When the wards and intensive care units filled up again due to the spread of the omicron variant, the same strategy as the first three waves was followed in many Italian hospitals: various scheduled operations were postponed, all or part of the holidays of health workers canceled, overtime hours have increased, and beds have been added and entire departments have been converted. “We are now almost 20 thousand hospitalized, a number not far from the 25 thousand of the tsunami of the first wave”, the Federation of hospital internists (FADOI) warned a few days ago.
Doctors and nurses are no longer unprepared as in March 2020, but they are practically the same as then: only more tired and worn out by a long and tiring period of emergency. Two years after the start of the pandemic, the staff shortage that had become evident during the first months of the outbreak has not yet been resolved.
There is a lack of anesthetists, doctors in emergency rooms, surgeons, nurses specialized in assisting people admitted to intensive care.
The problem, which is very worrying according to the associations representing health workers, is historical and in the last two years it has been addressed only in part thanks to the hiring of thousands of doctors and nurses with fixed-term contracts. In addition to the contracts, the interventions decided by the government were also partial: designed for the very short term, and not structural. The staff who had served during the emergency was only partially stabilized with the latest Budget Law: the measure will serve to cover the shortcomings in the coming months, not to plan the future of hospital healthcare.
It is difficult to accurately estimate how many doctors and nurses are missing in hospitals today, because there is no up-to-date data that shows exactly how many are currently in service.
According to Carlo Palermo, secretary of ANAO Assomed, one of the main unions of hospital doctors, today the situation is worrying not only because of the coronavirus: the problems were already there before the epidemic. “Between 2009 and 2019, the last year in which data is available, 46 thousand places among health workers were cut, including about 6,000 doctors,” he says. «We arrived at the appointment with history weakened, in exhausted conditions, because we had to return to the economic parameters of Europe. Considering pensions, resignations and new entries, we can estimate that at least 15 thousand doctors are missing in Italian hospitals ».
In the last two years, one of the biggest mistakes, unions and associations say, has been discussing spaces rather than professionalism. Great weight was given to increasing the number of places in the ICU and other wards without considering who would work around those beds.
Each patient, in fact, must be assisted by an adequate number of health workers, a relationship that has almost never been respected except by moving doctors and nurses from other departments, limiting other health services such as scheduled examinations and operations. It is one of the most underestimated collateral damage of the epidemic caused by the shortage of health workers, and with effects that are difficult to calculate in the coming years.
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Since the start of the epidemic, about a thousand actual beds have been added in intensive care after years of being cut. In the first phase of the emergency, the gap between the number of beds and operators was less burdensome because many doctors arrived in the intensive care units who had less work in the other wards due to the lockdown, for example the doctors and nurses of the trauma wards.
But today the situation is very different: road accidents, heart attacks, more or less serious injuries have been added to the coronavirus emergency.
In hospitals where the pressure of COVID-19 patients has become unsustainable, resources have been concentrated in intensive care, postponing ordinary activities.
“In the first wave we faced the increase in intensive care places by jumping through hoops with infinite shifts, skipping holidays and rests”, said Alessandro Vergallo, president of AAROI EMAC, the union organization of Anesthesia and Intensive Care doctors, 118 and first aid. «Having reached the fourth wave, our colleagues have been severely tested for almost two very heavy years. It is not possible to continue unloading the entire burden of an emergency on hospitals which, as we have now seen, is cyclical ».
(Michele Lapini/Getty Images)
Vergallo explained that a maximum of 7,500 beds can be managed in the intensive care units of Italian hospitals.
According to AGENAS, the national agency for regional health services, there are currently 9,637 places. This number was reached after the increase in beds decided by the Regions in recent weeks, with the aim of not meeting the criteria established by the government to move to the next colored area, with greater restrictive measures: sometimes this increase has occurred. suddenly, with hundreds of places created in a single day.
According to many doctors and nurses heard from the Post in reality nothing has changed, because there has not been a proportional increase in personnel in addition to the additional posts: only the working hours have increased.
Vergallo has defined the steps of what he considers a vicious circle: “Increase the” theoretical “places, loosen restrictions, circulate the disease even in a severe form, continuing to overload the entire hospital system, including the emergency rooms, even in relation to the ‘extra Covid assistance. A real game of massacre to which we have no intention of lending ourselves, and in relation to which we do not exclude actions of protest ».
In the last two years, help has come thanks to the extraordinary hiring of 66,000 temporary workers. It may seem a significant number, in fact, in addition to hospitals, all the new services that have required new staff such as the contact tracing, swabs and the vaccination campaign. Furthermore, the total also includes radiology and laboratory technicians, health assistants, biologists, qualified non-specialized doctors, postgraduates enrolled in the fourth and fifth year. In short, the blanket remained very short in hospital wards.
A substantial part of the staff who had been hired on a fixed-term basis was stabilized with a provision approved in the latest Budget Law. Estimates from FIASO, the Italian Federation of Hospitals, say that a total of 47,994 professionals affected by stabilization. In particular, the provision concerns 8,438 doctors, 22,507 nurses and 17,049 health and social workers and other health personnel.
Even in this case it might seem like excellent news, but the professionals who will retire must be subtracted from the calculations on the budget for the next few years. According to a study by FIASO, between 2020 and 2024 35,129 doctors, 58,339 nurses, 38,483 other personnel will finish their work. Analyzing the outgoing flows with the incoming ones, represented by those who have completed the training, between 2020 and 2024 there will be approximately 8,299 doctors and 10,054 fewer nurses available to the national health service.
Another non-negligible problem concerns doctors and nurses who have resigned, moved to private facilities, went abroad or even changed jobs.
Pierino Di Silverio, national manager of ANAAO Giovani, argues that dropouts will increase more and more because working conditions in hospitals have become prohibitive and in some situations even inhumane. “It is inadmissible for a patient to have the freedom to go into the emergency room, beat doctors and nurses, and leave without anyone saying anything,” he says. «The shifts are much longer and more tiring, the gain is relative. We are exploited and beaten up. In these conditions it is normal that after specialization 30 per cent of doctors choose to work in private facilities ”.
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Unions and associations agree: there is a shortage of doctors and nurses because the programming has been wrong in the last ten years.
An adequate number of training contracts, that is specializations, have not been financed for enrollments in degree courses in Medicine and Surgery. This imbalance has been called the “training funnel”. Many students have not been able to access a post-graduate training course, which is essential for entering the world of work, and have thus been stuck in a limbo of precariousness. “In the last ten years, about 12 thousand recent graduates have been excluded,” explains Palermo. “Every year about 1,500 young professionals prefer to emigrate rather than get stuck.”
Only recently have funding and forecasts been adjusted: the Ministry of Health has financed 17,400 post-graduate specialist training contracts. The problems, however, have not been completely resolved because this increase in professionals must be followed by careful planning work by the regions, which so far has been rather approximate. The risk is that some specializations, such as anesthetists and emergency medicine, remain uncovered in any case.
Before the pandemic, the AAROI EMAC union estimated a shortage of at least 4,000 anesthetists and resuscitators in hospitals.
Even in programming work, people should be taken into account, rather than spaces. Many regions, on the other hand, have given priority to projects related to the PNRR, the national recovery and resilience plan, and therefore to spaces. The 20 billion planned for Healthcare, in fact, are destined almost exclusively for the reconstruction of local healthcare and in particular for the construction of new homes and community hospitals.
According to many medical associations, it is not enough to discuss how many structures to build, but how to rethink health care in new and existing structures because the problems caused by the epidemic will continue in the coming years. “We would need multi-specialist structures with adequate spaces to manage an epidemic emergency, with departments and” clean “paths, and additional staff, already trained, to be moved without closing or limiting the other services,” says Palermo. “Otherwise, as is happening two years after the beginning of the epidemic, we will continue to deny the right to treatment for cancer patients, cardiovascular patients, those who need a knee or hip prosthesis, those who have had a aneurysm or has a heart valve to replace ‘.