2023/2027.
Our data derive from an analysis of the Onaosi * database relating to mandatory taxpaying doctors as of 31/12/2021 and public employees (USL companies, hospitals, Irccs). To this number, however, must be added that linked to voluntary resignation (the so-called Great resignation) phenomenon that we have analyzed in a recent work referring to the years 2019/2020/2021 using the Onaosi database and the Annual State Account. If the trend remains unchanged we could expect at least about 10.000 early resignation with respect to the achievement of the contribution and registry criteria for the pension.
At this point, compared to the 35.000 estimated outputs in the five-year period 2023/2027, we must ask ourselves what the real possibility of replacement is based on the number of new specialists who will be trained in the same five-year period.
The specialized training contracts financed by the state, by the regions and by private individuals from 2018 to 2022 are exactly 64.537 (National Observatory of Specializations). Obviously not all postgraduates will make it to the finish line. The Agenas indicates an abandonment of around 5%. The real data tell us how the percentage is much higher. There are few specialties that have a final graduation rate of more than 90% (Hematology; Gynecology and Obstetrics; Cardiovascular Diseases; Nephrology; Ophthalmology; Otorhinolaryngology; Pediatrics). For the other specialties the percentages are much lower, ranging between 24 and 81%.
Among the most important for the hospital organization, which also represent those with the highest number of post-graduate training contracts intended, we indicate Anesthesia and Resuscitation 63%; Internal Medicine 77%; General Surgery 55%; Emergency Medicine Urgency 53%. Therefore, an estimate of 15% of abandonments or non-assignment of the financed contracts is much more reliable. Ultimately, it will be approx 54.850 the new specialists who will actually be trained.
But of these, how many will accept the addiction relationship in the public health system? From many quarters a percentage of 75% is indicated. This is a percentage that dates back to about 12 years ago and that we have also used in our studies in the past. Today the conditions of the health care labor market have totally changed. We are in the era of Great resignation, Cooperatives burst onto the labor market, new specialists prefer to emigrate abroad for better salaries and greater professional development, competitions in hospitals are deserted and the most popular specializations are those that offer work opportunities outside the NHS. We therefore think that availability has collapsed and is between 50% and 66%. Therefore, only one in two specialists, or at most only two in three, would accept a job in the NHS today considering current salaries, workloads and occupational risks.
It is likely that compared to the 35,000 expected releases, the possibility of replacement will oscillate between 27,500 and 36,500. Ultimately, at most, we could guarantee one the status quo and that is a clearly lacking organizational context, as evidenced by the organizational criticalities that emerged during the epidemic and the waiting lists now evaluable in semesters, if not years, which have developed after the pandemic for ordinary hospitalizations, specialist visits, diagnostics and elective surgery.
ConclusionsThe prolongation of the hiring block, interrupting the regular supply of roles, has led to an increase in the average age of the medical staff employed by the NHS and in a few years risks plunging Italy below the average of the OECD countries (3.6 ‰ ) in the relationship between doctors and the population. The phenomenon of the “pension hump” linked to the peak of recruitment in the phase following the establishment of the NHS in 1978 will continue to fuel an important exodus from the NHS also in the five-year period 2023/2027, especially if evaluated together with that of the “Great Resignation”. This phenomenon, although it affects all healthcare personnel, naturally appears more threatening due to the already lacking professional profiles.
The categories most at risk undoubtedly include that of medical specialists of the NHS, also because of the insane hiring policies during the spending reviewthe glaring errors in the planning of post-graduate training between 2010 and 2018 and the sharp deterioration in working conditions during and after the pandemic.
However, as reported in the Agenas research, interventions limited to increasing the training offer in other European countries have proved to be partially ineffective. It is therefore crucial to make work in the hospital and in the territorial services of the NHS attractive in order to try to increase the option in favor of the NHS by new specialists. It is therefore considered necessary to combine the current training offer with a system of incentives and enhancements capable of making medical work in the NHS attractive in terms of social and economic recognition, as well as role within companies.
Also because only through an increase in the willingness to be hired, and therefore with an increase in staffing, will it be possible to improve those workloads that have now become unbearable for many NHS operators. The doctor today abandons the NHS because poorly paid, exposed to the risks of medico-legal litigation and because the working conditions take away the time that should belong to every human being to devote himself without obstacles to a social and family life that is a source of happiness and full fulfillment. personal. Politicians and health care managers at all levels should understand that without “human capital”, hospitals become cathedrals in the desert, territorial garrisons furnishing the urban landscape, Essential Levels of Assistance a chimera.
Carlo Palermo
National President Anaao Assomed
Giammaria Liuzzi
National Head of the Anaao Giovani Sector
* Thanks to the President of the Onaosi Board of Directors Amedeo Bianco and the technical staff of the General Management for access to data.
October 26, 2022
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