by Riccardo Asero and Roberto Polillo
From what we read in the proposals for the reform of territorial medicine and hospital standards, it is clearly evident that an irresponsible health planning policy is in place which tends to relegate allergology and clinical immunology to a residual and inessential role for the protection of health. If at the level of the Ministry of Health it was decided to completely privatize the therapy of allergic diseases, it is necessary to have the courage to declare it publicly
28 OTT – The COVID 19 epidemic revealed the extreme weakness of our NHS, where the policies of linear cuts, implemented as a response to the great financial crisis of the mid-2000s, have reduced and downsized health and organic structures, seriously compromising the capacity response to pandemic events.
The poor performance of our country has inevitably forced a change of strategy on the part of the public decision-maker and the Recovery and Resilience Plan (PNRR) has become the tool to relaunch our NHS. An ambitious project characterized by the provision, in the specific chapter of the “Mission 6” document dedicated to health, of a specific financing for health, quantifiable at 15.63 billion and the definition of two priority macro-areas of intervention.
The two intervention areas marked as M6C1 and M6C2, as is known, concern respectively:
• Proximity networks, intermediate structures and telemedicine for territorial health care: the interventions of this component intend to strengthen the services provided in the territory thanks to the strengthening and creation of territorial structures and facilities (such as Community Homes and Community Hospitals ), the strengthening of home care, the development of telemedicine and a more effective integration with all social and health services • (allocation of 7 billion euros).
• Innovation, research and digitization of the national health service: the measures included in this component will allow the renewal and modernization of the existing technological and digital structures, the completion and dissemination of the Electronic Health Record (ESF), a better delivery capacity and monitoring of the Essential Levels of Assistance (LEA) through more effective information systems. Significant resources are also earmarked for scientific research and to promote technology transfer, as well as to strengthen the skills and human capital of the NHS also through the strengthening of staff training (allocation of € 8.6 billion).
Parallel to the PNRR, the Ministry of Health and Agenas prepared a text amending Ministerial Decree 70 on hospital standards and a proposal on the reform of primary care.
These are coordinated measures that aim at a twofold objective:
• redefine the organization of hospital care with the promotion of a model based on the intensity of care, on the implementation of intensive and sub-intensive care places, on the expansion of clinical networks with the dual objective of giving a system that is too rigid flexibility, resilience and intervention priority criteria and to promote the reference disciplines of clinical networks by investing in these technologies and human resources.
• strengthen the primary care system with the creation, as part of a precise chronoprogram of community homes, community hospitals and home care with the aim of ensuring patient care, monitoring and assistance of patients with acute diseases / chronic not requiring hospitalization; define protocols for the implementation of hospital and territory continuity through the creation of operational centers in each district dedicated to this.
In this great reform process that will involve the overall structure of our NHS, the major absentees are the allergy-immunological (and to a lesser extent rheumatological) disciplines which risk becoming totally residual and inessential for the operation and functionality of both branches. assistance (hospital and territorial).
Proceeding in order, we highlight some critical elements that emerge from the reading of the documents:
1) Hospital assistance (Modification of Ministerial Decree 70)
• For the discipline of allergology and immunology, the previous standards relating to the number of structures / services without bed per population basin are confirmed: By allergology: a structure (indifferently complex, departmental or simple) per catchment area between 2 million and one million inhabitants; for immunology the numerical parameter is included between 4 and 2 million. This means that for a region like Lazio the maximum number of structures that can be activated would range between 5 and 3 for the first and between one and two for the second.
• For the rheumatology discipline, structures with beds are reconfirmed (1 every 1.5 million -700.00O inhabitants) and those without beds (1 million-500,000 inhabitants) are introduced as an alternative.
• For pulmonology, only structures with beds are provided and the reference parameters are lowered (one for every 600,000-300,000 inhabitants).
• The number of clinical networks (previously three in number) is implemented, strengthening their functional characteristics. In the document “Clinical networks represent an organizational method for the coordinated management of the entire care chain of specific pathologies or services in the context of population basins and the diffusion of specialties. The clinical network is based on a system of close relationships between centers (nodes) organized according to the Hub and spoke model …. In the definition of the networks, the integration of acute and post-acute activities with territorial activity must be envisaged …
• The networks defined in the document are:
1) time-dependent networks (emergency-emergency, cardiological, stroke, traumatological, birth points);
2) specialist medical networks (infectious diseases and epidemic emergency response);
3) oncological networks (oncohematology and rare tumors)
4) pediatric networks;
5) networks of neurodegenerative diseases
6) transplant network;
7) network of diagnosis and treatment services;
8) pain therapy network;
9) rare diseases network;
10) rehabilitation and hospitalization network.
It is quite evident that the lack of any reference to an allergological and / or immunological network acquires a clear meaning; in fact, the legislator does not consider these disciplines essential for the purposes of health care and therefore does not define standards such as quantities capable of guaranteeing universality of access and uniformity of the levels of provision. An unacceptable position both for the complexity, severity and chronic course of the pathologies that pertain to the discipline (ADR from drugs, allergy to hymenoptera venom, severe food allergy, severe asthma, etc.) and for the growing spread of allergic diseases .
• In the text amending Ministerial Decree 70, the standards of hospital structures are also redefined (basic facilities, first aid and first and second level DEA offices) and none of these include the figure of the allergist while almost all other specialties with different degrees of structuring within the presidium. The same considerations as above apply to this part of the paper.
2) Territorial assistance “Models and standards for the development of Territorial Assistance in the National Health Service”
Agenas and the Ministry of Health have prepared a new version of the document “Models and standards for the development of Territorial Assistance in the National Health Service” in order to completely redesign primary care and address the main issues strictly connected to the interventions envisaged in the of Mission 6 Component 1 “Proximity networks, structures and telemedicine for territorial health care” of the National Recovery and Resilience Plan “.
• In the document, a central role is entrusted to the District which will have the task of coordinating various services including the Hub and Spoke Community Homes, the Community Hospitals, the Usca, the Hospices, family nurses, home care and implementation of the European toll-free number 116117 for non-urgent care.
• The characteristics of the Hub and Spoke structures are redefined with the indications of the specialty disciplines related to these.
• Also in this case, no reference is made to the allergist, while the presence of a spirometer is among the mandatory instruments which inevitably will require the presence / advice of a pulmonologist specialist, favoring the replacement process already underway in various regional situations.
Final considerations
It is clearly evident that an irresponsible health planning policy is underway which tends to relegate allergology and clinical immunology to a residual and inessential role for the purposes of health protection.
An irresponsible choice that will deprive citizens of essential and irreplaceable services also in relation to the provisions of the new LEAs that have remained inapplicable, in which some services are instead the exclusive responsibility of the allergist.
The consequences will be the impossibility of adequate treatment by citizens suffering from serious pathologies and a mortification for those professionals who have dedicated their professional life to allergology or who after having obtained a regular qualification will not have access to the world of work. .
The scenario that is taking shape is therefore that of a dramatic impoverishment of the responsiveness of our NHS to growing health needs and the liquidation of a tradition that in our country has counted and can count on world-class excellence.
We need a clear and strong response from the scientific societies concerned and a spirit of service that has so far lacked.
Therefore, a terrible challenge awaits us that we can only win by joining forces and aiming at a strong and convinced dialogue with all the institutions involved by the Ministry of Health, at the state-regions conference, by Agenas and the representative bodies of the category.
It should be remembered that in industrialized countries (including Italy) about 25% of the general population suffers from allergic diseases. One wonders which structures these citizens will have to turn to in the future to be treated given the situations described above. It is necessary to define a territorial network of allergy specialists who take care of this mass of patients / citizens who would otherwise end up turning to the few hospital centers (obviously completely insufficient to meet the needs of all these people) or to private centers that wisely have the allergy specialist.
The recent SARS-Cov-2 pandemic has led to the rediscovery of the indispensability of the allergist specialist for the diagnosis and adequate treatment of adverse vaccine reactions, while in future health planning this professional figure is surprisingly completely ignored. Allergic reactions to drugs, foods, and hymenoptera venom, just to name a few, are frequent and only the specialist in allergology and clinical immunology has the necessary skills to be able to take care of patients suffering from these pathologies.
If at the level of the Ministry of Health it was decided to completely privatize the treatment of allergic diseases, it is necessary to have the courage to declare it publicly. There is only one alternative and consists in putting the above programming back to work to remedy this serious flaw.
Riccardo Asero
President of the Italian Association of Territorial and Hospital Allergists and Immunologists (AAIITO)
Roberto Polillo
Member of the National Board of AAIITO
October 28, 2021
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