30 GEN –
Dear Director,
disguised as an integration between hospital medicine and university medicine, the creeping “clinicization” of Italian hospitals continues unabated, a typical phenomenon of the relationship between the Faculty of Medicine and the hospitals of the NHS, which has always been characterized by frictions, conflicts, endless disputes, competition on many fronts.
The two systems are today, in fact, extraneous to each other, scarcely permeable, with personnel separated by different prerogatives and tasks, in a condition that makes the relationship tense and collaboration difficult.
One of the most important reasons for opposition is, precisely, constituted by the progressive occupation of hospital spaces, and careers, through the use of teaching as a lock pick for access to the management of welfare structures. Although there is no organizational, professional, economic or legal motivation, the identification of care structures external to the reference company “necessary” for carrying out the teaching activities is instrumentally used to entrust university staff, as a reward for a failed career academic, top positions that the legislation assigns to the NHS.
The phenomenon finds nourishment in the memoranda of understanding with the Regions which, instead of guaranteeing coexistence between the NHS and medical faculties, show difficulties in mediation marked by appeals, latency in renewals, inapplicability in current management, expensive and poorly productive results in terms of assistance. Above all, the absence of rules stands out, or their non-compliance, which establish, in a transparent and cogent manner, the structural endowment and the organizational articulation necessary for the performance of the teaching and research function. This makes the boundaries of the university presence within the Health Service structures undefined, perceived by the hospital staff as a threatening loose cannon within the Integrated Companies.
The vagueness of the limits, fixed and moved from time to time, in the regional convention, where the requests of the academic world are always well received, is due to the frequent inclusion in the assistance of second level professors with primary attributions, in structures in which subordinate medical personnel are mainly hospitals, and the creation, in many cases, of complex micro-structures in which the only university presence is made up of the head physician. Even the regulatory provision of having to respond to the needs of post-graduate training in NHS structures is substantially disregarded, because postgraduates constitute an important, albeit hidden, resource of university structures, capable of ensuring the production volumes that justify their existence .
The process of “clinicization” today seems to know no obstacles, ready to overcome the walls, and the concept, of the hospital of reference, to embrace other hospitals and the same territory, in the passive acquiescence, if not complicity, of the Regions. It hardly needs to be noted that such an organizational and juridical configuration is permitted by law only in regions with special statutes.
The numerical expansion of the Faculties of Medicine, today 48, public and private, distributed in 84 locations in all regions (except Val d’Aosta and Trentino-Alto Adige) has forced them to do without the model of polyclinics direct management to use NHS facilities and staff. In a model of bankruptcy integration, because the University feels, and is authorized by all governments, regional and national, of any political color, to feel “other” than the national interest, almost an independent variable.
Protected from reorganization and restructuring, spending reviews and cuts of complex and simple structures, today it is also exempt from spending. In a dissociation between power and responsibility, while contributing to determining objectives and strategies in resource management, it does not contribute to a balanced budget in proportion to the production factors absorbed and to the relationship between complex structures under hospital and university management. The additional costs induced by didactic assistance are borne by the FSR, in the triumph of the logic of privatizing the profits and socializing the losses.
Creating university departments in hospitals, as required by law 517/93, is certainly legal but the criterion for choosing who heads the departments appears questionable, also for the purposes of quality of care. Today, the choice of directors of complex structures takes place, as far as doctors belonging to the university world are concerned, by direct call, even without the specialization required for access to the NHS, with the handshake method between the Director General and the Rector , with the blessing of the Assessor on duty. While, for those who have chosen the path of pure assistance, for the doctor who works in the hospital, a competitive selection is envisaged complete with a commission, interview, score and ranking.
In the absence of a hold of the Regions, the Faculties of Medicine expand without brakes in the assistance area of health services. This leads to an inevitable collision with the legitimate rights of Hospital Doctors, to the subordination of care needs to real or presumed teaching needs, to the transfer of sovereignty by the elected representatives to the University, a third party institution whose mission is training and research . Without prejudice to the SSR for all the obligations associated with the loan.
Anaao Assomed rejects the theory of “manifest destiny” which condemns hospital doctors to give space and skills to university expansionism to take refuge in the reserve of a poor NHS and for the poor, leaving the magnificent and progressive fate of training to others, of teaching and assistance in highly specialized sectors. It is up to the Regions to intervene to make University-SSN relations less conflicting and more respectful of each other’s institutional goals. Also to build the level of integration necessary to overcome the “separate at home” experience that characterizes the current situation.
Pierino Di Silverio
National Secretary Anaao Assomed
January 30, 2023
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