Too many prescriptions? More than supervising doctors we need organisational appropriateness

An analysis by the Istituto Superiore di Sanità puts the spotlight on the the issue of appropriateness of care. The data invites reflection, but the debate cannot turn into a questioning of the clinical autonomy of the doctor, nor ignore the crucial role of places of care. Approximately 10% of the healthcare services provided have inappropriate profiles. In Italy, inappropriateness in healthcare is worth around 25 billion euro. The phenomenon manifests itself in two opposite but equally problematic directions: the so-called 'over-use', i.e. the excess of unnecessary examinations, therapies and hospitalisations, and the 'under-use', i.e. the failure to provide appropriate care to those who would actually need it.

An emblematic example comes from the ISS CeDAP 2024 report on the birth rate: in 77.1% of pregnancies, more than three ultrasound scans are performed, compared with only two recommended by national guidelines. An excess that configures apattern of inappropriate prescription and excessive medicalisation of care. It is now clear that there is a problem not only with investments in the NHS, but also, and perhaps above all, with the allocation of resources and their use.

Faced with this data, however, the most insidious risk would be to draw hasty conclusions from it, turning epidemiological analyses into a surveillance tool or a tool for squeezing the physician's professional autonomy. This would be a serious mistake, as well as conceptually incorrect. Moreover, such an error has already been made in the evaluation of waiting lists, confusing analysis tools and data. Clinical appropriateness is by definition a concept that is measured on the concrete patient, not on statistics.

As the ISS's own National Guideline System recalls, clinical recommendations are decision-support tools and not rigid prescriptions: Law 24/2017 (the so-called Gelli-Bianco law), moreover, expressly states that the healthcare professional must adhere to the guidelines 'without prejudice to the specifics of the concrete case'. This clause is not a bureaucratic loophole: it is the recognition that medicine is a science applied to individuals, not categories.

The doctor who prescribes an extra examination because he knows his patient's medical history, family background, co-morbidities or diagnostic anxiety is not necessarily committing an inappropriate act. That decision belongs to his professional sphere, his therapeutic relationship and his ethical responsibility. Confusing prescriptive variability with systematic inappropriateness is one of the most frequent methodological errors one is likely to fall into, indeed it is also easy to fall into in order to find scapegoats for complex problems. And this undermines not only the doctor-patient, SSN patient relationship, but also undermines self-esteem and the relationship between professional and institution, to the point that already today 10 doctors leave hospitals every day at non-pensionable age. And such an error in turn risks driving choices, as has already happened in the case of waiting lists, that cannot produce the desired results.