The 'boon' of the NRP and the risk of wasting the great opportunity to relaunch Italian healthcare

Three years of the National Recovery and Resilience Plan which, like manna from heaven, has been an unprecedented mobilisation of resources to modernise the country. Yet, looking at what is happening in the field of territorial healthcare, it is difficult to escape a blunt question: have we really used this extraordinary opportunity to the full?

Italia has now entered what scholars call a 'mass senile society': today there are more than 14.5 million people over 65, or 24.1 per cent of the population, and more than half of them live with at least one chronic disease. Approximately 4 million elderly are not self-sufficient, and by 2050 this could become 5.4 million. This demographic transformation would have required a radical quality leap in territorial and home care policies. Instead, the Italia system continues to be characterised by a strongly familistic model, in which the burden of care falls mainly on families. It is no coincidence that the country has over a million carers, with private family expenditure estimated at EUR 7.2 billion a year.

In this context, the strengthening of integrated home care should have been one of the strategic axes of the reform. The numbers, however, tell a more ambiguous story. According to the most recent data, more than 1.5 million elderly receive ADI services, equal to 10.9 per cent of the population over 65, a value that formally exceeds the target set by the NRP. But behind this figure hides a much less encouraging reality. The increase in users has not been accompanied by an increase in the intensity of care. On the contrary, each elderly person receives on average about 14 accesses per year from operators, a decrease compared to previous years. Even more significantly, we are seeing a growth in 'fast' home care, interventions that are open and closed on the same day, which increased by 39% compared to 2021, while true integrated home care with an individualised care plan is decreasing. In other words, what is growing is performance ADI, not real care.

The result is paradoxical: the numbers increase, but the capacity of the system to take care of complexity does not. Added to this is another structural problem: the fragmentation of the system. An analysis of the regional models reveals a veritable 'regulatory jungle', with more than 90 regional provisions that regulate home care in an inconsistent manner and produce inevitable inequalities in access to services for citizens. With the aggravating factor that, at a time when professional resources are, to say the least, scarce, in most parts of the country the system remains substantially public-driven, with in many cases only one or two providers per health district.

The algebraic sum of these factors is a system that struggles to guarantee pluralism, freedom of choice and real responsiveness to needs. It is in this framework that an even greater question arises. The resources of the NRP have financed important infrastructures: community houses, community hospitals, territorial operating centres. But who will really work in these facilities? With what professionals, with what organisational models, with what integration between health and social care? If these questions are not answered, the resounding risk is to have assembled containers without having built the system of services that should animate them.