The short blanket of the SSN: more needs than resources, choosing priorities

"In an ageing country that is seeing its active demographic base shrink, the National Health Service must abandon reassuring narratives and assume the courage of choices". This is the starting point for Francesco Longo, scientific head of the Oasis Report, published by the Research Centre on Health and Social Care Management (Cergas) of the SDA Bocconi School of Management, to arrive at the conclusion that "defining who comes first, with what services and with what intensity of care does not mean reducing universalism, but protecting it: it is the only way to generate value, reduce inequalities and design a SSN capable of facing the challenges of the coming decades".

The report's data are eloquent: we are in a historical phase in which citizens' needs are growing faster than the available resources. Italy, in fact, is experiencing a steady decline in the birth rate (370,000 births in 2024, -26% compared to 2014) and an ageing process that is among the most intense in Europe: in the last twenty years the over-65s have increased to over 3 million and life expectancy has reached 83.4 years. In parallel, the workforce is set to shrink by almost a third by 2050, with direct consequences on both tax revenues and the availability of healthcare professionals.

The Oasis report therefore recalls the need to set priorities without continuing to chase everything. "On the one hand," Longo continues, "the SSN must conduct a profound reallocation of resources to achieve true efficiency and sustainability, fewer small, unsafe and costly hospitals, concentration of departments, more efficiency in large hospitals. On the other hand, those who have a more intense, urgent and complex need must be protected first; we must define what intensity of services to offer; what information and accompaniment paths for those who are not a priority; how to integrate public and private spending'. These are 'the indispensable conditions' for making the universalism of the system sustainable and ensuring that chronic and frail patients are not left behind.

The Oasis Report identifies four phenomena that confirm the difficulty of the SSN in defining clear and shared priorities for intervention. Prescriptions exceed the system's ability to provide them, and only about 60 per cent of prescriptions result in a service under the SSN system, the rest are provided privately or feed tortuous paths (such as repeated prescriptions) and, sometimes, waivers in patients. Non-self-sufficiency is growing more than the system that should support it. The non-self-sufficient elderly number more than four million, but only eight per cent have access to an RSA; the inclusion allowance (ADI) covers 31 per cent of the frail, with the number of hours provided steadily decreasing compared to the pre-pandemic years. Wide territorial inequalities persist. The fourth and final sign of the NHS's difficulties is the use of health services in different and unjustified ways between regions and even within regions themselves: despite a substantially equal distribution of financial resources, the per capita consumption of services still depends too much on contingent and 'random' factors rather than on real clinical need.

Alongside the structural constraints, the Oasis Report identifies a number of areas in which action can be taken: working to attract nurses, less professional fragmentation, updating tariffs for private accredited providers, stronger and more qualified procurement, digitisation of general practitioners and multi-channel proximity. With 9,000 outpatient clinics and 2,400 Community Homes planned, Oasis warns that 'there is a risk of increasing fragmentation. True proximity is not only physical proximity: it means continuity, multichannel and a stable interlocutor, capable of responding throughout the care pathway'.