This is unfortunately a dreadful doubt, because it is aimed at cutting citizens into slices, healthy or sick that they may be.
I am referring to slices because, quite often, there is not much harmony between general practitioners (GPs) and hospital or territory.
They blame each other of managing the patients autonomously, of being too prone to grant prescriptions, of being impossible to find, of being illegible scribblers and of not respecting the collegial nature of their profession.
Collegial nature? I wonder.
Has there ever been a real collegial attitude within a profession headed by a federation which, for many years, has taken no interest in the professional destiny of hospital physicians?
This inaction is documented: single contract, health and national health reforms, health units converted into enterprises, healthcare expense, medical management, single level, irreversible option and incompatibility.
These are changes which have destroyed the career and the contractual chances of hospital physicians, and have been all introduced without the slightest intervention by FNOM (the National Federation of Medical Associations), which only aims at protecting the “strong” category of general practitioners. I am not crying over spilt milk. However, none of the FNOM executives in charge over the last twenty years can be said to have done something valuable for hospital physicians. No one.
Communication difficulties can change into resentment, and resentment into hatred. It is better to be aware of this because, within a healthcare organisation that is making losses, nobody can conceive to survive by taking resources away from others.
We therefore need to broadcast a different culture, based on common rules and on understanding, as well as on the systematisation of group medicine, to prevent the general practitioners from being bypassed by the current direct access to hospital.

The patient information (the patient’s medical records) should be shared, since the subject of the medical records is the patient under treatment, and no one else. We need to reach the point where we have a “virtual hospital”, where all the professionals involved in assisting the patient may synergistically and autonomously carry our their individual function.
Only in this way can we avoid the duplication of expensive and useless exams; only in this way will unnecessary admissions to hospital be avoided; only in this way will cost effectiveness be achieved. We need legislative and contract reforms.
But until that time, each one of us should actively cooperate for a real change to be achieved. Even if this involves resorting to provocations and strong words (as I did some months ago): debates have never killed anyone, but they allow the group to grow.
There is nothing we can do. Failing this, the bed number cutback for acute cases and the strengthening of the territorial activity will cause the conflicts to widen, since they will involve an ever increasing employment of hospital specialists on the territory, with no rules and no agreements. Who can benefit from that?

Hospitals

So far hospitals have been the chief place of treatment: for acute and chronic patients, for seriously and not so seriously ill people, including out-patients.
For over 150 years, hospitals have represented the core of the system, with a good quality/quantity outcome. However, the ‘aziendalizzazione’ process, whereby health units have been converted into enterprises, has redesigned the setup of Italian healthcare. The belief system centring on prevention, on out-patient treatments, on district and domiciliary assistance, has fascinated the most creative politicians and healthcare technicians. “Preventing and not curing”. “Chronic diseases are to be treated in national health facilities”. “Hospitals should be homes meant for brief cures and stays”.
The bed numbers for acute cases are being cut back without increasing those designed for rehabilitation or in the RSAs (Assisted Healthcare Residences). Money is wasted in prevention and district organisation, never taking into account the product/cost, quality/cost and cost/benefit ratios. Indeed, drawing up the accounts is an easy task only in hospitals and nowhere else.
Hospitals are to take second place: this is the desire of hygienists and prevention promoters. But pathology changes all the time, and it is difficult to prevent diseases which cannot be diagnosed because they have not been coded yet. Can we prevent rare or genetic diseases?
Can we prevent uraemia, diabetes, strokes, or dilated cardiomyopathy? How much prevention activity can really be implemented with respect to the top 40 diseases, which are responsible for 90% of healthcare costs? Nobody wishes to deny the strong role of diet, physical activity and stress reduction in preventing aging and atherosclerosis. But what are we really doing to improve the life of over-fifties? Cancer prevention: is this a myth or reality? Genic therapy: today or in twenty years’ time? Hospitals, of course: hospitable places, places designed for hospitality and therapy. Nursing homes and health facilities. A time for existential reflection. It is sufficient to be lying down in a hospital bed, waiting for something or somebody, to see the world and one’s private life in a totally different light. In hospitals you are looking for comfort, but above all for professionalism and humanity on the part of the healthcare staff. Weak amongst the weak, you find yourself waiting for the verdict: not guilty, guilty or committal for trial.
Hospitals do not represent a stage of life (which we all have to come across sooner or later).
Hospitals provide a symbology of life: birth, growth and death; joy and pain; wait and hope; anxiety and tragedy; scheduled and routine activities; emergency and improvisation; individual and team work; real or theoretical hierarchy; victory or defeat in acute cases; sudden complications and unexpected remissions; unforeseen miracles or forecasted worsening; agonies and pain … without sense. … without sense had there not been God. And in hospital, you often get to perceive the presence of God. How many times, with our thoughts or with our words, have we thanked Him for unexpected help, for a diagnosis that was more benign than expected, for an unconceivable clinical improvement? Pain and joy. Profession and humanity.
Technology and love. This is what hospitals have been so far. Will they be able to continue being all this with current and future lean times? Shall we again see the “excess” beds lined up in the corridors; the long admission lists; tears for early discharge; repeated admissions for social security and not healthcare purposes; the squalor of facilities? Somebody has decided to leave hospitals to their fate: local hospitals will disappear (for “asphyxiation”), whereas healthcare migrations will increase, with little discomfort for active and financially independent people, but with serious problems for all the others: the weak, the poor, the disabled and the elderly. These will all have to be content with a myth: the District. A rarity with a hundred lives and a hundred different functions. The excellent kingdom of time-ruled bureaucracy (from 8:00 a.m. to noon or from 9:00 a.m. to 3:00 p.m., with a fascist-style closing day on Saturdays): here there is little medicine and lots of paperwork.
They want the District to be the heart of the system: the common element which MDs, ADI (Integrated Domiciliary Assistance) and Hospitals or RSAs are to hinge on. This is what they want, but the good old hospital will not let go, and year by year, will regain possession of the healthcare spaces denied today. Indeed, a hospitable place has neither a timetable nor a closing time; a hospitable place accepts all pitiful cases, without restrictions, as it is a major responsibility centre and not only a cost centre, just like the other facilities mentioned above.

Enterprise-Hospital?

Of course, the good old hospital cannot be run as a business, because here the organisation of financial resources continues to play a marginal role versus the typology of services, which are personalised and not standardised; they are quality services without discrimination. In the teeth of those , who, even though not being physicians, have the impudence to view the hospital as an enterprise, influenced by economic resources and by the organisation system regulating such. We wish to reiterate that it is right to control costs: but woe betide the system that should deny the 101st angioplasty because the stunts are finished! This is not the health system we want: an equal, just, sympathetic, efficient and professional system; a universal system, that is a system meant for everyone; an essential system that denies unnecessaries. Today it does not work that way, also because of people like Borgonovi. Hospitals today are meant for everyone. Tomorrow they may only be for selected patients, validated by one of the many committees that Italian imagination produces every day.
Patient selection: is this what they want? Or are they aiming at imposing guidelines, gathered together in bulky volumes, to be rigidly applied without professional “imagination” and without personalisation? Medicine is an art, rather than a science. It is for the patient, not for the disease. The individual component prevails over the general picture. These are three axioms, three truths. Medicine is an art, the physician is a professional. Something doesn’t add up here. Indeed, physicians’ professionalism depends on their knowledge (both inborn and acquired), on their personal motivations and on their commitment within the team. It depends on the way in which they conceive their profession: in a professional style or from a clerk’s point of view; aware of professional risks or restrained by defensive medicine; fully part of the team or playing a marginal role.
Clinic work is a form of “self-employment”, and not a managerial job. An organisation that is excellent from a theoretic point of view leads to nothing if adequate professionalism is missing. This is what has happened to whole departments and to many hospitals: in a peak position with certain professionals and declining or deteriorated once they have left. Rovigo is an instructive example. It was an enterprise before and after those professionals’ contribution. It used to be a good hospital; it is a modest hospital, now that 5 of them have left. So much for the healthcare tendencies to favour the corporate sector.
Still, some decided to call the hospitals “plants” (sic) and then “enterprises” or “facilities”. But plants and enterprises are not hospitalization places… they are facilities providing a product that differs from man and from his health. That man is looking for the professional who can solve his personal situation: and (if he can) he will find one even if he has to go to the ends of the earth. That man is not looking for an enterprise or for corporate culture: he is looking for a doctor, a team that can tackle his problem. And, if he can afford it, he will choose that doctor or that team wherever they are based. That woman does not want to give birth to her child in plant “X” but in a delivery room complying with all professional requirements, even if the facility is a bit dated and it does not offer all the mod cons of a hotel. Healthcare economists (including Mr “B”) are a race apart: they preach but they do not administer. Unlike the “People from AIOP” (Italian Association for Private Hospitalisation), who very well know how much private (AIOP) and public (NHS) hospitalisation depends on medical professionalism and not on the corporate myth. It makes no difference.
Suffice it to say that, once again, economists are the theorists of mistakes!

1992-2002: 10 Years of Healthcare Turmoil

It is not my intention to go through the whole history of the De Lorenzo (1992), Garavaglia (1993) and Bindi (1999) reforms. The readers may, during their sleepless nights, carefully re-read the integrated text of the three reforms, so as to appreciate all their innovatory, fanciful, highly imaginative and punitive aspects. In an attempt to reduce healthcare centralism, a huge role was assigned to the new Moloch called “Regional Authority” and to a monocratic organ unique of its kind worldwide: the General Manager.
This is a powerful and weak figure at the same time; a local sovereign who is heavily influenced (as regards appointments, annulment of appointments, wages and funding) by the Regional Council and moderately but daily influenced by local authorities. We are not so much referring to Municipal Authorities (which were cut out by Mr De Lorenzo and partially resuscitated by Mrs Bindi), but to local political party exponents, who are always looking for smaller or greater favours. On one side we have the uncontrolled management of hundreds of billions. Uncontrolled because it lacks any analytic assessments by a Board of Directors. On the other side we have the granting of favours to local politicians: a reporter, an auxiliary, a contract for cleaning services, or a batch of computers. At the centre is the bottomless pit of human cupidity: contracts for services awarded in no time; the usual walls; the goal projects; the catering; the great technical services.
“Aziendalizzazione”? How can it be introduced under such conditions? Starting from the organisation setup and all the way through to the various types of funding, which differ according to the ASL (Local Health Enterprise, involving fee or DRG payment) and AULSS (Local National Health Enterprise Unit, involving share capital payment). Different rules apply, depending on the Region; ASL and AULSS health units differ significantly in size and activities; funding is regulated by “the Prince” (the Regional Council), without project integrations on a province or region basis. Barbarous competition exists, between one AULSS and the other; between AULSS and ASL units; between departments; between hospitals and the very AULSS or ASL unit; between hospitals and territory. Uncontrollable competition, without common regional rules and with an obvious explosion of costs. The lack of planning activity, or the absence of physicians in the planning stage, accounts for the rest: not to mention the periodic interference of the government in charge.
Prescription charges: yes or no; LEA levels: yes or no; therapeutic manual: broad or brief; National Healthcare Plan: fanciful rather than realistic. Last but not least comes the boom in administrative and auditing duties, only to the detriment of medical activity. DRGs, budgets, assessment units, technical committees, appointments, reviews, administrative directives, circular memoranda, nursing management, Legislative Decree no. 626/94, persons in charge, hospital medical managers, EDP… About twenty small corporate gems, source of chaos, bitterness, estrangement and expenses.
That’s right: they cause expenses. So much so that the ‘enterprise’ system declared bankruptcy on 8 August 2001. And not even the mid-August treaty, providing for a subsidy by the Government of 16 million old little liras managed to solve the problem.
The Regional Authorities signed an agreement and that agreement (Law no. 405/2001) fixed the funds to be granted to the NHS at 5.88% of GDP, for at least 4 years. But with this “aziendalizzazione” and with this organisation, somebody will be forced to declare bankruptcy.
The 2001-2002 expense is under-funded by as much as 14,000 billion. “Hot packs” (prescription charges and regional income tax increases) will certainly not be sufficient to cure the “patient”. A deep organisational change is required: a reform that clears the corporate myth completely and adapts the National Health Service to the new healthcare requirements of the Country.
The distinction between ASL and AULSS (provincial) units; ASL units and Hospitals as parts of a network as far as functions and instrumentation are concerned; hierarchic classification of hospitals; payment for services with a ceiling price; competitiveness among facilities; relaunching of professionalism and of the medical career with the reappearance of hierarchy; a distinction between professionals and managers; new rules for LEA levels; prescription charges that are moderate, but extended to all services.
These are a few hints for a new and final modern reform.

Stefano Biasioli
CIMO

Translated by interpres sas