Health in the coming territory

The reform has taken the first step. The plant is good, but there are gaps and risks. Well the structures, the homes and the community hospitals, but nothing is said about who is going to operate them

It entered into force on 7 July, that is it Ministerial Decree of 23 May 2022 n. 77the one that – in addition to the bureaucratic definitions – must implement a significant part of the NRP’s mission 6: the reform and reorganization of local social and health care. The title would be a compelling program, primarily because it finally combines social assistance with health care, we have long argued that one without the other is incomplete. All the more so if, with this reform, we really want to tackle the legacy of the pandemic in the years to come, reduce non-urgent hospitalizations, deal with chronic diseases and lack of self-sufficiency. Will the promises of the title be fulfilled? And how, in accordance with Article 32 of the Constitution, which affirms health as a right to citizenship and thus the universality to be guaranteed by the public?

CGIL’s judgment on Decree 77 is articulated. The measure is consisting of four articles and 3 annexes, it defines a new model for the development of territorial assistance within the national health service, the qualitative, structural, technological and quantitative standards for the structures dedicated to territorial assistance and the prevention system. Almost. Within six months, the regions must adopt the planning and reorganization measures for the territorial assistance and prevention system based on the defined standards, a biannual monitoring is planned to verify their implementation, which will serve for full access to funding for each region.

The design of the reform, as outlined in the first annex, is acceptable and positive. His the overall system is right, but important issues remain open, starting with resources and staff, without which the reform risks being a lost opportunity;. If the aim of pressuring the regions to adopt the new model in a uniform way in order to ensure the essential levels of territorial assistance that is indispensable both for overcoming the current fragmentation and for organizing convergence paths in disadvantaged regions, the uniformity of Lea. weakened in several parts of the text.

Let’s try to understand better. The focus of the territorial aid reform is represented by District (one for every 100,000 inhabitants), as an articulation of the local health company, a privileged place for the management and coordination of the network of local health and social and health services. But it is worrying that the District disappears from the prescribed entries in Appendix 2. In the same way it happens for the family or the local nurse. Therefore, a serious shortcoming is not to anticipate some of the basic elements of the concrete realization of the reform as prescriptive and functional among them.

This is one of the most critical points in the provision. Annex 1 “describes” the reorientation of territorial assistance in a detailed and in our opinion appropriate to needs. But Annex 2, what prescribes the regions what “shall” to do is much less punctual and precise. The risk we see is that the areas, given the required minimum prescribed, will then regulate themselves as they see fit. In short, the region you go to health in the area you find.

That Communal houses, which must function under the direction of the districts, are central hubs in the network of territorial health and social health services; in them will work in an integrated and interdisciplinary way teams of general practitioners, pediatricians of free choice, nurses, social workers and other professionals. They are divided into “hub” community houses (one for every 40-50 thousand inhabitants) and “spokes”, which are to guarantee medical care and nursing care and other services, such as one access point, home help, basic diagnostic services, as well as integration with the social administration, etc. . The problem is that not everything that shines is really a star. First of all, communal houses are defined as basic public structures in the NHS in the descriptive annex, but this definition disappears in the prescriptive one. For us, this is a rather worrying choice. And it’s not enough, nowhere in the provision are the standards that refer to all the numbers that make up the multi-professional team stated.

Again, if on the one hand the obligation to be present in Casa dei is positive general practitioners (which they at least can also operate in their affiliated offices to ensure greater capillarity in primary care), not having provided for a direct recruitment from the service, maintaining the scheme of the agreement does not allow real integration into the interdisciplinary team, and at the same time it provides a glimpse of the risk that other professionals may also operate under the Convention by secretly opening the door to private individuals. This risk is also found in other parts of the decree.

But let’s continue to examine the text. L ‘hospital of Community (one with 20 beds per 100,000 inhabitants) will have to perform an intermediate function between home and hospitalization with the aim of avoiding incorrect hospitalizations and encouraging protected discharges. A new role that we believe is right will be assignedfamily or local nurse is the professional figure given as a reference that provides nursing care at various levels of complexity. It is a pity that it does not appear in Appendix 2. On the positive side, therefore, is the desire to set up a district mobile team for management and support to take responsibility for those in particularly complex clinical conditions. It will be calledContinuity care unit (Uca) and will consist of a doctor and a nurse for every 100,000 inhabitants. Clearly, this whole system needs coordination: one is foreseen Territorial Operations Center (Cot) for every 100 thousand inhabitants. FinallyMaid service it should be the focus of territorial assistance, but it represents the main investment in the National Reform Program. However, the decree completely lacks staff standards: this presupposes the possibility of leaving the service to an accredited private individual. While the prescriptions for the network of palliative care, health, environmental and climate prevention are also envisaged, there are no restrictions for the health care regions for minors, women, couples and families. Since a number of basic issues are missing: mental health, addiction and gender medicine.

The reform has gone in the right direction, in fact everyone Institutional development contracts between the Ministry of Health and the individual regions and autonomous provinces (CIS) for the implementation of the first interventions planned by Mission 6 of the Pnrr to which they have been allocated; the first 8 billion Of the 20 euros available, 1,350 communal housing, 400 communal hospitals, 600 territorial operational centers are to be built by 2026, and home care is guaranteed for 10% of the population over the age of 65. However, there are two big open questions.

The first is that of resources which is a major concern: we are repeating it strongly the level of funding, both for the national health insurance fund and for the various social insurance funds, it is insufficient to ensure the reorganization and development of health and social care integrated territorial. Not only that, one of the biggest problems revealed by the pandemic is the huge shortage of staff: boundaries and mistakes have become apparent in the planning of the training of some important health professionals. A staffing plan is not only necessary to provide legs and arms for the new structures envisaged in Ministerial Decree 77, but health workers are in short supply in a large part of the country.

It is necessary to make the health professions more attractive, remove the staff expenditure ceiling completely imposed by applicable law, enable an appropriate definition of training needs and the associated recruitment plans, including the stabilization of insecure staff. In fact, the derogation from the staff expenditure ceiling in relation to the new standards for territorial assistance, laid down by the 2022 Budget Act (L. 234/2021), is not financed by a corresponding increase by the National Health Fund. In addition, special attention must be paid to the decree, which will have to allocate these expenditure appropriations between the regions in deviation from the current ceilings, in order to avoid penalizing those regions that may have already taken steps to ensure higher standards with ordinary CSF resources. The comparison between CGIL, CISL, UIL and the Ministry of Health has not yielded significant results in terms of staffing needs.

The second problem is that concrete danger of privatization of part of the system. Creeping, in some ways already in place, and one can see all the danger. Some things I have already mentioned. But what raises more than one confusion is that in Appendix 1, the district, the center of gravity for future territorial assistance, is defined as a “client.” If the idea is that the District does not directly provide the services, but ensures that other professions (private profit or non-profit) do, we do not agree. As well as without the stable employment of health and social professionals promotes an unacceptable privatization of aid, which – as I said – is already under way;.

Healthcare is and must remain public and universal, its scope – as the pandemic should have taught us – must expand and not shrink.

Cristiano Zagatti, Head of Health Policy at CGIL

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