by Claudio Maria Maffei
03 MAY –
Dear director,
I borrowed the first part of the title of the letter to three doctors (Jennifer L. Wiler, Nir J. Harish and Richard D. Zane) who on December 20, 2017 published a speech entitled “Do Hospitals Still Make Sense? The Case for Decentralization of Health Care,” in NEJM Catalyst Innovations in health care delivery, a digital journal of the New England Journal of Medicine Group. The subtitle of the speech was “The future is here: moving care out of the hospital and into the home and community”.
The intervention from which I stole the title comes from a very different healthcare system from ours such as that of the USA and from a period preceding Covid, but it is significant for an authoritative innovative approach, as in the spirit of the magazine, with respect to the role of the hospital in the health services network: “The exponential growth of digital and virtual healthcare, the development of advanced technologies increasingly rooted in the community and the transfer of part of acute care to outpatient levels creates the opportunity to move from a healthcare system made from large centralized facilities to care delivered in smaller, faster and more convenient facilities where healthcare becomes more accessible, more sustainable, more personal and closer to where people live – their home.”
Equally authoritatively, Lancet editor-in-chief Richard Horton wrote a piece last year entitled “Primary health care is not enough” in which it is stated that the current almost exclusive concern about primary health care condemns millions of people to illness, pain and death. And he concludes that this failure is unbearable. These statements refer to health in the world and especially to the poorest countries, but they serve as a reminder that specialist hospital care still plays a fundamental role in health protection in all healthcare systems. Richard Horton takes inspiration from oncology care, which not surprisingly in Italy too is characterized by a strong gap between North and South, a gap that significantly concerns hospital care.
Obviously there is no ongoing debate between the NEJM and the Lancet on the weight to be given to hospitals with respect to primary care, but the two interventions I cited are useful for reminding me that even in the highest level scientific journals the role of hospitals with very different points of view. This leads me to make some reflections on some recent interventions here on Qs regarding the hospitals of the NHS and therefore of Ministerial Decree 70. I am referring in particular to the two interventions by Ivan Cavicchi and Alessandro Giustini, to whose reading I refer because their articulated positions they advise against a summary, at least on my part. What they have in common is the “condemnation” of Ministerial Decree 70. Cavicchi states that “The only thing this minister wants to do is to comply with Ministerial Decree 70, that is, to resign himself to a fate of the declining hospital considered unavoidable when it is not”, while Giustini he writes that “we read great appreciation for Ministerial Decree 70 which contains full coherence with the errors in the approach to hospital activities in past years”. I mention these two interventions because they are recent and authoritative and because they represent a prevailing point of view at least here on Qs: in Italy we need more beds and in general “more hospitals”. Rather than repeat the considerations on the topic that I have already written here on Qs many times, I prefer to limit myself to once again proposing a different way of dealing with “the hospital question”.
Since the reorganization of hospital care continues to constitute a priority regardless of the point of view used (that of the “bone collector” rationalizers in which Cavicchi included me or that of the defenders of the hospital seen as a point from which reborn our healthcare system) we go into the merits of the individual issues that Ministerial Decree 70 addresses and we use the data that Agenas makes available to us in its Statistical Portal to verify the impact it has had in the different Regions to formulate targeted proposals for modification /integration. In the many interventions condemning Ministerial Decree 70, these data are never cited, just as the individual points of Ministerial Decree 70 which should be corrected are never or almost never cited. Simply speaking, few people look at that data and few people have read the DM 70 “extended version”. The temptation prevails to lump together all the enormous problems of the NHS together with Ministerial Decree 70 as the responsibility of politics and an inadequate managerial class: underfunding, imbalances between regions, failed personnel policies, growth of the private sector and lack of access to care. All real and very serious problems which however have nothing to do with Ministerial Decree 70. Ministerial Decree 70 is a technical act that politicians in many regions do everything not to apply in order not to lose consensus. Thus an alliance is effectively forged between those who do not want Ministerial Decree 70 and those who do not want to apply it. In this way a considerable (very considerable) amount of resources is spent to keep up dispersed hospital networks which are simultaneously inefficient and sometimes unsafe (think of the too many underused operating blocks and the emergency rooms and birth centers which are supported by cooperatives or too many underused operating blocks) and take resources away from local services.
In short, everyone united against Ministerial Decree 70. Luckily not everyone.
Claudio Maria Maffei
Coordinator of the Pd Marche Health Table
03 May 2024
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