New health needs

“The availability of good medical care tends to vary inversely with the needs of the population served”: this concept was illustrated in “The Lancet” in 1971 by Julian T. Hart, a general practitioner who for thirty years treated 2,100 people in Glyncorrwg , coal mining village in South Wales.

Hart developed the theory ofreverse healthcare law (law of reverse care), which years later was translated into practice in Anticipatory Health Care, a model of care for chronic disease management that consisted of the early identification of treatable health problems in patients in a system managed by general practitioners, with the help of previously trained nurses, in a pre-established minimum visit / listening time, including assistance to patients who do not usually undergo checks and through the organization of groups of people with common chronic diseases.

The study, which recruited 1,800 patients and was carried out in the midst of the liberal reform of the Thatcher government, showed a reduction in mortality (30%), a drop in the average blood pressure of hypertensive patients and a decrease in the percentage smokers (from 56 to 20%).

Hart’s model was based on enhancing the role of general practitioners and the community. The experience of Covid-19 has reinforced this model, which must nevertheless today face a hospital-centred vision of care and an ever-increasing specialization of medicine.

If it is true that one should “never waste a good crisis”, as Winston Churchill once decreed, then the pandemic must be considered as an opportunity: that of having widened the gap between the new needs population health and the response that our model of care can meet those needs.

We must see the pandemic as an opportunity: that of having widened the gap between the new health needs of the population and the response that our model of care can provide.

According to the Osservasalute 2019 report, in Italy the over 65s will increase from 14 million today to more than 19 million in 2040. Likewise, in 2030 the chronically ill (diabetes, hypertension, obesity, etc.) will become 26.5 million and the multipathological ones will be 14.6. It is the latter that are the most worrying, because multimorbidity is associated, in addition to a poor prognosis, with a sharp increase in hospitalizations. To solve the problem, various realities in the Italian territory are implementing the made in USA model of the chronic care model, based on the transition from “medicine on hold” to “health on the initiative”, a process that, due to of its complexity, will not be so immediate. .

Linked to the increase in the number of elderly people, but also to diagnostic and therapeutic progress is the incidence of tumors, which every year in Italy see 377,000 new diagnoses and which require continuous assistance, under penalty of a negative impact on adequacy of care, patient compliance and survival.

Beyond that, there arises the age-old question of long term careas well as assistance after discharge and the need for strong integration between the health and social aspects, especially if the patients are single elderly people, fragile people or disabled people.

The situation is also aggravated by the large retirements of general practitioners, around 3,900 this year, according to estimates by the Federation of General Practitioners and the Union of Chief Medical Officers, who will not be compensated by as many new hires. Mountain areas often remain without medical coverage, where the problem worsens in proportion to the distance from the city and where job offers are notoriously less attractive for health professionals.

Several scientific studies have shown how, where primary care is stronger, a more equitable distribution of health in the population is guaranteed and the costs borne by the National Health Service tend to decrease.

According to the OECD, Italy ranks fifteenth among the 30 most developed countries in the world for spending on treatments and medicines, in which 9% of GDP is invested. If we then look at the beds before the Covid, which worsened their scarcity, Italy had 3.2 per 1,000 inhabitants, when the EU average was 5 per 1,000 inhabitants.

Thanks to the emergency, despite the lack of funds, we have been able to put into practice some tools and processes that have proven their effectiveness.

In terms of integration between the hospital and the territory, the organization of Special Continuity Care Units (Usca), made up of general practitioners, pediatricians of free choice and other professionals, has created an important postulate, ( re-)highlighting a proactive vision of medical performance. To counterbalance the prospect of greater territoriality, however, there remain the problems linked to the search for dedicated professionals, to their essential training, as well as to their fair distribution throughout the territory.

The need for isolation during confinement has prompted healthcare centers to practice telemedicine. According to the Osservasalute 2020 report, between March 1 and June 30, 2020, more than 170 digital initiatives were launched in Italy to facilitate patient management: more than half were web-based (38%) and the telephone (20%), the rest of the offer was made on platforms (29%) or applications (13%). More than 60% of televisions were dedicated to non-Covid patients.

The emergency has led to an increase in telemedicine and increased collaboration between specialists and general practitioners

Telemedicine tools have proven to be so useful that they will be maintained even in the “normalcy” phase. A step forward, yes, but often the categories of subjects who could benefit from digital technologies are precisely those who have the least access to them: the elderly, rural populations, low-income or low-cultural categories.

Again, the urgency meant that collaboration between specialists and GPs was strengthened and improved. In Modena, for example, the “on-call specialist” service has been activated, a telephone line with which general practitioners can consult specialists. The service has improved patient journeys, streamlined the work of specialists and enhanced the relevance of visits, examinations and therapies and will also be maintained in the post-Covid era.

In Parma, on the other hand, the multidisciplinary, multi-team mobile units born in the pre-Covid era to bring “the hospital to the sick” the elderly in RSA or at home, have been reinforced, avoiding having to go to the hospital. In the time of Covid, the Units were then converted to support the Usca. An example of assistance efficiency that could represent a model, perhaps in the perspective of having specialists also in the field.

Although still in the absence of a law that recognizes them, in the midst of the Covid emergency, projects have been born that have tasked community nurses, with dedicated clinics and linked to general practitioners, to guarantee a ongoing and proactive community support. remote reference. This figure is partly reminiscent of that of the family nurse, provided for by the Health Pact signed in December 2019 by the Minister of Health Roberto Speranza with the Regions, but never seen the light of day – due to the arrival of the Covid.

Moreover, the pandemic has demonstrated the indisputable validity of territorial structures and principles, such as community houses and community hospitals. Also thanks to this, the Pnrr 2021, aimed at promoting local medicine, has included among its objectives that of setting up or strengthening the two structures, which are however either little present on the national territory, or very unevenly present. Emilia-Romagna is at the forefront of the so-called “Health Homes”, physical primary care structures in which a multidisciplinary team of general practitioners, pediatricians of free choice, specialists, nurses works: it has 120 of them.

And precisely in Emilia-Romagna in 2021, the Region’s Health Commission has given its consent to the regional law – the first in Italy – to guarantee the general practitioner to the homeless, who in the rest of the country continue to be entitled to emergency services only. .

Significant progress, but the country still needs to progress, particularly in terms of a control room and uniform guidelines, in terms of the training of general practitioners and the integration of the different levels of assistance (primary, (ultra-) specialized and social) and faced with a huge disparity between regions. To pass from theory to practice, it will be necessary to deal with the will to invest in the structures, the tools and the training of the personnel and in a fluid communication hospital-territory.

At stake are the benefits of a successful balance between a field that could manage prevention, primary care and chronic disease and hospitals that could focus almost exclusively on acute cases and those requiring hyperspecialization.

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