by Fabrizio Cossutta
19 OTT – Dear Director,
I am a young family doctor from Friuli, graduated in Italy and moved to Lisbon about ten years ago. I follow from a distance the dispute in progress in Italy between the convention and the dependence of the MMG and after reading the letters “General medicine in Italy, from the citizens’ doctor to the doctors subordinated to the buildings?” by Pier Luigi Bartoletti and “We do not want to become employees, no to the dependence of family doctors” signed by Fimmg Formazione, I decided to give my contribution of daily experience as a family doctor employed by a NHS.
In both cases they seem to me articles full of statements without knowledge of the facts, rather the result of the imagination or indoctrination and therefore not considering myself either subordinate to buildings or an “employee” (indeed!) I consider some clarifications appropriate and perhaps useful. But before doing so I would like to tell you my path. After graduating in Padua, I moved to Portugal with the idea of becoming an internal doctor.
Arrived in Portugal, during the common year that starts all the Specialization Schools, I entered a Unidade de Saúde Familiar (USF), a territorial structure of family medicine. For three months I followed a multidisciplinary team, made up of doctors, nurses, clinical secretaries, trainees, and a few days a week also by psychologists and social workers. This macro-team was divided into family mini-teams, each made up of a family secretary, a family nurse and a family doctor. They were all public employees and worked in a “matrix” way with responsibilities shared by all the different professional categories.
Although they were employees of the state, they enjoyed absolute organizational, operational and above all technical-scientific autonomy. After this experience, I decided to specialize no longer in Internal Medicine but in General and Family Medicine. The training lasted 4 years. The internship took place on the territory, with only a small part of the training carried out in the hospital. The resident family doctor is a civil servant and has the same salary as his hospital colleagues (other than the Italian 800 euros!).
At the end of the training process, trainees are subjected to three exams and on the basis of the outcome a national ranking is drawn up which will be used to access the NHS. I specialized in 2017 and it was proposed to me to coordinate the formation of a USF in the neighborhood of Arroios, in Lisbon. Having said that, when my colleague Bartoletti reports that “Portugal, cited as a model to be imitated, leaves a million citizens of Lisbon on the street without a family doctor”, he probably speaks from hearsay, given that there are 544,851 inhabitants in Lisbon. for clarity, I must say that about 900,000 patients are today without a treating doctor in Portugal, of which about 600,000 distributed in the 12 districts that together with Lisbon form the Regional Health Administration of Lisbon and the Tagus Valley, which is the area of the country where the phenomenon is most felt.
So the problem partly exists, but the cause is not in the dependency relationship but rather in retirements, in the investments that started first in the north of the country, in the hospital-centricity that crossed Europe between the 80s and early 2000s. , in the absence of incentives for training specialists in General and Family Medicine precisely in the areas where it was most needed, to which the economic crisis that began in 2009 has recently been added. All situations that Italy is also beginning to register and which have already begun to produce the same effects. In spite of everything, there is in Portugal a capillary network of state structures able to offer organized and quality care throughout the territory, even in the mountains, and no one is ever without reference points.
Can we say that this is also the case in Italy, in rural areas in particular, where at most a family doctor works 1-2 days a week? Furthermore, unlike Italy, in Portugal even patients without a doctor are entitled to health care, free and managed by the District, with virtuous examples such as UCSP Olivais (ACES Lisboa Central) and Via Verde Saúde Laranjeiro (ACES Almada / Seixal). The fact that all health workers in the District are public employees allows for effective coordination, and a striking example was provided by the management of the COVID19 pandemic.
As everyone knows, Portugal underwent an unprecedented wave between December 2020 and January 2021 becoming the country with the highest rate of new cases per million inhabitants in the world, and nevertheless the doctors and nurses of the districts managed to cope with a number of patients under surveillance 6 times higher than the first wave, avoiding the collapse of emergency services, not neglecting patients without a doctor, off-site students and foreigners in an irregular situation. All this was also possible because all the computer programs for contact-tracing, the register of positive results, notifications and medical records are state-of-the-art, allowing rapid data integration that would otherwise be impossible.
The dependence also meant that the lack of IPR was a responsibility of the District and the Regional Administrations. The result? In over a year of the pandemic, 19 health workers have died, including 6 doctors, and no family doctor. Can we say the same about Italy? Another inaccurate statement by Bartoletti and colleagues lies in the assumption that with addiction the technical autonomy of the doctor would cease and consequently the relationship of trust between doctor and client would be lost. As already mentioned, the health workers of the USF have total organizational, functional and technical autonomy (Decree-Lei 298/2007).
Can we say the same about our family doctors, subordinate to hospital doctors, their treatment plans, union decisions and so on? At the same time, here patients can choose their referral health professionals within the USF (secretary, nurse and doctor), they can choose to change doctor in the USF, USF within the District and they can choose to move their enrollment between Districts , regardless of your residence. In all these steps the medical record is computerized and therefore follows the patient.
In Italy, colleagues Fimmg, does the same happen? And furthermore, I do not understand why people continue to argue that with the relationship of dependence the patient loses the faculty of free choice and the relationship of trust. Here in Portugal this is not the case. We maintain the fundamental principles of our profession as in Italy in addition to the rights and protections of workers. And again Bartoletti states that “the models where dependence is the primary care contract are characterized by having a public network mainly dedicated to those who do not have insurance, supplementary funds, mutuals, and a large private network with a lot of” out of pocket ” “.
From 2020, all services carried out in primary care or requested by family doctors are exempt from tickets. Almost all of the “out of pocket” expenditure is attributable to private visits by hospital specialists, ophthalmologists and dental medicine, and therefore cannot be ascribed to primary care. In conclusion, there are many aspects of the binomial “primary care / addiction of the MMG” that Bartoletti and colleagues talk about but which they show they do not know at all, well beyond those that for reasons of brevity I have been able to deal with. In short, more slogans than knowledge!
Fabrizio Cossutta
Family doctor, training tutor and coordinator of the USF Almirante.
Coordinating member of the Task-Force responsible for outpatient care of COVID19 cases in ACES Lisboa Central
October 19, 2021
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