by Bruno Agnetti
11 OTT –
Dear Director,
some managerial / organizational articles published in this period on QdS reconfirm the inevitability of a medicine, especially basic, fundamentally administered (ACN, Communication of the State-Regions Conference, DM77, Metaprogetto). At the same time, it is not known, except for the ACN, whether there was a preliminary discussion between the parties before their publication.
The frenzy of making available a structural system in favor of the PNRR in the shortest possible time has inevitably created important difficulties of method and merit aggravated by the known global contingencies.
The first bottleneck is represented by the modification of Title V which justifies the ex cathedra predictability of the autonomous regional actions. Operationally, culturally and cognitively, those who manage the health decision-making power have always been the same people for decades.
Radical reforms, innovations, territorial welfare strategies calibrated over the long-medium term that do not only exist in the capital account but that know how to give a meaning and a vision to the essence of healing and taking care remain evanescent in the texts dropped from above that appear too much far from the daily profession.
As a result, numerous critical issues arise.
Despite the long decades of training that saw the members of the Ausl Senior Executives as learners, today the same managers are required to apply a skill that they have not been able to experience in many years of learning. What is missing is that justice and prudence that ultimately knows how to choose (overcoming the times and bureaucratic ties) right and useful paths for the clients and professionals. It is legitimate to doubt that all this training could have been of little use if not to respond to a regional economic and non-welfare need / need that in the end proved its sad unsuccessful ending.
Some think that the treatment or care should be based, for functional issues of administrative efficiency and effectiveness, fundamentally on an “initiative medicine / health care” and that people should be classified according to the pathologies. If necessary, they can thus be involved in ad hoc initiatives (health education, adequate lifestyles, periodic checks). This argument may have some sense but it lacks a fundamental element that can be connected to the ontological essence of the disease and the treatments that establishes a true dependence on man’s care that will last for a lifetime. It is not possible to de facto exclude a “waiting” or “opportunity” medicine without running the risk of creating accounting hierarchies divorced from value elements experienced by suffering people united by the dependence and fragility inherent in anthropology. Capital account structures will certainly not be able to tackle such a pervasive and ultimately never resolving problem.
Perhaps only the medical author, expert, freely chosen with confidence and able to build a community care environment can appropriately address the issue. In the field of basic medicine, an author and independent doctor has the opportunity to group sick people (not stratifications of pathological cases), then proceed with an intelligent and humanitarian analysis of the needs and needs to be met even systematically in case of need . This task cannot be tackled by senior management and by the institutions managed by them for reasons already mentioned but only by the mmg, an expert in his own area who co-operates with all the socio-health actors and with patients and who could possibly take advantage of further aids such as coaching or professionalizing tutoring. Over time, the general practitioner also develops a particular skill in the communication systems with their patients and in the interaction with voluntary and third sector associations which are extremely useful for dealing with the complexity of single sick people or their family contexts.
By definition and according to the legislation in place, the mmg remains conceptually, operationally, fiducially and experientially the first entry point into the SSN. The professional who has a specific doctor-patient relationship with his client can recommend simple or complex paths regarding the problems that emerged from the diagnostic process. These transversal paths to the territory, to services, to the third sector and to the hospital must be easily accessible in real time and easily recognizable.
The territorial organization must therefore be entrusted to professionals who work in the field on a daily basis as “author” doctors, autonomous, voluntarily associated according to agreed affinities. All this involves the elimination of territorial areas or the mandatory neighborhood. A close-knit aggregation that is chosen independently without incentive limits or number of adherents (including coaching and tutoring) is able to solve organizational, logistical, clinical governance, territorial coverage, co-operation with services, with the hospital with the third sector.
The logistical needs of professionals should inevitably be, in most cases, complex, large, pleasant and able to accommodate many healthcare professionals. They should directly contain the intermediate structures, well integrated into the territories, be real points of reference for the population, able to find adequate resources (mixed public-private-third sector), etc. It is clear that this organizational system requires maximum management autonomy of the territorial professionals and in particular of general medicine. Senior Executives should be entrusted with an alternative role of guarantee relating to the main values of the NHS: universality, fairness, access to care, transparency.
finally, a theme that requires particular attention and that justifies the territorial organization described: the generational change. In particular, the gender change of general practitioners should be highlighted. The “doctors” are in the majority and are rapidly populating the basic profession. A reform is needed even more than before that allows to meet professional and personal needs that can only be addressed by close-knit aggregate groups based on free pact agreements able to regulate the relations between “female authors and self-employed” within a community welfare system.
Bruno Agnetti
Health Planning Study Center (CSPS), FISMU-Emilia Romagna
11 October 2022
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