It’s the late morning of any Monday and psychodrama is taking place at the general practitioner’s selection and revocation desk. In the Lombardy of health excellence, a landing point for patients who come from all over the peninsula to find the best treatments, are now lacking 1,540 family doctors (I am 5,700 vacancies throughout Italy), and Mrs. Silvana – 83 years old, her doctor has just retired, leaving more than 1,300 patients without assistance – has found only one alternative: a professional with a clinic many blocks from her home. «I don’t know how I will manage to go to the visits, but I still consider myself lucky, because even today many people were unable to get a place: I came to queue five times and in the end I made it. It’s likely that this doctor’s client has just died and so today there was a “hole” for me.”
Cynicism aside, it is our bitter truth: there are no longer enough general practitioners and therefore, in spite of the much invoked relationship of trust, to find one you need to take a number in the place lottery. In many areas of the country, retirements are happening much faster than new arrivals and thousands of citizens are left without a reference point in the area. It is on this deficiency, even before that on the organizational models, that the reform of general medicine is being played out, to which the minister Orazio Schillaci has been working for weeks, amidst controversies, crossed vetoes from unions and corporations, but also from the government majority itself: Forza Italiawith Antonio Tajaniexpressed opposition to “making family doctors regress to anonymous bureaucrats closed in community homes”.
The reform of doctors and the great crossroads of community houses by June
The emergency decree, discussed with the Regions and unions, will arrive in the Council of Ministers by the end of the month. Also because a sword of Damocles hangs over the executive: the problem of Community houses. By June 30, Europe will ask us to account for their implementation, and Italy risks losing funding from the Mission 6 of the Pnrr for not having achieved the objectives: according to the latest monitoring, in fact, only 4% (66 out of 1,715) of these structures are active. For community homes to become operational, it is necessary to intervene on the rules governing the relationship between general practitioners and the National Health Service. This is the reason for the minister’s “rush”.
But what are the salient points of this decree? «The Schillaci reform redesigns local medicine with a dual-channel model» he tells Panorama Roberto Carlo Rossipresident ofOrder of surgeons and dentists of Milan. «Family doctors will be able to continue to work as affiliated freelancers, but for those who want there will be the possibility of becoming employees of the National Health Service and serving in community homes: with new organizational obligations and integration into the territorial network. For us, however, this idea entails some critical issues: the relationship of trust with patients would be lost, and two “categories” of professionals would be created within the same branch. It doesn’t seem right or fair to us.”
But already now, with the thousand difficulties encountered by citizens in obtaining a visit to the general practitioner, one could say – ironically but not too much – that the relationship of trust in many cases is only possible with their secretariats. In the minister’s intentions there is also a change in the remuneration criteria: no longer linked mostly to the number of patients, but also to participation in patient care processes, to a quota of hours (6 per week) to be dedicated to community homes, to participation in monitoring, and to results.
Meritocracy and university education: why the decree divides the category
It could be defined as “meritocracy”, but there is controversy on this topic too. All against, except Ugl Health. “Moving to a remuneration linked to objectives and the obligation of hours in the new structures is a necessary challenge to strengthen primary care”, says the secretary of the union, Gianluca Giuliano. «We can no longer think of maintaining a “status quo” that is proving to be lacking». A reorganization of training is also envisaged: if today, in order to become a general practitioner, one follows a three-year course on a regional basis, with the reform a specialist university course lasting 4 years will be required. General practitioners would no longer be – according to the imagination of the healthcare category – the “black sheep” of the situation, those with less skills, but specialists equal to the others. Because it is a fact that – currently – doctors are all complaining. Hospitalists with the territory, because it doesn’t filter the patients and causes them to become flooded Emergency roomfamily doctors with bureaucracy, with colleagues who belittle them and the system that does not guarantee them the right to sick leave and holidays.
Furthermore, patients have also changed: in the era of Doctor Googlethey are certainly more “erudite” than they used to be and the doctor who visits “with their bare hands” (assuming they find one) no longer inspires trust: if when you go for a visit you don’t get at least an ultrasound or a prescription for other tests you leave the office dissatisfied. However, another problem weighs on the idea of hiring general practitioners to send them to community homes, at least for the Regions in the recovery plan, namely Abruzzo, Calabria, Molise, Sicily, Lazio and Puglia. «Given that 90% of emergency rooms are now perpetually overcrowded and that 70% of accesses are inappropriate, that is, people who should be seen elsewhere, then it is necessary for this elsewhere to work» he says Renato Costaresponsible CGIL Healthcare for Sicily.
«Only that for the Regions in the recovery plan it is not possible to hire new doctors for the community homes. Will it therefore be necessary to turn to cooperatives? Will we fall back into the mechanism of the token holders? We’ll see what happens.” The fact is that for at least twenty years everyone has recognized that local healthcare needs to be reorganised, but every time we try to change something the reform stalls. Is it excessive to say that there is a veto power over general medicine capable of influencing governments, regions and parliament? «It’s not exaggerated at all, on the contrary» he confirms Gilberto Turatifull professor of finance science at Catholic of Milan and coordinator of the master’s degree in healthcare management. «However, we must not think that corporations are united in blocking innovation: there is a hard core of elderly healthcare workers anchored to the past, but there are many young general practitioners who accept this challenge. We need to realize that the general practitioner model of the past is no longer what is needed. Let me make a comparison: in the Seventies it was realized that the worker of the past, the one who knew how to do more or less everything, no longer corresponded to the needs of the large manufacturing industry. The problem was managed with the inclusion of specialized ones. In the case of general practitioners, we can proceed to exhaustion: with the retirement of the older ones, we enter the new system, with updated professionalism and university training”.
The studies closed in the bridges and the real impact on Italian emergency rooms
Will it take 10-15 years? It will also be necessary to start somewhere, rather than entrench ourselves in the concept that “series A” and “series B” doctors would then be created within the category. «The history of the training of these health workers is not so much in the concept of “let’s take it away from the Regions in favor of the university”», concludes Turati. «But it is rather that of creating new figures, because this is needed. Citizens ask for services, and right now, when you look for a general practitioner, you can’t find one. You call a minute after 9 and you can no longer get a visit and maybe your child has a high fever: obviously you go to the emergency room. If there is a community house, the problem is solved. He may not be your pediatrician, but he is still a doctor. It is the meaning of the reform.”
And in fact, while the Fimmg (Italian Federation of General Practitioners) and other acronyms raise the barricades and threaten strike, so much so that remuneration and university courses could be included in a subsequent bill, the real world has precisely these problems. Rachele is a single mother, and is in the pediatric emergency room Buzzi of Milan with her 4-year-old daughter, for a persistent ear infection that may not be particularly serious, but there is no other way to know than to seek a doctor.
And the pediatrician of free choice? «The law allows you not to work on the day before a holiday. So our pediatrician went on a long weekend for May 1st, closing the practice on Wednesday and will reopen it on Monday. And yes, if the little girl has something serious? In recent years, the government and the Regions have tried to stem the shortcomings of local medicine with emergency measures such as raising the retirement age to 72 and exemptions from the increase in the maximum number of patients: fresh water. «Complexity medicine cannot be managed with twentieth-century tools», the professor tells Panorama Paolo Nucciprofessor of ophthalmology atUniversity of Milan and author of the book Then I take care of myself (Piemme editions) dedicated to the difficulties of today’s patients. «No matter what trade unions and trade associations say, the only possibility of saving the system lies in progressively overcoming the artisanal format. The GP must become part of a network, not remain a separate entity. It can maintain the relationship of trust, but must participate in an organised, measurable and multi-professional system.”
The real test will therefore not be the text of the decree, but what will happen on a Monday morning in front of a counter or on a Thursday afternoon behind the door of a clinic. If for a visit we still have to hope that a place will become available somewhere, or that our doctor – his goodness – will keep it open on the eve of a holiday, then we won’t have reformed anything at all. In addition to losing European money. The world has changed: like it or not, doctors need to change too.
