Health service sustainability and chronic diseases, reviewing competencies is the necessary and urgent step

In essence, great differences are observed in the outcome, in relation to what has been invested, once again with an absolute preponderance of this phenomenon in the southern regions. Such a marked difference cannot be justified, also in the light of the fact that the North has slowed down the performance growth that allowed answers to the citizens of the South. Hence, organisation is seen as strongly conditioning outcomes, to the point that it must be adequately reviewed to limit the lack of equity for citizens. The focus of healthcare action was, until 2019, channelled to what was the dominant problem, i.e. the taking care of chronic diseases. The pandemic has profoundly changed the existing horizon, presenting the healthcare world with new challenges, new arrangements and new perspectives. Covid has highlighted the disastrous demolition operation on the Prevention Departments, which are considered a source of additional funding to cover other sectors and are often reduced to receiving a 2% share of the company allocation, as opposed to the 5% provided for by law. The country's well-established vaccination culture has lost ground due to a substantial inability to adapt the information systems: the societies have thus become enemies and hostiles rather than supporters of those policies that, over the years, have eradicated diseases that return to knock on the doors of our nation with potential risk for the entire population. General medicine and primary care have practically disappeared from some territories and, although they have paid a heavy price for the epidemic, they have shown a lack of flexibility in reshaping their professional standards. Pharmacists have seen the 'Service Pharmacy' project strongly consolidated, having contributed with vaccinations and swabs to the health response against Covid.

The National Recovery and Resilience Plan had brought a breath of optimism, leading us all to think that we would finally arrive at a rebalancing of the hospital and territorial supply, with a consequent optimisation of pathways and a recovery of the gap accumulated in past years on chronicity, which was once again becoming the primary object of organisation. In actual fact, today we are witnessing worrying delays in the construction of Community Hospitals, sanctioned by the recent Agenas Report on the last six months, and even more significant delays in community hospitals, which are not clearly identified, since they are completely different from real hospitals, but are often treated as if they were, with obvious difficulties for operators, who are often called upon to work in facilities that are 'read' as emergency rooms, but which, in reality, lack any equipment or services to be considered as such. Another obvious problem lies in the lack of awareness that the PNRR is an episodic event that will have to become a current expense and historicise what has been achieved, in order to enhance the taking in charge. Who and, above all, how will the nurses be recruited and paid, through whose work care targets such as 10% of the over-65s in ADI will have to be reached? Strange, moreover, is also the fact that spoke community homes, which are valuable in guaranteeing proximity to service provision, have disappeared from the scene. In truth, there is evidence of movements that would suggest the entry, in this specific role, of private or partially private facilities, the nature, location and accessibility of which should be clarified in order to characterise precisely and transparently the standards and sources of financing.

If in the case of doctors, the problem is sectoral, i.e. related not to the absolute number of doctors working, but to the coverage of specific specialist branches, the case of nurses appears much more complex. There are far fewer applications for degree courses than there is need, and migration abroad is increasingly frequent, with professionals attracted by salaries that are far higher than those offered by Italian facilities. The very recent case of San Raffaele testifies, in clear terms, the crisis of this professional world, a crisis that must be addressed and 'attacked' by numerous interventions that, in addition to the revaluation of salaries, include the possibility of career development that can overcome the axiom: 'born a shift worker, die a shift worker'. It is worth reiterating, however, that these processes take a long time and must be accompanied by structural reforms of care. The variables, to date negative, where the system operates must be considered. By this we mean identifying a work site that must remain open and coexist with transformation and renewal interventions. Without prejudice to the fact that the first variable is the underfunding to which, moreover, an initial response has been sought with the next financial act, it remains to be defined how to recover the precovid condition, i.e. the need to provide territorial responses that are finalised and, above all, integrated between social and health, given the changed nature of needs, which are often social in nature.

The rising number of chronic patients sees two tracing lines to be codified. The first one is represented by the early taking into charge, the identification of subjects at risk and the consequent implementation of everything that can lead us to an initiative medicine with two defined protagonists: the primary care physician with a single role and the community nurse. Beyond the logistical difficulties mentioned above, there is the feeling that there is a substantial awareness and adherence to this binomial in an AFT perspective and under the direction of the District.

Much less clear and well-defined is coming into contact with the world of professionals that unfolds from the nurse onwards. These are subjects with 'variable geometry' who see the socio-health professional as their first point of contact but who often enter the care system as caregivers or carers. The first difficulty in impacting these figures is the knowledge base to which they belong. Doctors and nurses are certified by a university diploma that defines their contours, social and health care workers (Oss) have, on the other hand, attended courses of a varied and sometimes questionable nature, with training bodies or agencies that raise some perplexity as to the nature and modality of the contents proposed.

Carers and caregivers, even, may have had no training other than that derived from an experiential experience, conditioned by economic need (carers) or family needs (caregivers). Obviously, in the second case, there may be a rejection and a distance from any empathic aspect, to the point of considering the role as a heavy and conditioning frill in one's personal life.

It is worth reiterating, however, that the role of the elderly and the inescapable care burden they bear is experienced as a burden on society. This is certainly true, but it is no coincidence that a few years ago Marco Trabucchi, President of the Italian Society of Geriatrics and Gerontology, spoke of 'third age, third economy' precisely to emphasise the positive financial inducement given by the consumption of drugs and devices, by the genesis of new professions that the chronically elderly patient pours into the industrial and commercial world. Longevity, today, is certainly an economic lever. It should also be noted that the ratio, reported by O.C.S.E.'s Pensionsat a glance2025, between people over 65 and the working age population will increase in Italy to 53% in 2050, with obvious pension implications. The sustainability of such an articulated system will not allow the coexistence of forms of (undeclared) work that will have to emerge from tax avoidance and necessarily become part of state financing

In essence, it seems impossible to increase the specific financing of chronic care or to increase it proportionally to the increase in their number. What appears, on the other hand, to be possible and in some respects optimal is to offer care where there is a redefinition of competencies, and redistribution of responsibilities.

Starting from this concept, nurses can certainly become responsible for the out-of-hospital care chain, assisted by re-engineered OSS on a training pathway that homogenises their knowledge and broadens their scope of action. The doctor remains the sole protagonist of diagnosis and treatment, but the management of the care pathway (Rsa, community hospitals, etc.), takes place between nurses, coordinators and OSS. The entire extra-hospital network should move with this structure, creating a further link with carers and caregivers whose aptitude is certified in registers that define their attendance of training processes that assimilate these figures to what the Oss is today.

Re-evaluating skills would legitimise and, at the same time, verify not only skills, but also the quality that the state finances in any case, whether through healthcare or pension and/or care allowances. More trained personnel could certainly make more facilities usable, which today may suffer delays in operation due to lack of staff. This is a long path to be followed through successive stages but, in the long run, certainly capable of offering correct answers to needs that, let us reiterate, are absolutely foreseeable and cannot be absorbed by staying at home alone. The family and the home remain the main place of care outside the hospital: usability cannot be left to a problem of relatives' conscience, but must be supported by an innovative definition of figures who enhance the natural capacity of family members to respond. Maintaining a certain degree of equity and respecting the dictates of Article 32 of the Constitution, which have already been partially superseded by the current situation, run the risk of generating extreme situations such as the request for differentiated autonomy already made by some regions. There will be a process where these requests will have to be examined and defined with great care, as they could generate a further increase in inequality phenomena that, to date, are true pathologies of the system. The reform table must be quickly orchestrated. The speed at which we are rushing towards other forms of management is very high.

On the one hand, it generates doubts about the possible dramatic expropriation of some of the contents that are essential to the performance of the profession, and on the other hand, the hope that the 'modus operandi' can be facilitated and streamlined by simplifying the burdens linked mainly to bureaucratic formalities, which today weigh heavily on the working time of doctors and nurses in particular.

* Coordinator Chronic on