by Roberto Polillo and Mara Tognetti
An important part of the institutional actors is aware that overcoming the crisis requires a profound revision of the neo-liberal policies pursued in the last two decades, but the solutions and proposals for overcoming this unstoppable drift are once again not very effective because outlined and developed by simply considering one’s point of view, one’s position of power, without a concrete and real comparison on the important issues raised in a sectorial way
19 DIC –
The waters of the institutional health field are deeply troubled. The situation is that of the manifest crisis in which the old is dead but the new is struggling to be born to quote a concept by Antonio Gramsci.
In this contingency, the old is the ex post of the past decade in which linear cuts were made with the closure of hospitals, (113) of emergency rooms and senseless reduction of beds. All seasoned with the progressive impoverishment of the human resource due to the failure to replace the personnel in service.
Even heavier is the professional debasement due to the grounding of an administrative bureaucratic management system that has chosen the path of authoritarianism by exercising an autocratic power over the professional component disinterested in any real confrontation mediation. The linear cuts starting from the personal resource.
The depth of the crisis, dramatically highlighted by the initiatives of the unions of the addiction medical management and by the confederal unions who demonstrated in Rome in recent days, cannot be resolved with small adjustments or the adoption of formulas and parameters that are out of touch with reality, but requires a profound revision of the governance model which has been structured over time. In other words, it requires a paradigm shift and a new balance between the various institutional subjects.
Let’s proceed in order by analyzing the position of the various players in the institutional field.
Health producers Healthcare professionals directly involved in the field are now well aware of how the expropriation of any real planning and management skills has transformed the doctor and nurse into a mere executor of routine work; in a sort of worker of that post-modern Fordist factory into which the few remaining hospitals have been transformed. Exhausting shifts, plurality of part-time qualifications with a generalization of piecework (Co.Co co contracts and cooperative hiring) and consequently with a fragmentation of interventions, settings and visions that mortifies the ordering function of knowledge that the hospital has represented starting from the nineteenth century.
The trade union components suffer from divisions and the inability to get to the heart of the problem by proposing in a unitary way a profound revision of the legal position of personnel and aiming for a single supply chain contract for all public and private personnel by establishing a new special category, removed from the vexatious management control.
Even more serious is the attitude of general practitioners who are supporters of a liberal medicine which is not liberal and who, in order to maintain their corporate privileges, condemn the young generations of GPs to the isolation of laughable micro-teams complete with an associated pharmacist and often the scarce professional texture.
scientific societies
Aware of the crisis, scientific societies have also broadened their field of intervention hitherto limited to updating and research activities, seeking direct dialogue with the ministry on issues concerning standards and work organization. Interventions unwelcome to the unions who have raised harsh criticism of what they consider an unjustified invasion of the field.
The truth is that a review of hospital standards and service models cannot be defined without talking to the scientific societies of the various disciplines. In fact, beyond any consideration, it is the scientific societies that have direct knowledge of their healthcare environment and of how services and clinical networks should be organized to respond to the real needs of patients.
However, it is a new fact, an indication of a state of manifest crisis, that all scientific societies have asked the minister to open an institutional discussion table on topics affecting the profession as a whole.
Manufacturers of diagnostic means
In modern medicine, advanced diagnostics increasingly uses sophisticated analytical methods whose scope is molecular.
The procedures for defining the reimbursement rates are still on the high seas but the proposed ones are so underdimensioned that they do not even allow the coverage of the production costs of the latest generation of reagents.
With the consequence that these precious diagnostic methods will leave the public to pour into the private sector with a dramatic deterioration in the quality of the services rendered because no company will be willing to sell below cost to anyone.
Patient associations
The patient associations now close around “their disease” are unable to see the system and the distortions that surround it, stooping to positions of demand and breathless indications but with the sole purpose of producing documents or obtaining social legitimacy from public institutions
The state and the regions
The regions have openly declared that at least 4 billion are missing for healthcare and that the two billion plus allocated by the budget law currently being approved will only cover the extra costs of expensive energy, leaving the problems of insufficient funding unresolved, dangerously down to 6 point % of GDP.
The current government has continued on the path of definancing the NHS by committing fresh resources not for health care but to raise the tax burden of the self-employed and first retire workers who will then often continue to work illegally.
Even more serious is the cut in the revaluation of high pensions, including those of doctors, first glorified as heroes and now transformed into cash withdrawals to pay electoral promises
The regions have identical responsibilities, many of which have squandered huge resources and put in place a top-down and self-referential management system for healthcare companies and hospitals.
Much could have been done to create institutes for professional comparison and yet they have done nothing guilty to introduce effective tools to implement participation in public choices.
Even worse is the proposal for differentiated autonomy with which you want to delegate not the tasks to the local authorities, as Sabino Cassese acutely observed, but the resources. An option that our constitution does not allow.
In other words, the regions try to overcome problems of poor planning and management by deluding themselves that an expansion of their powers is sufficient or by referring to those of the South by depriving them of further resources
A hypothesis that certainly cannot count on valid evidence.
Get out of the crisis
We have tried to highlight how an important part of the institutional actors is aware that overcoming the crisis requires a profound revision of the neo-liberal policies pursued in the last two decades, but the solutions and proposals for overcoming this unstoppable drift they are once again not very effective because they are outlined and developed by simply considering one’s point of view, one’s position of power, very limited to the field to which they belong, without a concrete and real confrontation on the important issues raised in a sectorial way.
We are not talking about single acts but about a health system, which has many dimensions and many interests but which can find a way out only in a new organic design in which at the center, in addition to the healthy or sick citizen, there is the resource human, personal.
The continuous single downward measures adopted in recent years have caused the central and main objective of the health system to be lost, which is certainly that of punctual effectiveness and efficiency, but above all that of a system that is precisely strongly interconnected in objectives and interests . The logic of unloading programming errors and shortcomings on individual parts, the interests of categories and lobbies are not useful for a health system that requires forecasting skills and abilities as well as a great desire to measure up to reality.
The reorganization of one part (for example of the hospital system) cannot ignore the reorganization of the others (medicine of the territory), any type of reorganization then cannot ignore the personal question. Categorical positions there and cross vetoes only lead to further deadlocks. The new is created in a co-planning logic.
Roberto Polillo and Mara Tognetti
December 19, 2022
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