Proximity is not only expressed in the form of structures

by Mario Oppes


Dear Director, ie
The risk that the adoption of a new model for territorial health care will pass in the absence of an adequate comparison is concrete. Therefore, I will not escape the temptation to express some considerations. The National Health Service – proposes the document prepared by the Ministry of Health in agreement with the State / Regional Conference – pursues the provision of universally accessible, integrated and person-centered services in response to most health problems for the individual and society, through the development of proximity structures.

But can proximity, the key word in the territorial aid reform project, be expressed in terms of structure? How is it possible to imagine that the need to bring treatments closer to the patients’ living environment can be satisfied simply by creating new structures? We all agree that the Covid-19 pandemic has confronted us with a reality that many have been trying to ignore for a long time. Now we are finally convinced of the need to overcome the criticalities of the territorial care system (but also the hospital system certainly has many to deal with) and the possibility of being able to invest a wealth of resources as I in forty years of medical profession. do not remember it, as we have ever seen it available, it finally allows us to redesign the care system.

If the principles that inspire the proposal (universality of access, integration of interventions, the centrality of the person) are certainly acceptable, some problems will arise when you try to transform them into a real model of care. The first feeling is that you want to invest in structures rather than people. The articulation of the system actually provides for the confirmation of the districts (with new tasks), establishment of community houses, territorial operational centers, 116117 operational centers, community hospitals.

All structures to which coordination roles are planned to be transferred to: The district (in which the community centers, territorial operational centers and community hospitals will be located) will oversee the integration of the various health structures to ensure a coordinated effort on an ongoing basis to the needs of the population. coordinate free choice of general practitioners and pediatricians with directly administered care facilities; the community center will coordinate the network of professionals working within it or in similar networks belonging to the hub and spoke network or with other territorial structures; the territorial operations center will be tasked with coordinating the takeover of persons and interventions.

Then the translation of the principle of taking responsibility is at least confused. Fælleshuset will guarantee this through the local nurse (who will act by facilitating and monitoring the processes to take responsibility and continuity in care; the Continuity Care Unit (a doctor and a nurse working in the local area in collaboration with the general practitioner or pediatrician of your choice) will support (but will not replace) the professionals responsible for taking responsibility, the territorial operational centers will be tasked with coordinating human responsibility.

The interpretation of the proposed methods of caring for patients admitted to Community hospitals is even more uncertain: health and hygiene and the clinical responsibility will lie with the doctor (we do not know how identified), the nurse, in connection with the operating room. Territorial, will take care of transitions of care (?) Ensure their takeover and continuity in care. Medical care during the day will be provided by dedicated doctors, and medical care at night will be provided to continuity doctors. A complexity that can not avoid raising doubts about what type of relationship will be possible to establish with the patient. What (or should we think how many?) Professional references will the patient have, and with whom will he be able to establish the basic relationship (based on trust)? And will proximity be understood as the proximity of a healthcare facility to the patient’s home? Do we not risk giving the concept of subsidiarity a purely geographical meaning?

Proximity – reminded Pope Francis – means that “taking responsibility” ceases to be a bureaucratic issue and becomes a meeting, accompaniment, sharing. Getting close, the pope said again – also means breaking down distances, ensuring that there are no “Series A” and “Series B” patients, putting energy and resources into circulation so that no one is excluded from social and health care. It is therefore not a question of defining proximity to the meter, but to the relationship.

Will we end up building so many containers, no matter how difficult they are to fill, given the current difficulties in finding qualified healthcare professionals? And what content could we wish for? It would be desirable to imagine that motivated health workers, freed from useless and dangerous bureaucratic burdens, often aimed at a “business” control of “productivity”, which risks distorting the profession and creating confusion as to the purposes that would be necessary to pursue.

In the belief that it will be difficult to have such opportunities, at least over the next ten years, it may be necessary to reflect again on the choices to be implemented and reconsider some aspects of the reform, perhaps from the basic assumption. that care is first and foremost a matter of human relations.

Mario Oppes

Former director of a complex structure in the field of hospitalization and emergency medicine and surgery
National Vice President of the Italian Society for Bioethics and Ethics Committees (SIBCE)

June 8, 2022
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