TRENT. “Today the Trentino it needs a real reform of local medicine. At present we have only been thinking about resources but a basic idea has been missing“. To say it in an interview with the Dolomites And Elisa Viliottinew president of Provincial health council.
Viliotti succeeds Renzo Dori, outgoing president and in office since 2019. There are numerous challenges and critical issues that the Trentino healthcare system finds itself facing: from the many transformations which will happen thanks to Pnnr funds to the lack of people up to the criticality of the birth points regarding which Viliotti explains: “I funds currently spent for the maintenance of birth points by way of derogation they could be usefully used to integrate the helicopter transport of pregnant women and for theextension of the territorial birth of Community path in order to improve all activities relating to pre- and post-natal”.
President, local healthcare doesn’t work. The emergency rooms are under attack because many white and green codes cannot find answers in the area. What should be done to prevent this situation from exploding?
Territorial medicine and socio-health integration must be reformed to take care of the most vulnerable, enhancing and investing in organizational care networks in concert with the implementation of the potential deriving from a Pnrr which aims to reform healthcare territorial with proximity criteria (proximity to users), according to an overall vision and planning, not limited to the pure design of the structures (Community Homes and Community Hospitals) to receive European funding, but which derives from a real co- programming based on the needs and requirements of people, implemented with stakeholders and, primarily with the provincial health and social councils, which are the representative bodies of the associations, cooperatives and social enterprises on which the maintenance of the territorial health unit. We therefore need to reopen the debate on local medicine, thinking about integrated systems, the new role of the District and its real management capacity, the reform of RSAs, community homes as a point of reference for proactive and local medicine, the function of continuity of care and rehabilitation support of the Community Hospitals and, therefore, on the implementation of the Pnrr (DM 77/2022), because at present the focus has only been on resources but there has been no basic idea of reform concerted with all social-welfare and social-health categories, to think about the role we want to give to the territories and the capacity for co-programming and co-planning between Apss and the Third Sector. It is necessary that company management not only dedicates itself to defining the emergency but acts based on an overall vision.
One of the aspects that lead us to talk about a system in collapse is the lack of personnel. Do you believe that medical school can help?
The shortage of medical health personnel in all provincial services, and in particular in general medicine, must be addressed according to a future vision of healthcare and not with stopgap solutions such as increasing the number of patients. We need to lighten the bureaucratic part and equip GPs with simple initial diagnosis tools to avoid and reduce the need for specialist services. Special efforts are needed in the valleys to make affordable housing available. The medical profession must be made attractive to very young people, to ensure that an increase in places in the Faculty of Medicine corresponds to a real increase in enrolments, also considering that in Trentino general practitioners over 55 are 69% and paediatricians of free choice 65%. In general, adequate economic incentives are needed for all healthcare professions, considering that an Italian doctor earns 70% less than a German colleague and 40% less than an English colleague and, in this context, the salaries for token doctors are growing , to which a maximum ceiling should instead be applied, if anything differentiating the disadvantaged locations to make them more attractive. The issue of self-employed freelance doctors has negative repercussions both on the internal organization and on the healthcare system as a whole. Internally in healthcare organizations, not being integrated into the care team, token operators feel less responsibility, guaranteeing less appropriateness of care, not having any corporate objective, then there is the risk of conflict linked to a notable disparity in pay with colleagues and the possibility of decide how much and when to work, with a bargaining power that is too strong and ethically questionable. With retirements in sight, if there is no cap on compensation, healthcare spending is destined to explode. We need to invest in attractiveness and the ability to retain, creating unique, high-quality professional services and experiences, increasing the contracts of healthcare personnel and thinking about an incentive system linked to the actual skills of the professional and based on merit, as well as improving the organizational climate.
Critical issues have been highlighted in keeping the Cles and Cavalese birth centers open (by way of derogation). What do you think? There is a security issue, what should politicians do?
Our position has always been inspired by the need that every health service and, therefore, also Birth Points, must guarantee maximum safety, in this case both for the mother and the unborn child. The literature maintains that the low volume of activity of a birth center can, in fact, constitute a critical element with respect to the skills expressed by professionals, especially with regard to obstetric and/or neonatal emergency/urgency situations, and this requires constant rotation of the assistance staff of the Birth Centers opened in derogation with the larger ones. This risk condition, which also applies to professionals, does not facilitate the recruitment of doctors willing to work in the suburbs. Beyond the costs disclosed by the Court of Auditors, priority must be given to the safety of services in the choices that politics is called upon to make, first and foremost verifying compliance with the standard operational, safety and technological requirements indicated in the State-Regions Agreement 16 December 2010 on the guidelines for the birth process, such as the presence of a 24-hour active guard of anesthetist, obstetrician, gynecologist, pediatrician as well as all the other required requirements. It should also be considered that many pregnant women from that valley prefer to go to S. Chiara because they feel better protected and this further burdens the operational functionality of the Birth Center in Trento. The funds currently spent for the maintenance of the Birth Points in derogation could be usefully used to integrate the helicopter transport of pregnant women and for the extension of the territorial Community birth path in order to improve all activities relating to pre- and post-birth.
The private sector is managing to conquer more spaces. Do you believe that public health is in danger?
There is no opposition in principle to the provision of healthcare services by the private sector, the approach is to protect the public healthcare system to safeguard the constitutional dictates of universality, equality and fairness of care. In Italy, 300 hospitals have been closed since 2009 and 80,000 beds have been lost. Accredited private hospital facilities have doubled in the last 10 years, private specialist outpatient facilities have gone from 5587 to 8778, private facilities for residential care have gone from 4884 to 7984, private facilities for semi-residential care have gone from 1712 to 3005, private rehabilitation facilities from 746 to 1154.
Even at the provincial level, there is growing concern about the increase in the allocation of resources to the private sector, taken away from public health services. The private sector does not feel the duty to respect these constitutional principles, inspired by the logic of profit, with the risk that healthcare becomes less accessible and an increase in the number of people who do not seek treatment and this is not acceptable.
Regarding spending for the private sector and what was said by councilor Tonina who, examining the data from the Court of Auditors, speaks of a burden of 80 million euros, I would like to point out that in truth the indirect costs from services reimbursed to citizens are not calculated and the costs borne directly by private citizens. How much does having to resort to private care affect the family budget because the waiting lists are prohibitive?
Why don’t we try to build an aggregate data, accessing the tax returns and in particular the deductible expenses of Trentino people? That is collective spending on private healthcare. It will not affect the public budget but it does affect the budgets of all citizens.
Then there is the question of waiting lists for visits and operations.
It is necessary to delve into the merits of each individual waiting list to understand how they are constructed and where the critical issues arise, analyzing both the coherence of the provision of services by the health system with respect to the demand for health and the organizational deficiencies and lack of supervision of the list management system. In my humble experience as President of Avis del Trentino, I encountered the problem of a waiting list of 1,300 aspiring donors waiting to take blood tests, which, over the years, not only persisted but increased. By promptly going into the organizational merit of collection unit by collection unit, we managed to eliminate it in a short time. By this I mean that we need the courage to question an organizational model that is now consolidated but not therefore functional. Going into the merits of the organization of each individual waiting list, punctually, understanding its functioning, but also identifying the users who are stalling due to the availability of the service offer while remaining on the list. Failure to reverse the trend will have repercussions on access to care, forcing less well-off citizens to renounce the right to health, causing excessive pressure on emergency rooms (white and green codes), forcing citizens to turn to expensive private healthcare which presents itself waiting lists or even no availability for certain types of diagnostic tests. Furthermore, it should be noted that in the 2024/2026 budget forecast the resources allocated to reduce waiting lists have not been increased.
He recently assumed the role of president of the Health Council in Trentino. Given the situation we are facing, what is your appeal to politics?
The public health system must be placed at the center of the political agenda and supported by adequate resources, reversing the drift towards the private sector, considering the financing of public health an investment and not a cost to be contained in the public budget. Trentino enjoys numbers, availability of resources and valuable professionals, we need to regenerate the system to make it virtuous
