Health and territory: a strategic document with limits

The territorial health planning document has many merits and strategic importance. However, it raises some problematic aspects, which should be resolved immediately. From the insistence on physical localizations to the territory-hospital fracture.

The boundaries of community houses

The so-called Dm71 is the accompanying document for component 1 of Mission 6 (health) of the Recovery and Resilience Plan, which will be launched soon by the government. It is centered on the development of territorial networks of services, with an effective presentation of the principles, actions and reference standards. In a previous contribution, I pointed out the problem of the consequences this will have on current expenditure. I analyze here some critical points of the document, without however wishing to diminish its considerable merits and its strategic relevance.

The first critical issue concerns community houses, an extension of the old definition of nursing homes to emphasize their openness to social issues as well. The presence on the territory of physical places is certainly important where patients find a single and global point of reference for their health problems and where professionals find spaces for socialization and coordination. But in some ways it’s a bit of an outdated approach, in a society where more and more services are accessed electronically and physical credentials are becoming less crucial. For example, most citizens are not looking for a physical location to book services or receive a wide range of services. He expects well-functioning telephone and online reservation systems and access to nearby facilities. This seems particularly relevant in large urban areas and where computer literacy is more advanced.

Providing homogeneously throughout the national territory the same model of community house appears inappropriate and perhaps even unrealistic, given that in some regional realities (Emilia-Romagna, Veneto, Tuscany) they have already been established for some time, so whereas in others they are virtually unknown (Lombardy and most southern regions). It is also a matter of population stratification: young people expect quick and easy access to services, even at the cost of less continuity of care, for example withwalk-in centers“, places where you can easily access a medical service without a reservation and without necessarily being seen by the general practitioner you are registered with. Many of these, probably, would also rely on automated systems for which, for minor problems, indications and prescriptions are given on the basis of validated and tested algorithms (see the example of Babylon UK).

For middle-aged patients, on the other hand, the main issue is the prevention of chronic diseases and easy access to screening. Here, strengthening prevention, inside and outside community homes, becomes central and access to testing must be facilitated with electronic booking systems and choice of location where the service is provided. . Finally, for the most vulnerable people, for whom the community home certainly has more meaning, the central theme becomes the continuity of care and the ability not only to offer local services, but to facilitate assistance to the patient’s home (as on the other hand, foreseen by the ambitious increase in the coverage of these services for the over 65s).

In summary, we can say that the community house is certainly an important element in strengthening territorial support, but it risks offering a model that is somewhat behind in terms of demographic and technological dynamics and service use profiles.

The second critical aspect concerns the development of a planning document for territorial assistance distinct from hospital assistance. If on the one hand this is understandable for a rebalancing action, compared to the Dm70, on the other hand it risks favoring a dangerous fracture. The hospital is and will remain the center of specialized knowledge and skills and as such will continue to be the point of reference for the diagnosis and treatment of patients with acute events, but also chronic diseases. As psychiatry teaches, the most suitable model for combining proximity, territoriality, specialization and hospital services lies in departmental logics combining hospital and territory. There is no mention of the issue in Ministerial Order 71 and this could lead to a dangerous division of health care with two areas, provided that territorial aid really manages to take off, without coordination between them. But perhaps, trying to be optimistic, the question of the recomposition of hospital-territory relations could be the next step in the planning process.

Functionality and efficiency

Then there is the question of functionality and efficiency. The establishment of local structures poses the problem of the number of users and the availability of professionals. For example, for family clinics, there is a standard of one clinic per 20,000 inhabitants, up to one per 10,000 inhabitants in rural and interior areas, including those where fertility is lower. This is an unrealistic and clearly ineffective standard. Referring only to the birth process and neonatal care, it would be a matter of providing the National Health System with a clinic for 60/70 children born per year (30/35 if the norm is one clinic for 10,000 inhabitants ). Among other things, the birth process cannot remain completely inside the houses of the community because it necessarily involves interventions to be carried out in the hospital (for example amniocentesis). But even if we want to consider the whole part relating to reproductive health, we must take into account the fact that the needs of young people (for example on the contraceptive part) have changed substantially with the radical socio-cultural changes they have observed, both at the level of families and at school, greater attention to these matters compared to 30 or 40 years ago, when the consultors were promoted and established. The issue of the mental health of young people, particularly affected by the pandemic crisis, is different. But here we need a broader rationale, which recognizes the need for greater NHS engagement for psychological issues that are not serious and a link to mental health centres.

In summary, the PNR is also a great opportunity for health because it provides resources for structural and technological investments, but leaves open the question of the consequences on current expenditure. Moreover, although innovative and with a good synthesis between principles, actions and standards, the Dm71 has significant limitations that should be addressed quickly.

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John Fattore

Giovanni Fattore studied at Bocconi (BA in Economics and Social Disciplines), Harvard (MSc in Health Policy and Management) and LSE (PhD in Social Policy). It deals with health policies, medicines, nutrition, health technology assessment and public administration reforms. He was Director of the Department of Policy Analysis and Public Management at Bocconi University where he is currently Full Professor of Business Economics, SDA Lecturer and Senior Researcher at CERGAS. He is associate editor of Health Policy and a member of the board of the IRCCS San Matteo di Pavia Foundation.

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