“New ideas for a fair and sustainable National Health Service”: this is how 15 universities aim to safeguard the right to healthcare

1) In order to maintain the universal nature of healthcare provision, it is considered necessary to adopt a governance model that distinguishes the function of health protection from that of service delivery, and which is capable of implementing models for health promotion and demand management, whilst ensuring the coordination of public and private funding, whether through intermediaries or out-of-pocket payments; In practical terms, a governance structure comprising three concentric levels is proposed: a) the ‘One Health’ approach addressing the determinants of health; b) the health services system, comprising all economic sectors and the entities operating within them; c) the National Health Service (SSN), that is, the collective body of public and private entities, funded and regulated directly by public intervention.

2) It is also considered necessary to define priorities (see the full document setting out proposals on the criteria that could be adopted) in order to avoid the abstract assertion of rights that are not always effectively enforceable; In practical terms, it is considered that the principle of promising only what can be delivered in terms of planning, system funding and the definition of the service provision structure should be applied: unless they expressly waive this right, citizens should be entitled, at the time of referral, to a corresponding booking within a reasonable timeframe in accordance with scientific guidelines, such as to safeguard the continuity of care (with a permanent healthcare professional) and ensure the accessibility of the facility, whether in person, digitally or via multiple channels.

3) Equity should be understood as the ability to provide ‘different services for different needs’, so as to reduce disparities in health outcomes, achievable through appropriate stratification of the population that also takes into account the level of health literacy and the consequent propensity to adhere to treatments and care pathways, as well as the capacity to promote proactive health interventions aimed at the timely and early identification of even unstated social and health needs

4) In order to reduce geographical disparities, it is considered necessary to ensure the mobility of the (best) professionals and the use of remote technologies in every region

5) With regard to humanisation, in order to encourage patients’ involvement and participation in their own care journey, the concept of care as a relationship must be adopted, so as to draw on the patient’s own resources; To achieve this, it is necessary to promote communication channels and tools suitable for reaching different population groups, developing an information process that takes into account culture, educational level, sensitivities, language, ethnicity, religion, gender differences and all other types of diversity, as well as implementing integrated measurement systems, such as PREMs and PROMs

6) Funds allocated by the National Health Service (SSN) for those who are not self-sufficient, municipal social care funds, INPS carer’s allowance funds, national and local funds for long-term care (LTC), and funds for supported housing should be gradually merged into a single LTC fund, managed by local health authorities at district level, in agreement with the local authorities

7) Decisions on major public or private infrastructure investments and, more generally, on all public policy, should (without adding to the bureaucratic burden) be subject to an assessment of their impact on health determinants, which should also form part of the multidimensional assessment process for Equitable and Sustainable Well-being (BES).

8) The State’s remit should include: a) the establishment and revision, on the basis of an assessment of regional performance, of a list of the types of health authorities from which the Regions may choose, together with their respective institutional structures; b) the definition of different levels of regional autonomy, to be graded according to performance achieved in terms of health standards, equity and economic balance, in accordance with explicit criteria and rules; c) the development of a national management cadre for the National Health Service (SSN) serving the entire system, geared towards the transfer of responsibilities across all contexts

9) The powers of the Regions therefore include: a) the ability to establish organisations with different missions and strategic directions; b) the trialling and introduction of flat-rate payment schemes for private contractors; c) the establishment of a legal framework for the adoption of institutional and contractual arrangements between health authorities, local authorities and other public and private bodies for the integration of social, health and care services; d) the coordination of the network of public and private stakeholders within the health services system;

10) The demand for professionals – which forms the basis for coordinating university admissions planning with the Ministry of University and Research (MUR) – must be determined at central level on the basis of population trends, epidemiological trends, knowledge, organisational models and the resources available within the National Health Service (SSN) as well as in the private healthcare sector, and coordinated with the plan for care professions, which is necessary for social and healthcare integration.

11) Companies should be permitted to recruit staff on non-standard contracts (public sector contracts with additional incentives, private sector contracts or freelance arrangements) up to a maximum of 5 per cent of the staffing requirements set out in the plan. Remuneration may exceed the National Health Service (SSN) contract rate by up to 30 per cent, subject to a maximum company budget for this purpose agreed with the Region, with provisions also made to take account of the varying levels of regional autonomy achieved.

12) The general managers of the National Health Service (SSN), who form part of a national management body, may be freely appointed by the Regions from among those registered on a national register; their remuneration must be aligned with that of senior state executives, comprising a fixed component of 70 per cent, 15 per cent variable depending on the achievement of targets and 15 per cent variable depending on the complexity of the healthcare trust, with an additional lump-sum allowance provided for general managers working off-site in another region; for other senior positions, the maximum ceiling would be 80 per cent of the Director-General’s fixed remuneration.

* University of Rome Tor Vergata and C.R.E.A. Sanità (on behalf of the authors of the document)