by Ester Maragò
Primary care at the center of the discussion promoted by Alliance for the Reform of Primary Care in Italy, Cittadinanzattiva and Forum Inequalities Diversity which hosted Andrea Mandelli for the Center-Right, Sandra Zampa for the Center-Left e Maria Domenica Castellone for the Five Stars. The Ministerial Decree 77 can be a good starting point, but the criticalities are not lacking. For some they can be overcome, for others, however, there is no lack of perplexities
09 SET –
How to ensure that Ministerial Decree 77 does not become a wasted opportunity and that a real reform intervention is carried out to strengthen the Territorial Health Services? Is it really possible to hope for a reorganization of Primary Care, with the Community House at the center, as a great gateway to the NHS located in a Social and Health District as a binding and strictly public institutional-organizational framework?
These questions were answered by representatives of political forces in view of the upcoming elections. And if there are those who say they are optimistic for the future, there are also those who, on the contrary, hold back the enthusiasm (the expiration date set at 2026 is not so far away)
Certainly, a lot of work still needs to be done on primary care, whether or not Ministerial Decree 77 constitutes a good starting point: the failure to reform general medicine and the training of Mmg, and the significant shortage of personnel are in fact the main stumbling blocks on which action must be taken.
On these tami they confronted Andrea Mandelli for the Center-Right, Sandra Zampa for the Center-Left e Maria Domenica Castellone for the Five Stars, during the confrontation promoted at the Acli National Headquarters in Rome, by Alliance for Primary Care Reform in Italyto which 16 organizations belong, Active citizenship e Forum Inequalities Diversity. A face to face between the representatives of the various camps – moreover already solicited before the summer break by the Alliance in an open letter – who responded to the reflections put in black and white in the Blue Book for the reform of primary care and represented by Elena Rubatto e Fulvio Lonati
The District must be regulated at a unitary level throughout the territory and must be the place where all the interdisciplinary activities are integrated for a complete management, he argued. Maria Domenica Castellone for the Five Stars. “The District must be a place where health is promoted at 360 degrees and it is clear that the criteria must be uniform throughout the national territory. This is why I believe that thinking of a differentiated autonomy is risky, especially for Regions already in economic difficulty ”, said the senator, proposing a new vision of care in the area.
“At the beginning of the pandemic we formulated proposals with young neo-specialist doctors and in training – he said – that went towards a new vision of primary care: we believe that general medicine cannot be the only provider of primary care. Both because the current training of Mmg does not meet the criteria and standards that must be respected for specialists who deal with these areas of care, and because we already have specialists in community medicine and primary care. It is a school established in ’96 which has produced professionals with ad hoc training but who paradoxically cannot operate in general medicine despite two interministerial decrees have recognized this competence. We therefore need courageous choices: it is a mistake to leave general medicine as extraneous to the organization of the NHS and to allow an agreement with the system, it is a mistake to think that training in Mmg should be separate from the specialized one “.
On a real grounding of the Community Houses, Castellone says he is optimistic: “I believe that the Regions will be obliged to build them in order not to lose the second and third tranches of European funds”. Of course, there is a risk that the Community Houses become, like the Health Houses, polyclinics: “It must not happen – he added – this is because we did not have the courage to transfer the clinics of the Mmg and Pls and also of the 118 in the Community House. Unfortunately, there has not been a reform of general medicine, but I am optimistic for the future ”.
In short, for the pentastellata one must focus on: hiring staff with important dedicated funds; specialized training for Mmgs in the wake of those in community medicine and primary care and moving from a training contract to a job training contract; research to “create a scientific collection also on the territory”.
He is cautious Andrea Mandelli and curbs enthusiasm. For the exponent of Fi, there is a risk that the strong District will remain an entity only on paper. “I think that DM 77 is certainly to be read as a step forward – he said – but in fact it does not fully satisfy anyone. He is unable to draw a certain line of what the system of care in the area will be. The weaknesses that we have identified in these pandemic years are not being addressed, they are not being resolved. Also on the front of the allocation for health I see some difficulties: the idea of considering health as an investment and not as an expense has not yet materialized. I believe that more courage and more will are needed to tackle the root issue, starting with that of general medicine. The issue is delicate: there are no doctors. Therefore, a prospective reorganization is needed, which also starts from Ministerial Decree 77 – he concludes – but I believe that alliances are needed to solve the problems synergistically. I am not confident on the path we have taken, but we certainly cannot waste the possibility of putting things back in order ”.
On the Community Houses he does not hide his concern. “I believe that the realization of the Community Houses model spread homogeneously throughout the national territory by 2026 is very difficult to achieve – explained Mandelli – some Regions are still at the starting line, and I believe that the Health Houses have not given in the expected response is general, except for some virtuous examples that have animated them in a virtuous way. We therefore have a temporal problem to ground the designed system, but not only. If we think of the chronic and consider that a Community House absorbs a load of about 50 thousand people we already see a first great limit to the possibility of conceiving these places for the chronically ill as the great gateway to the NHS: human resources are lacking. A problem that weighs on the entire health sector. The situation is not under control: thinking of having places equipped without staff is useless.
We then have a serious financing problem: how will we support the evolution of these places? Now we can count on the funds of the NRP, but for the future the National Health Fund will be able to support them and above all maintain the desired level of quality? ”.
On the plate there is then the issue of the training of Mmg whose skills must evolve. We therefore need a specialization. In any case, the crux of their employment relationship remains for the exponent of Centro Destra: “How do we contract it, do we think of it as an employee or as a freelancer? This is a fundamental issue to understand what the evolution of primary care will be “. In short, for the exponent of the Center-right, the expected turning point cannot take place without first being sure of having all the people in the right place.
“We must not make the mistake of not seeing the great opportunity that Ministerial Decree 77 offers for a real relaunch of territorial assistance” said the representative of the Center-Left Sandra Zampa. “The Democratic Party has some points very clear, at the head of everything there is public health and the District that we think should become a real health agency in a framework of public guarantee and the Ministerial Decree 77 certainly does not open to different scenarios. In our program – he continues – we underline the need for a timely application of Ministerial Decree 77 in all its parts and in all Regions. In particular, we propose to attribute the multiple functions of the territory to the social and health district: this is the first step to overcome the fragmentation of competences, because the social cannot be separated from the health care “.
And in this context the Community House, for Zampa, must be the place where this integration is carried out to all intents and purposes in a structural way: “Before criticizing them, let’s activate them as they have been conceived. With multidisciplinary teams, with a single access point and immediate taking charge of the person and his family. We firmly believe that the Community House can guarantee the public nature of the system. Unique place of access, proximity to care, a place that allows citizens to be able to participate in the life of the community house, in the frame of the District. And all this is foreseen in Ministerial Decree 77, it is wrong to demolish it a priori ”.
Zampa finally regrets the failure to reform general medicine: “It was not possible to carry it out, it reached the last breath but then the government fell. But on closer inspection both in the new Acn and in the Ministerial Decree 77 there are important indications capable of producing regional acts to overcome the lack of reform ”. He then recalled that in the program of the Democratic Party there is a paragraph on the District and on the Community Houses: “But I have not seen the same in the other programs”.
Finally, how to get to the realization of what is foreseen by 2026? For Zampa it is all a question of “political will”: “Change things and I am convinced that what we have written in our document is achievable”.
As for regional autonomy, Zampa has no doubts: “Health should be removed from the draft law on the new autonomy presented by Gelmini. Instead, there must be a major strengthening of the Ministry of Health. Public health is sustainable and this is a political choice. The Mef cannot continue to decide ”.
Ester Marago
09 September 2022
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