A ‘special management structure’ for doctors: the arguments in favour and the obstacles ahead

For many years now, medical and healthcare managers have come to symbolise the crisis in the public health service. The National Health Service faces many problems, almost all of which are difficult to resolve; yet the challenges facing healthcare staff – first and foremost doctors and nurses – are mounting and indeed appear to be getting worse. The issues do not merely concern pay or contractual matters but touch upon the very essence of the profession and the role it is meant to play in society; as mentioned, this applies in particular to doctors and nurses. The pandemic seemed to have shifted the paradigm regarding the recognition of the fundamental social importance of these two professions, but it has taken only a few years to return to a situation that, paradoxically, is far worse than that which existed prior to 2020.

It is no coincidence, therefore, that amongst the proposals put forward by the Anaao Assomed trade union during its last congress, one of the most important – and certainly the most strategic – is the recognition of the specific nature of medical and healthcare management, or what is termed ‘special management’. Until this becomes a reality – the trade union argues – it will be difficult to restore the central role of patient care. The medical profession has characteristics that are completely different from those of any other public sector manager. If doctors do not have the tools to organise and manage the course of treatment, they cannot carry out their work to the full. It is also for this reason that so many professionals choose to leave the National Health Service.

In reality, the proposal is not entirely new, as the largest doctors’ union has been advocating a different institutional framework for the profession for years. As far back as 2018 – when the magazine ‘Il Sole-24Ore Sanità’ was still published in print – the author had already highlighted the significant differences between doctors and the rest of the public sector management, stemming from distinct and indisputable specific characteristics. This is not merely a comparison of functions and prerogatives, but an objective identification of distinctive aspects, without any intention to emulate or compete.

Let us therefore review these characteristics. Given that having as its mission the protection of a right which the Constitution defines as a ‘fundamental right of the individual’ would in itself be sufficient to demonstrate the absolutely unique nature of the profession, perhaps the most striking of its distinctive features is the right to practise independently, whether within or outside a hospital setting. It is abundantly clear that this subjective right characterises the profession of doctors and other senior healthcare managers in a wholly exceptional manner and places them in a situation of delicate compatibility with Article 98 of the Constitution and Article 60 of Presidential Decree 3/1957, which, as is well known, impose the requirement of absolute exclusivity of the employment relationship on public servants in general.

From a regulatory perspective, there have been numerous exceptions over time to the general and common rules governing public sector management as they apply to healthcare management: pre-defined working hours, the continued existence of overtime, the option of part-time work (even if it is referred to as ‘reduced working hours’), the provision for a professional appraisal alongside a managerial one, an exemption from the obligation to publish salaries on the website, the regulation of working hours, rest periods and shifts, which was brought back into line with the requirements of Decree 66/2003 in 2018; and, in recent months, the scope of administrative liability, with the discrepancy between the Gelli-Bianco Act and the Foti Act. Whilst the undeniable specific nature of doctors’ work was a matter of debate until a few years ago, it has now taken on the characteristics of a genuine emergency – above all, in my view, due to two converging factual elements that were unknown until recently: the insurmountable recruitment difficulties in far too many specialisms, exacerbated by the simultaneous and widespread exodus to other fields of work, and the growing, shameful phenomenon of assaults.