{"id":3095,"date":"2024-06-26T18:39:53","date_gmt":"2024-06-26T16:39:53","guid":{"rendered":"https:\/\/www.rivistaeco.com\/?p=3095"},"modified":"2024-06-26T18:39:53","modified_gmt":"2024-06-26T16:39:53","slug":"unlearned-lessons-from-the-pandemic","status":"publish","type":"post","link":"https:\/\/www.rivistaeco.com\/en\/2024\/06\/26\/unlearned-lessons-from-the-pandemic\/","title":{"rendered":"Unlearned Lessons from the Pandemic"},"content":{"rendered":"

Mission 6 of the PNRR (National Recovery and Resilience Plan) outlines a new model for responding to the needs of healthcare services. It focuses on community medicine, expanding initiatives and experiments conducted by various regions, and ensures the resources to start the process of change. To make it work, adequate healthcare spending is necessary.<\/span><\/i><\/p>\n

The Rise of Community Healthcare<\/b><\/h3>\n

Community healthcare, previously of interest only to sector experts, has returned to the forefront with the pandemic. This happened for several reasons. The first is linked to the need to detect health phenomena at their onset in care locations, which are natural surveillance outposts: the boom in pneumonias that preceded the first case of Sars-Cov-2 infection in Codogno is an example. Doing this means moving from managing individual cases to a \u201cpopulation vision\u201d that involves using the wealth of information produced daily by every diagnostic and treatment intervention: every booking, admission, and report feeds a data flow that on an aggregate scale allows us to understand what is being provided and for what reason.<\/span><\/p>\n

The second reason refers to the opportunity to bring services closer to the citizen, making them more accessible. This means not only building new nearby care locations (proximity as it is commonly called) but also overcoming the idea that offering health means only hospitals and doctors. Technologies exist that allow meeting any care professional without physically going to the hospital, just as the patient’s home itself can be a place of care and assistance. During the pandemic, home interventions were intensified, and artisanal forms of telemedicine were born, which should populate future healthcare services. Beyond the technical issues that can lead us far in defining what \u201ccommunity healthcare\u201d is within the framework of the Italian National Health Service (SSN) articulated in different regional models, we associate the concept with everything outside the hospital. The pandemic has shown us two main paths: overcoming fragmentation between different care locations by building a more integrated system closer to people, and reinterpreting care models by formulating new responses.<\/span><\/p>\n

Health in the PNRR<\/b><\/h3>\n

Based on this, all European countries have launched specific \u201creforms\u201d to revive proximity care and service integration. In Italy, the territorial shift is at the centre of one of the two components of Mission 6 of the National Recovery and Resilience Plan, which proposes \u201cproximity networks, structures, and telemedicine for community healthcare\u201d with the aim of \u201caligning services to community and patient needs\u201d by strengthening \u201cproximity healthcare structures and services and home services.\u201d Seven of the 15.82 billion euros allocated to the Mission are dedicated to this task.<\/span><\/p>\n

Three investment lines have been defined to support the new vision: the first is linked to new physical locations called \u201ccommunity health centres\u201d (1038 are planned) offering health services (e.g., clinics for chronic patients) and other services (e.g., social workers or administrative services for booking appointments) in collaboration with hospitals and general practitioners and pediatricians. Community health centres are an evolution of already mature experiences in the country\u2014called health houses or territorial assistance centres\u2014as these \u201cproximity physical locations easily identifiable where the community can access and contact the healthcare, social, and health system\u201d promote and produce health not only by offering health services but also by integrating those who help create community, from social workers to the third sector and volunteers.<\/span><\/p>\n

The second investment line focuses on the \u201chome as the first place of care\u201d and the possibility of overcoming the single service model that always forced physical access to care locations. Telemedicine should allow the patient to benefit from remote visits (televisits) or receive teleassistance from an on-site professional (e.g., a nurse) and another connected remotely, or allow professionals to consult even if in different locations (teleconsultation). This is a true Copernican revolution, and the recent PNRR remodulation has further increased the resources available to implement it, projecting a target of 300,000 people involved by the end of 2025. The national telemedicine services platform will be the reference architecture for providing these services, which need specific choices regarding management, evaluation, and funding. By mid-2026, home care services should cover at least 10% of the population over 65 years old.<\/span><\/p>\n

The goal is to align with the best European practices, starting from a national average just below 5%. However, home care services are particularly necessary in a country like ours facing progressive population aging. Between 2020 and the beginning of this year, the average age in Italy increased from 45.7 to 46.4 years. Over 65s are more than 14 million, representing 24.1% of the entire population (they were 23.8% in 2022); those over 80 are 7.7%. Non-self-sufficient elderly people deserve specific consideration, and according to Istat, they are just under 4 million. These are significant numbers that make the average hours provided in integrated home care per case a measure of the system’s effectiveness in responding to the needs of vulnerable people. Well, the measure dropped from 18 hours in 2019 to 16 in 2021. Certainly, the pandemic contributed to the decline, but it is evident that the starting point is too low.<\/span><\/p>\n

Another part of this investment line consists of the 480 territorial operational centers (COT) available to professionals to facilitate patient transitions between different facilities in particularly complex cases: consider, for example, discharges from hospitals to another health or social-health facility.<\/span><\/p>\n

The last investment line concerns \u201ccommunity hospitals\u201d: 307 are planned, which are health structures with an intermediate function between home care and hospital admission. The Ministry of Health’s website helps us understand who the users will be: \u201cpatients who, following a minor acute episode or chronic disease flare-up, require low-intensity clinical health interventions potentially deliverable at home but needing continuous nursing care and monitoring which cannot be provided at home due to unsuitable home conditions (structural or familial).\u201d Practically, they are the response for cases where the hospital is too much and home or outpatient services are too little.<\/span><\/p>\n

A Revolution to Be Implemented Quickly<\/b><\/h3>\n

The main feature of the proposals designed by the more territorial component of Mission 6 of the PNRR is that they are not based on models imported from abroad but extend experiences with different names that some regions had already fully developed and others were trying to experiment with nationwide. In short, despite the complexity of the PNRR framework, there is an attempt to converge the entire National Health Service towards a unified and renewed vision of responding to citizens’ health needs.<\/span><\/p>\n

Is this a design to be implemented in the very distant future? No, the PNRR deadline set for 2026 imposes timelines linked to the liquidation of funding tranches. Therefore, two elements become relevant: the institutional capital (understood as trust in institutions and interpretation of public institutions’ prerogatives) of each region and the managerial capacities of regional health systems to seize the opportunity of these investments to redesign the entire care service offering system.<\/span><\/p>\n

Precisely because it is a Copernican revolution, the proposals are not limited to isolated \u201creformative grafts\u201d here and there but involve the \u201crevascularisation\u201d (as doctors would say) of the entire system. Designing community services according to the PNRR guidelines primarily challenges the hospital. First, because in the new system, the model of \u201cstationary teams\u201d of professionals in hospital locations can be associated with \u201citinerant teams\u201d that can move to multiple locations (such as community health centres) but above all can provide services in different forms: in-person visits, remote visits, even interacting with the patient through apps or other devices. Secondly, because the hospital’s identity itself transforms: how many of us have gone there for medical visits that could have been provided outside the hospital? Thus, the boundary between hospital and community (as often labelled, everything outside its walls) becomes increasingly blurred. Thirdly, because the complexity of medicine increasingly pushes towards multidisciplinary and multi-professional approaches, requiring responses to individual patient needs by aligning multiple professionals’ evaluations. The PNRR proposals seem to go precisely in this direction.<\/span><\/p>\n

The Missing Personnel<\/b><\/h3>\n

Another major chapter concerns medical and other personnel. According to the Ministry of Health’s website, \u201cin 2021 there were 617,246 employees in the National Health Service, personnel from local health authorities and public and equivalent hospital institutes (local health authorities, hospital companies, university hospital companies integrated with the SSN, hospital companies integrated with universities). In 2019, there were 603,856 in total.\u201d<\/span><\/p>\n

Italy is in an intermediate position between the UK and France\u2014both have 3.2 doctors per thousand inhabitants\u2014and Spain and Germany, which have 4.5. Our real problem lies in the numbers of nursing staff, the lowest among these countries and about half compared to Germany. The current debate focused on removing the restricted access to medical school instead of working on career paths and development for nursing professions, crucial for an aging population like ours.<\/span><\/p>\n

Citizens Must Also Change Attitude<\/b><\/h3>\n

In the new scenario, how can we not talk about the citizen? Each of us has a part in the script: first, we must become more aware and active in protecting our health by learning to prevent illness and slow its progression. Educating and informing citizens also improves adherence to therapies and the management of chronic diseases.<\/span><\/p>\n

But all this does not solve the funding problem. The PNRR cannot replace state budget resources: how can a country with a growing share of elderly people guarantee care and assistance if the percentage of public healthcare spending relative to GDP progressively decreases? The 2024 Economic and Financial Document certifies a healthcare expenditure\/GDP ratio of 6.3% for 2023; in absolute terms, healthcare spending was 131 billion euros. In the same year, Germany spent 423 billion and France 271, as the Court of Auditors’ report to Parliament attests. At equal purchasing power, Italy’s per capita spending is less than half that of Germany.<\/span><\/p>\n

To use an automotive metaphor, the PNRR is building an engine or rather multiple engines for the general reconfiguration of the healthcare service offering model. But without fuel, it will remain stationary.<\/span><\/p>\n

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

Rosanna Tarricone<\/strong> is Associate Dean of the School of Management at Bocconi University. She focuses on health policies and public health.<\/span><\/em><\/p>\n

Valeria D. Tozzi<\/strong> is an associate professor of practice in healthcare management and director of EMMAS (Executive Master in Management of Healthcare and Social Care Organizations) at the SDA Bocconi School of Management.<\/span><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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