by Giuseppe Belleri
30 APR – Dear Director,
the intent to reduce the inappropriateness of prescribing in defensive medicine, the objective of the soon-to-be-approved ministerial decree, is acceptable but not as easy.
The NHS emphasizes the citizen’s freedom of choice and equality between public and private companies but the affiliated, employed or accredited specialists do not always issue requests for further investigations deemed necessary to delve deeper into the clinical case at the end of the consultancy, as required by current regulations. . There is therefore the risk that the services suggested to the GP by other actors will be improperly attributed to the administrative responsibility of the first level, by virtue of IT procedures which do not allow the identification of the actual decision maker and first prescriber.
As a result of the induction of demand by supply, an iron law of health economics, the control of the system “must be rethought as the governance of the supply structures, which are in any case capable of inducing the demand they deem appropriate satisfy” (Longo 2004). Furthermore, it cannot be forgotten that alongside the excessive defensiveness there is also a defective inappropriateness, which is why “any strategy to reduce professional inappropriateness must be guided by the principle of ‘disinvestment and reallocation’, because in all care paths areas of overuse and underuse coexist” (Cartabellotta 2026).
Research published in 2006 in the journal Politiche Sanitarie (n. 4 October-December 2006) quantified the prescriptions issued by the GP at the suggestion of level II (employed, affiliated, accredited or private specialists) or of the patients. During the observation period, 19,063 specialist outpatient services were recorded (excluding biohumoral tests) with the following outcome: 40% of the requests attributed to the GP were induced by level II and to a lesser extent by the patients, a share which exceeds 60% for tests such as CT scans, MRI scans and scans.
On the basis of these data it is possible to draw a map of the complex ‘prescriptive system’, made up of interactions between NHS patients and level I and II professionals. Compared to 2006, the structure of the prescriptive system in the area has evolved due to the formal and informal impact of some regulatory, organizational and socio-cultural changes, which can be summarized as follows:
• in 2016, the LEA on tests was introduced, which obliges the prescriber to indicate the diagnostic question on the request and which authorizes only the specialist to prescribe certain tests subject to compliance with eligibility criteria;
• the priority codes of requests have come into force and at regional, ACN and Collective Contracts levels the rules which oblige the specialist to prescribe on his own initiative the tests necessary to answer the GP’s diagnostic question;
• after the pandemic, due to long waiting times, the demand for visits under a freelance regime increased, in which the doctor is not required to observe the appropriateness criteria of the LEAs;
• for these reasons, a growing number of citizens have taken out insurance policies supplementary to the services offered by the NHS;
• the patient, who in the meantime has become “demanding”, informed and sometimes demanding, does not limit himself to reporting his ailments but actively intervenes by requesting specialist services from the doctor (consultations, diagnostic tests, etc.);
• the extreme case is that of the patient who independently turns to a private specialist, bypassing the GP, who then requests the “transcription” in the NHS recipe book of tests of dubious appropriateness or in violation of the LEAs, resulting in controversy and tensions to the point of verbal aggression.
The combination of these trends has given rise to two parallel prescriptive systems, the divergence of which has induced a sort of dis-integration of healthcare, the distorting effects of which fall on the local doctor, forced by circumstances to take on the uncomfortable role as a mediator between holders of conflicting interests. The shift of balance towards the freelance area, evidenced by the proliferation of private specialist centres, is in itself an incentive to defensive medicine, self-guided by the convenience of private providers, who are also not required to observe the constraints of the LEAs . To rebalance the system, an increase in the public offer of specialist services, as an alternative to the freelance one, would be needed as a priority, to bring the provision back under the control of the NHS and inhibit defensive tendencies at the source.
It is doubtful that without this macro-systemic reorganization of the balance between supply and demand it will be possible to reduce the defensive inadequacy, unfairly placing the last and weak link of the prescriptive network in the crosshairs of the controls, on which the decisions of others fall and which despite itself it suffers like a lightning rod the contradictions generated by the divergence of the prescriptive system.
Best regards
Dr. Giuseppe Belleri
Former GP – Brescia
April 30, 2024
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