Marco Geddes da Filicaia
For over a decade our National Health Service has been exhausted by attrition which has caused an unprecedented crisis in the healthcare personnel sector. This article (and the following one) describes the mechanisms that came into play in causing the “great crisis”: from the hiring freeze to the failure to plan the training of doctors, from the decrease in the salaries of doctors and nurses to the flight to abroad for professionals.
The long siege of the NHS, a metaphor that well illustrates the situation that has been going on for over a decade[i]has been implemented for some time with a specific strategy. A siege is aimed at conquering the city, with hunger and thirst, by interrupting the supply of water and food. In the specific case it was not just a question of interrupting the financing of the NHS, since it cannot be cured with paper money, but of specifically interrupting the supply of what is indispensable and can be acquired with financing. The purchase of healthcare equipment has not been interrupted or reduced, which are also relevant to the functioning of the activities. Our country has an abundance of technologies (CT, MRI, PET, hybrid rooms, surgical robots, etc.), as highlighted by the comparison with other European countries; a resource that is often not well distributed and not fully used[ii]. It wasn’t a drug shortage; we certainly cannot say that we have a shortage of this resource at a national level. In Italy the vaccination calendar offers wide coverage and some territorial areas or types of vaccination are characterized by reduced adherence, certainly not due to a lack of vaccines; The free availability of very expensive drugs is guaranteed and the wide availability of antibiotics is associated rather with improper and excessive use, certainly not with a scarcity of this resource.
The siege has therefore progressively reduced, and often interrupted, the supply of food and water, that is, human capital: doctors and nurses.
The health workforce crisis is a common problem in many European countries. Hans Kluge, director of WHO Europe, on the occasion of the 73rd session of the Regional Committee defined the shortage of health and care personnel as a “tremendous crisis”, a real “time bomb”[iii]. A bomb whose intensity is, for Italy, much more relevant and the timing of the explosion is now imminent; a device for which no bomb squad can be seen approaching to defuse it.
The health personnel crisis is in fact part of a national scenario that is complex in many respects.
The first factor is represented by demographic trends which does not appear rosy, since the percentage of the population aged 0 – 14 is among the lowest (12.9%) and therefore the working age population, net of migration, will further reduce until reaching, in 2030, The highest elderly dependency ratio among European countries.The second factor consists in the reduction of the state presence in many production and service sectors, with a ratio of public employees/population equal to 5.5 x 100 inhabitants (Germany 6.1, Spain 7.3, UK 8.1, France 8.3). A bloodletting carried out over the years which has affected schools, universities, local authorities, public research centres, state museums, libraries, superintendencies and social services and, to a significant extent, the national health service.The further, third factor concerns the decrease in wages. The average annual salary, over the last thirty years (1990 – 2020), has decreased in Italy by 2.9%. The only European country with a negative sign, while there was generalized growth in Europe: Spain + 6.2, Portugal + 13.7, Austria + 24.9, Greece + 30.5, France: + 31.1, Germany: + 33.7, Denmark: + 38.7, Sweden + 63.0.
This set of problems would have duly suggested human capital planning (or workforce, to use a more brutal term) of healthcare particularly accurate, far-sighted and for a long time span, in consideration of the high qualification of the workforce employed in this sector, the relevant burden for training, estimated, for a doctor to qualify for employment purposes, around €200,000, as well as the constitutional relevance of the right to health which, through the health service, materializes.
Finally, the pandemic experience should have revealed, even to those who had not previously understood it, the relevance of an adequate public health service, and therefore imposed appropriate reforms and the necessary funding, taking into account, as the Commission established by WHO Europe and chaired by Senator Mario Monti wrote, that “… the pandemic has revealed that inadequate health investments, especially in public health systems, can in themselves constitute a source of macro-critical risk, not only for the country in question, but for the world“[iv].
The two largest sectors of NHS staff are represented by 102,491 doctors, with an average age of 50.9 years, representing 22.9% of the staff (51.2% women) and by 264,768 units of nursing staff, representing 59.2% of the workforce, with an average age of 46.9 (77.8% women).
Doctors in Italy are not few compared to the population (4.0 x 1,000 inhabitants) in line with the European average (EU 27). A comparison with the average of four countries for more “proximate” aspects highlights a number of doctors per 1,000 inhabitants in Italy of 4.06, compared to an average of 3.58 in France, Germany, Great Britain, Spain; in absolute numbers in Italy + 28,981 doctors. However, the result changes if the ratio is carried out with respect to the population over 75; in this case there are 17,189 doctors missing in Italy[v].
The situation is actually much more critical for nurses. The European average of nurses compared to the population is 8.3 x 1,000 inhabitants, while in Italy it stands at 6.3! This means that the nurse/doctor ratio is very low: Italy 1.6; EU 2.2. If we use the comparison made with the four countries identified above (France, Germany, Great Britain, Spain) 237,282 nurses are missing in Italy; if the comparison is made with respect to the population over 75 (a very relevant criterion especially for nursing staff), Italy is missing 350,074 staff units!
The decimation of doctors and nurses has, consciously or unconsciously (in legal terms one would say: maliciously or culpably) used multiple tools.
The hiring freeze
The hiring freeze was implemented through spending ceilings for NHS staff introduced in 2005 with law 266/2005 (Berlusconi III Government, Minister of Health Storace); only partially revised in 2019 and still subject to spending limits, see Table 1.
Table 1. Spending ceilings for personnel. The legislation.
The next article will be published on Wednesday 17 January.
References
[i] https://www.saluteinternazionale.info/2023/10/il-lungo-assedio-al-ssn/
[ii] In Italy we have 31.24 MRI scans per million inhabitants (year 2022) with 65 tests per 1,000 inhabitants, in a usage ratio of 2.1 compared to a usage ratio of 4.4 in the Netherlands; in Spain 4.7; in Austria 5.6; in France 7.5 and in Belgium it is 7.6.
[iii] Hans Kluge: “These are the three pillars for a resilient European region”. 73rd session of the WHO Regional Committee for Europe. Quotidiano Sanità, 25 October 2023.
[iv] WHO, Drawing light from the pandemic. A new strategy for health and sustainable development, Report of the Pan-European Commission on Health and Sustainable Development, Edited by Professor Martin McKee, 2021
[v] Crea Sanità, processed from OECD Health at a Glace 2019 data.
International health systems hiring freeze, health personnel crisis, decreasing wages., human factor, doctor training, nurses, European average of nurses, doctors, health personnel, human capital planning, National Health Service (NHS), employment ceilings personnel expense