The general practitioner: a missing protagonist in care

Every day in the wards and emergency rooms of hospitals and university polyclinics, the irreplaceable value that the general practitioner, known in the not so distant past as the family doctor, should have is clearly felt. Proximity general practice is the first health service, the one where the professional knows the patient's history, his family and his social context. And yet, in the face of demographic challenges and the growing complexity of chronicity, the current model, while valid in its basic approach, must be modified and strengthened to ensure closer collaboration and continuity between territory and hospital.

This is well known by citizens and the sick, who experience the difficulty of what should be the first contact with care: surgeries open a few hours a day with doctors in difficulty and overburdened by bureaucracy and an excessive number of patients that often exceeds 1,500. Hence another emergency affecting proximity care: more and more citizens are finding it difficult to find a family doctor, especially in densely populated urban areas. Not only that: the inconveniences increase in rural areas where incentives for young doctors called upon to replace retired colleagues are not enough. Then there is the bewilderment of the elderly and lonely, left without a doctor, who are unable to find another one close to home and are forced to travel up to 30 km. It is precisely from this daily experience that the need for a strong, integrated and protagonist proximity general medicine emerges forcefully, and never just a spectator of the care pathway. This is the only way in which the family doctor can return to fully exercising his role as coordinator of the integrated care of chronic conditions: to perform first-level examinations on the territory in community homes, to manage primary and secondary prevention programmes, and to treat diabetic, decompensated or Bpco patients on an ongoing basis, to coordinate in real time with the hospital specialist and to avoid duplications and interruptions in the treatment pathway. He becomes, in short, the patient's true 'case manager'.

It is within this framework that Minister Orazio Schillaci's decree-law on the reform of general medicine is set. It is by no means a matter of dismantling a profession, as the most blind defenders of the current situation have said, but of releasing its potential and finally making it a protagonist. The measure introduces a voluntary double track, a reformed convention with greater integration in the territorial structures and a dependency relationship with the National Health Service for those who choose it, which allows family doctors to work in multidisciplinary teams within the Community Homes, which have just been financed with an investment of 2 billion euros from the NRP. On the other hand, the reform restores professional dignity to the general practitioner, putting him back at the centre of the care pathway, where he should be: no longer an isolated figure, but a coordinator of the integrated care of chronic conditions. A virtuous model in this sense already exists in Europe and shows how the structural integration of general practice produces concrete results.

In France, the Maisons de Santé Pluridisciplinaires or multidisciplinary centres, created in 2007 and enhanced by the 2016 law, have strengthened the collaboration between family doctors, nurses and other professionals, improving continuity of care, reducing inappropriate accesses to emergency rooms and relieving the pressure on hospitals, without affecting professional autonomy. In Spain, the great primary care reform of 1984-85 created Health Centres with territorial multidisciplinary teams (family doctors, nurses, paediatricians and other professionals), guaranteeing comprehensive care, prevention, home care and community activities: a system considered among the most solid in Europe, highly cost-effective and capable of improving the population's health outcomes thanks to strong hospital-territory integration.

Again: in Germany, integrated care models based on the Hausärzte (family doctors) and the Medizinische Versorgungszentren (Mvz), multidisciplinary centres, have enhanced the gatekeeping role of the proximity doctor within coordinated networks with hospitals and specialists, as demonstrated by successful experiences such as Gesundes Kinzigtal, where multidisciplinary management has reduced chronic exacerbations and optimised the system's resources. The benefit for the patient is extraordinary: true continuity of care.