The proposals of the Forum of the 30 Scientific Societies of Italian Hospital and University Clinics. Francesco Cognetti, Fossc coordinator: “The reform of Territorial Medicine is insufficient to fill the serious and increasingly evident gaps, which risk compromising the quality of care in hospitals. We ask for more resources and personnel to stop the bleeding of white coats and we reiterate to the Minister the need for a common table to tackle all the serious problems of the health system, which in a decade has been depleted by 37 billion “
14 JUN –
The progressive weakening of hospital care in our country is in the numbers. In ten years (2010-2019), care institutions have decreased from 1,165 to 1,054, with a cut of about 25 thousand ordinary hospital beds (from 215 thousand to 190 thousand). Not only. The employees of the National Health Service decreased by 42,380 units (from 646,236 to 603,856) and the definition of health care reached 37 billion.
The pandemic has shown the weakness of the system and the current crisis in the emergency room is nothing more than the result of years of cuts and the tip of the iceberg of a hospital system in trouble. And the proposals for the reform of territorial medicine (Ministerial Decree 71) are insufficient to fill the serious and increasingly evident gaps, which risk compromising the quality of care. The need to bring treatments closer to the patients’ living environment cannot be satisfied simply with the creation of new structures, the so-called Community Houses (one for every 50 thousand inhabitants), which is an improper definition since it is not a community but rather a population, or worse, the health districts (one for every 100 thousand inhabitants), as required by Ministerial Decree 71.
For this we need a new model, in which the territory and the hospital are interconnected. Starting with an “adequate” hospital, which is extended to the territory, redefining the parameters that have characterized its organization up to now and that date back to 1968.
This is what the “Forum of the Scientific Societies of Italian Hospital and University Clinics” (FoSSC) asks, today in a virtual press conference, with the intervention of Walter Ricciardi (Member of the Executive Council of the World Health Organization and President of the ‘Mission Board for Cancer’ of the European Union).
“We agree on the need to strengthen local medicine – he claims Francesco Cognetti, Coordinator of the Forum -, but we believe that it is not enough to solve the problems of the hospital, starting from the waiting lists and the collapse of the Emergency Department: the most obvious problems that are in the news represent the immediately visible part of a much wider suffering, which involves the entire National Health Service and which is already progressively manifesting itself in all its drama. In this regard, the solutions to be envisaged must not take place in isolation, but in a systemic logic. The historical duality between hospital and territory must be overcome, in favor of a single interconnected, continuous and complementary system of services in which the idea of a hospital extended to the territory and adapted to the needs of the population prevails, bearing in mind its scientific and clinical complexity and organizational “.
“For this reason, the organizational parameters of the hospitals sanctioned with Ministerial Decree 70 (Ministerial Decree 70 of 2 April 2015) must be completely revised, of which we hope for a profound and radical revision. We ask that the hospital be rethought based on the epidemiological needs which are clearly changed in recent years, whose responses require both quantitative and qualitative measures. The number of ordinary hospital beds must grow well over 350 per 100,000 inhabitants today, reaching at least the European average of 500. intensive care beds must exceed 14 beds, which remained on paper and never reached, to reach at least 25 per 100,000 inhabitants. “Learning from the lesson of the pandemic, it is also necessary to provide for semi-intensive care areas both in the Medical Department in the Emergency Department.
There is also a real risk that the activation of territorial structures in the absence of adequate medical personnel compromises the primary care system, already defined by an International Convention and carried out through the general practitioner with the taking in charge of all citizens. near their threshold of residence. In fact, primary care has nothing or little to do with the Territorial Services, instead they represent the first opportunity for individuals and families to come into contact with the Health System and constitute the first element of a continuous process of health care, a well-defined sector of assistance to be preserved and indeed to be strengthened.
“Furthermore, there is a progressive prerogative of services in favor of the private sector compared to the public which is thus impoverished – continues Cognetti -. As Pope Francis reiterated in the recent audience with the leaders of ‘Federsanità’, ‘the importance of the public health system must be confirmed and in order to reduce inequalities in terms of health, it is necessary to work so that everyone has access to care, the public health system is supported and promoted, and continue to be free. Cutting resources for health is a real ‘outrage’ to humanity ‘. These are the harsh and solemn affirmations of the Holy Father which represent a warning for all ”.
Healthcare workers are inadequate in relation to the population of our country: hospital specialists are about 130,000, 60,000 fewer than Germany and 43,000 fewer than France. In Italy, as highlighted in a recent article published in “The Lancet”, the bleeding of white coats also affects general practitioners: there are about 40,700, but every year 3000 retire. And we are witnessing a consistent exodus of newly graduated and postgraduate doctors, because abroad salaries and working conditions are much better.
“The new articulation of territorial care outlined by Ministerial Decree 71, although highly desirable, presents a structure and a model corresponding to a community philosophy or rather a population philosophy (50,000 / 100,000 user citizens) which flattens the diversity and complexity of the modern demand for health and it seems completely disconnected from the hospital environment with which it should structurally collaborate – explain the 30 Scientific Societies gathered in the Forum -. The feeling, or rather the conviction confirmed by the facts, is that we want to invest in structures rather than people. In reality, the system is close to collapse. The construction of new buildings is not enough, such as the Community Houses, which do not respond at all to the idea of proximity to care and risk remaining cathedrals in the desert without any connection with the hospital. Proximity is not a mere geographical criterion. Ministerial Decree 71 also outlines a counter-reform, because it minimizes the function of the family doctor, who ceases to be one of the pillars of the system and is undermined in his efficiency and effectiveness in primary care. It also attributes, at least in part, primary care to the so-called Community Houses, that is to polyclinic structures that in fact represent a different care setting mainly dedicated to the assistance of chronic stabilized patients but also possibly to other multiple activities “.
“And initiatives such as that of the Lombardy Region are worrying, which announced that it was launching an experiment to promote the ‘organizational’ replacement of nurses with general practitioners – say the Scientific Societies -. This is a confused, wrong and almost desperate answer to the problem of severe staff shortages. We appeal to the legislator to consider at the same time the reform of territorial and hospital assistance ”.
“Furthermore, the hoped-for decrease in low priority access to the emergency rooms is not achieved only with the strengthening of the territory, on which the less acute clinical needs must be redistributed – underline the Scientific Societies -. We need a cultural change. What is territorial must be considered pre and post-hospital, in an integrated vision of the two realities. In fact, the problem of acute situations remains, including those recurrent in the chronic patient: this type of assistance requires skills and technologies that do not fall within the Community Homes. With the exclusion of a small number of cases and to avoid potentially very serious accidents, the seat of the evaluation of these patients remains the hospital, in particular the emergency room “.
The pandemic has highlighted a double criticality: the absence of the territory and the insufficiency of the hospital. And the latter does not correspond to the shortcomings of the territory, because it contains an enormous share of clinical, technological and specific skills needs, which are decreasing more and more in hospitals.
“The parameter of the beds must no longer be considered static, but dynamic in relation to the needs – explain the Scientific Societies -. The beds must be assigned to the individual medical and surgical disciplines and calculated on the basis of the prevalence data of the various pathologies. An investment in medical disciplines is also needed. We are asking for a consistent increase in the number of hospital specialists, such as to reach the standards of other Western European countries, and an increase of the same amount of nursing staff. The overall system will have to configure a sort of departmental logic with the idea of the real hospital (general or specialist classically understood), which functionally also extends to the territorial health realities. We realize that revising the Ministerial Decree 70, as per our proposals, implies an increase in expenditure for the health fund “.
“It is in fact impossible to rethink hospitals, increase their functionality and increase their degree of adequacy with the need for care of the population at an invariance of cost – they conclude -. If one enters the logic of re-hospitalization, it is necessary to pass from saving to investment. We demand a reasonable refinancing of hospital spending, but at the same time we are willing to seek a sustainability agreement with the institutions to eliminate diseconomies, overcome disorganizations, reduce waste still largely existing at the local level, in a word to find solutions that allow, following an increase in spending, to guarantee added value “.
June 14, 2022
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