Primary care reform: family doctors between convention and community house recruitment

But besides the risk of not opening them all, the real big fear is opening them without the staff inside, starting with the doctors.

Orazio Schillaci

Ministro della salute

orazio schillaci

That is why Minister Schillaci - after two agonising years of discussions with the regions on a possible reform - decided he did not want to wait any longer.

'The decree,' reads the outline of the guidelines of the possible decree-law, 'was created to ensure that the Community Homes are fully operational. The urgency is linked to the need to make the new model of territorial assistance concrete and functional.

The objective is not only organisational, but systemic: strengthening primary care, caretaking and territorial continuity'.

For the Ministry of Health, the Community Centres are the 'core of the reform', becoming the 'structural place of the new territorial organisation' and the decree will in fact have to clarify that the activity within them 'is no longer only incentivised but becomes a stable component of the organisational model'

As mentioned, the decree constructs a dual-channel structure: the ordinary channel with the current but 'reformed' convention and then the possibility of hiring doctors as employees, a second channel with a 'selective dependency' for structured territorial functions.

This dual channel, according to the ministry's technicians, should make it possible to maintain the capillarity of general medicine by introducing 'a stable garrison where more organised and continuous functions are needed': that is, in the Case di comunità (community centres).

The convention will still remain the ordinary model so as "not to abolish the relationship of trust", but the contracted doctor will be redefined, introducing minimum obligations and also changing the method of remuneration, which today is by per capita share, that is, the number of patients the family doctor looks after, but in future will have to be by "objective" (from taking care of chronic patients to the hours spent in the community home).

There will be a national minimum organisational debt that can be modulated territorially, therefore not rigidly in a uniform manner that includes at least the work in the territorial network, the presence in the Community Houses, the use of information systems, the adherence to indicators and audits also to monitor the prescriptive appropriateness is multi-professional integration.

This debt - the Ministry's guidelines write - is 'one of the main tools for making the system enforceable and measurable'.

The decree does not, in the first stage, transform all general medicine into dependency, but introduces a 'selective dependency', planned and not generalised, which is necessary to 'cover the most organisationally intensive functions'.

In the transitional phase, the local health authorities may 'employ on a permanent basis doctors already working in general medicine who also have a specialisation'.

Access will be on a 'voluntary basis', within the limits of the planned quotas for structured territorial functions. The choice is therefore 'gradual, selective and planned'.

With the regions assuming a central role in planning. It will be up to them to define the needs for activities in the Community Homes, the territorial priorities, garrisons and functions to be covered, the minimum organisational and information standards, and the contingents and locations of the dependent channel.

In short, the decree aims to enhance 'strong territorial governance within a common national framework'.

The aim in fact is to move towards an ordinary transition phase and without affecting the accounts of the Enpam, the social security body that collects the contributions of family doctors. For this reason, the decree will also have to provide transitional regulations to clarify various aspects: from access qualifications to equivalences, and the coordination between the old conventional relationship and the new employee relationship