{"id":3059,"date":"2024-06-26T18:42:40","date_gmt":"2024-06-26T16:42:40","guid":{"rendered":"https:\/\/www.rivistaeco.com\/?p=3059"},"modified":"2024-06-26T18:42:40","modified_gmt":"2024-06-26T16:42:40","slug":"what-cure-for-the-public-health-system","status":"publish","type":"post","link":"https:\/\/www.rivistaeco.com\/en\/2024\/06\/26\/what-cure-for-the-public-health-system\/","title":{"rendered":"What Cure for the Public Health System?"},"content":{"rendered":"

The English and Italian health systems face similar challenges and share characteristics of universalism and free services. How can we ensure these remain sustainable in the future? Public health must adhere to principles of effectiveness, sobriety, and economy, avoiding models of health consumerism.<\/span><\/i><\/p>\n

Signs of Crisis in Public Health Services<\/b><\/h3>\n

Evidence of crisis in public health services can be seen in several European countries. The parallel between the English and Italian systems is justified by the fact that our National Health Service (SSN) was modelled after the English system created by Ernest Bevin and William Beveridge in 1948. Some solutions adopted in London could also be beneficial in Italy.<\/span><\/p>\n

Respecting the Founding Principles<\/b><\/h3>\n

The UK\u2019s National Health Service (NHS) has achieved numerous significant milestones: the first liver transplant in Europe in 1968, the first CT scan in the world in 1971, the first test-tube baby in 1978, the first combined heart-lung-liver transplant in 1987, and the first systematic vaccination against meningitis in 1999. However, its greatest success has been equality in access to care\u2014universalism\u2014a founding characteristic now at serious risk in both the UK and Italy.<\/span><\/p>\n

The roots of the difficulties are common, particularly the prevalence of chronic diseases that require long-term and often expensive therapies (e.g., diabetes). In Italy, chronic patients comprise 38-40% of the population and consume between 70 and 75% of the SSN\u2019s resources. The prevalence of chronic conditions is 50% at age 55, with an average life expectancy of about 82 years, meaning chronic conditions last on average 27 years. The situation is similar in the UK.<\/span><\/p>\n

The founding principle of the NHS was that assistance should be based on need, not the ability to pay. Services were to be universal and free. Today, 75 years after its founding, the UK health service costs about 8% of GDP (a high 9.9% in 2021) compared to a modest 6.5% of the Italian SSN. The NHS’s founding intention was a strong link between universality, scientific evidence, sobriety, and economy. These principles also inspired our Health Service and today are the basis of essential levels of care.<\/span><\/p>\n

Since World War II, our societies have radically changed with significant social, technological, and economic phenomena: the rise of consumerism (general and health-related, meaning the use of healthcare services even when unnecessary); the technological imperative whereby every new technology tends to be introduced into practice even if its contribution to health is marginal; and a general liberal attitude based on consumer \u201cfreedom of choice.\u201d Despite these historical changes, the principles of effectiveness, sobriety, and economy must remain central to public health systems, leaving the private sector to satisfy individual needs inspired by \u201cfreedom of choice.\u201d In this case, too, the state must exercise a role of guaranteeing and controlling the safety of practices. Without adherence to the founding principles, public health services risk becoming economically unsustainable or losing their universality.<\/span><\/p>\n

A key issue is appropriateness: it is estimated that up to 40% of diagnostic tests, with regional differences, are prescribed inappropriately, meaning they are not useful for diagnosis and can lead to incorrect results. Appropriateness problems have been addressed in the UK, particularly by NICE (National Institute for Health and Care Excellence), a Health Ministry body tasked with producing guidelines in the name of clinical excellence and scientific evidence. NICE has played an important role in combatting the technological imperative, i.e., the introduction of new technologies without considering the incremental advantage relative to costs.<\/span><\/p>\n

The Crisis: A Common Problem<\/b><\/h3>\n

The English medical community agrees that the NHS is in crisis. According to a recent document from major English medical organizations (including the Royal College of Physicians), today patients with acute medical conditions are brought to hospitals with some delay, spend prolonged periods in overcrowded emergency departments, and are treated in different wards with little continuity of care and knowledge of the patient. There are further delays in leaving the hospital due to difficulties with social care, and patients are at risk of readmission following pressure to discharge them too early. These are problems experienced by many Italian patients and also in other countries, as explained by a recent OECD publication. Some years ago, a Lancet Oncology editorial asked: \u201cIs the UK at risk of losing the NHS because the government is uninterested or unable to make the necessary efforts to save it?\u201d<\/span><\/p>\n

One consequence of staff shortages in some areas has been a dramatic increase in insurance costs related to \u201cclinical negligence\u201d (from \u00a3400 million in 2006-2007 to \u00a31.6 billion in 2016-2017). Indeed, the NHS shows several chronic conditions of distress, beginning with the difficulty in recruiting staff, with the result that many doctors and nurses are hired from abroad (post-Brexit increasingly from non-EU countries); and real health spending has gradually decreased, although less so than in Italy.<\/span><\/p>\n

Regarding Italy, the value of the National Health Fund based on general taxation is substantially lower than the percentage of GDP invested in most European health systems, which are based on principles of solidarity and distributive justice, although our country has the highest prevalence of elderly people in Europe (24% of the population is over 65 years old). The suffering of the Public Health Service results in increased private spending, amounting to \u20ac41 billion per year for healthcare (plus \u20ac25 billion per year for long-term care for the elderly) against \u20ac128 billion for public healthcare. If the ratio between private and public spending were to grow further, it could threaten the principle of universalism underlying the SSN. Private health spending is indeed highly uneven across Italian regions: for example, it is \u20ac800 per person in northern regions like Lombardy and Emilia-Romagna and \u20ac300 per person in southern regions like Calabria.<\/span><\/p>\n

The SSN Staff<\/b><\/h3>\n

It is often said that Italy has a shortage of doctors, but this is not true. Italy’s four doctors per thousand inhabitants are more than the UK’s three or France\u2019s 3.3, although the count varies slightly in different countries. There are, however, significant gaps in specialist training in Italy, particularly in disciplines such as microbiology and virology, radiotherapy, clinical biochemistry, community medicine and primary care, pathological anatomy, palliative care, thoracic surgery, and general and vascular surgery. The problem, therefore, is not a general shortage of doctors but a shortage of specialists in some disciplines, which can be attributed to the low attractiveness of these specialisations. Conversely, disciplines offering opportunities in the private sector, such as dermatology, ophthalmology, and cardiology, show no signs of crisis; essentially, there are distortions in the distribution of personnel resources due to private healthcare market incentives. A hemorrhage from the public to the private sector is observed not only because of relatively low salaries compared to other countries but also due to managerial, organizational, and administrative aspects and the lack of non-medical staff. The shortage is particularly significant in the nursing sector, a chronic problem in our country.<\/span><\/p>\n

A consequence of the hemorrhage from the public to the private sector is the lengthening of waiting lists and a certain degree of evasion of healthcare problems, especially for the less well-off. Existing data on waiting lists are fragmented and often difficult to interpret, making the phenomenon currently unquantifiable. Apparently, the number of citizens who give up care due to excessively long waits and the inability to turn to the private market is growing. Of course, the perception of the crisis varies depending on whether it is professionals or the public. For example, many waiting lists are simply linked to inappropriate services that are unnecessary, superfluous, or counterproductive (both due to doctors’ initiatives and patient pressures). Defensive medicine also comes into play here, i.e., doctors\u2019 tendency to defend themselves from possible legal complaints by overprescribing tests.<\/span><\/p>\n

In healthcare, the private sector has many limitations: for example, the market can artificially create a shortage of a good to generate a higher price. Public and democratic control, rather than the market, is considered the optimal solution even by medical associations like the British Medical Association. Furthermore, it is often forgotten that public spending serves a very specific purpose\u2014to guarantee good health for all and mitigate social health inequalities\u2014but it is also a multiplier of private initiatives, i.e., it has a positive impact on the overall economy.<\/span><\/p>\n

Six Prescriptions for the Health of the System<\/b><\/h3>\n

It must always be remembered that the Italian SSN is one of the best in the world, as evidenced by good levels of life expectancy and other health indicators: 83 years of life expectancy in our country compared to 78.4 in the US. These results are achieved with substantially lower spending than other European countries, but there is now widespread belief that the system cannot hold up and that there is a risk of transferring resources (starting with human resources) to the private sector. In addition to finding a better balance than the current one between private and public spending to face future challenges, it will be necessary to focus more on health promotion and disease prevention with a more concerted effort to understand and address the multiple social, environmental, and economic factors underlying health inequalities.<\/span><\/p>\n

I mentioned diabetes at the beginning: at least 50% of cases could be prevented with adequate efforts focused on nutrition and physical exercise; this would result in enormous savings for the health system and reduce health inequalities. Spending on prevention bears fruit in the long term and is therefore unattractive for short-sighted politicians.<\/span><\/p>\n

Incremental funding should instead be allocated to a special fund for regions below performance standards but only based on innovative policies whose effectiveness should be monitored with quantitative tools.<\/span><\/p>\n

In conclusion, all countries, including ours, should resume reflecting on the founding values of their health services, define what essential services are, and guarantee them adequate funding, avoiding both health consumerism and the technological imperative.<\/span><\/p>\n

If this is the set of problems threatening the Italian SSN today, some solutions could be: a) increased public funding for the health sector to bridge the gap with other countries; b) more attention to the governance of the overall system, including the private sector; c) better policies to recruit doctors and nurses by addressing organizational and job quality aspects as well as salaries; d) greater appropriateness in prescriptions following the NICE example; e) including general practitioners, currently freelancers, among SSN employees; f) promoting prevention at all levels, not just within the health system.<\/span><\/p>\n

Bio<\/span><\/em><\/p>\n

Paolo Vineis<\/strong> is a Professor of Epidemiology at Imperial College London and an Accademico dei Lincei.<\/span><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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