“The emergency that the country is facing has made more evident, where necessary, the importance of being able to count on a efficient healthcare and able to respond to threats made more insidious by a economic system increasingly open and globalized. An experience that has also highlighted it strengths and weaknesses making theunavoidability of choices that, beyond the extraordinary emergency produced by an unexpected “enemy”, were already in front of us “, we read in the premise of the in-depth analysis on health contained in the last Report on the coordination of public finance, in which the accounting magistrate de facto puts on black and white that repairing the health accounts has in some cases jeopardized the effectiveness of the service.
BALANCE OF ACCOUNTS AT THE BENEFIT OF SERVICES – According to the analysis, “the success recorded in recent years in the reabsorption of imbalances in the use of resources it has not always prevented the occurrence of critical issues that it is necessary to overcome today: these are the unacceptable differences in the quality of the services offered in the various areas of the country; of the staff shortages due to constraints placed in the recovery phase, ai limits in programming of the necessary professional resources but also to one progressive escape from the public system; of the insufficiencies of territorial assistance in the face of the growing phenomenon of not self-sufficient and chronicity; of the slow progress of the investments sacrificed in the face of current needs “.
Difficulties that are likely to increase for the aging of the population combined with the near-zero birth rate, with foreseeable consequences in terms of costs for workers: “It is well known that in just 20 yearsLooking at the forecasts, the ratio will shift to one retiree for every two people of working age, decreasing the wealth generated and the public resources available in the face of an increase in health and assistance needs – the accounting magistrates still write -. In addition, the drop in resources available to retirement of the younger generations today raises strong questions about the possibility of to charge citizens for increasing portions of health care costs and above all socio-sanitary not covered by the NHS“.
IT’S TIME TO MAKE CHOICES. AWARE – So the Court of Auditors invites you to make a choice in the awareness that if you decide to increase funding for the public health system, you need to review “the attention, hitherto found to be prevalent, to measures that involve direct monetary transfers or lower tax levies”. In other words, it is necessary to cut subsidies and tax breaks and to balance public accounts. Not only. Account must be taken of the need to continue to control healthcare expenditure to prevent, as in the past, “inefficiencies and poor management“Eat the additional resources intended instead to increase services to the citizen.
CUT MORE THAN SPAIN AND PORTUGAL – In 2019, Italian healthcare spending reached i 115.4 billion, with an increase of 1.4 percent compared to 2018, lower than that foreseen in the document of economics and finance of that year and keeping “the incidence in terms of product substantially unchanged compared to 2018”. However between 2009 and 2018 there has been a reduction, in real terms, of resources destined for “particularly substantial” healthcare. In fact, per capita expenditure at constant prices (2010 prices) went from 1,893 to 1,746 euros with an average annual reduction of 8 tenths of a point. “A much smaller decrease compared to other countries in difficulty (Greece -4.5 points per year), but which differentiates us, while remaining higher in level, from the trend recorded in Spain is Portugal (respectively -6 tenths and -7 tenths), countries that have lived like Italy significant financial difficulties“, Comment the accounting magistrates. Spending, on the other hand, increased (always on an annual average) by 2 per cent France, 0.5 percent in Holland, 2.2 percent in Germany. The result is significant gaps in terms of public health expenditure per capita (expressed in purchasing power parity). According to the estimates of theOECD, in 2018 in Germany and France the per capita expenditure was, respectively, double and 60% higher than the Italian one. Spending that remains, however, more than 8% higher than the Spanish one.
ON THE SHOULDERS OF FAMILIES – The prolonged attention on the expenditure front, the processes of reorganization of the health structures in the area and the difficulties of adapting the public offer to the changing characteristics of the demand for assistance were reflected in a expansion of household expenditure which between 2012 and 2018 continued to grow which increased by 14.1%, compared to 4.5% of that of the public administrations. The growth of the one covered by regimes is also significant volunteer financing (+31.5 percent).
With distinctions at the regional level. If on average the private expenditure per capita nationwide it is approx 612 euros, it varies between around 720 euros in the North-West regions and 471 euros in the South. The differences between Regions are even greater: come on 1,000 euros from the Aosta Valley to 420 of Campania. Furthermore, the composition of the expenditure is different. If on the whole more than 53 percent of the expenditure is destined to purchase drugs and medical equipment and equipment (it was 51 percent in 2014), in the North-West regions it affects only 51 percent of exits against more than 60 percent of the South. A difference due to the strong importance in the South and Islands of spending for drugs (which absorbs more than 3 quarters). Compared to the 55 euro family members for outpatient services, in the South there is less than 40 compared to 65 in the North, of which 37 go to dental services against the 16 euros of the Mezzogiorno.
In the lower income regions, then, the share of total expenditure absorbed by healthcare is growing more than in the rest of the country. “Even if it concerns a volume of resources much lower than that used in the richest areas of the country, a path that will see the share borne by the citizen increase still risks being not very sustainable“, Comment the accounting magistrates.
DRY TERRITORIAL STRUCTURES – Coming to the Covid emergency, the concentration of care in large hospitals occurred in recent years and the consequent impoverishment of the system assistance in the area, which has become less and less effective, has left the Italian population “Without adequate protection” in the face of the pandemic. The crisis, the accounting magistrates explain, has also and above all highlighted the risks inherent in the delay with which we moved to strengthen the territorial structures, in the face of the strong effort made for the recovery of higher levels of efficiency and appropriateness in the use of hospital facilities.
“If it certainly had a justification for protecting the health of citizens, the concentration of hospital care in large specialized structures reducing the minor ones which, due to the number of cases and availability of technologies, did not guarantee adequate results of care, the lack of an effective assistance system in the area has left the population without adequate protection. – underline the accounting magistrates – If up to now these deficiencies had discharged not without problems on the families, counting on private economic resources and on assistance often based on low-skilled labor socio-sanitary (carers), ending up affecting the individual detail, they ended up representing a weakness also from the point of view of overall defense of the system when a new and unknown challenge arose ”.
In the Court’s opinion, it is in fact “increasingly evident than one adequate service network on the territory is not only a matter of civilization in the face of the difficulties of the individual and people with disability and chronicity, but it represents the only one defense tool to deal with and contain phenomena such as what we are fighting quickly. L’insufficient resources intended for the territory made later and did find unarmed the first front that must have been able to oppose ramp of the disease and that he found himself involved in the difficulties of the population, paying a price in terms of lives very high”.
A focus on these issues was seen in the last Budget law with the provision of funds for thepurchase of equipment for general practitioners, “but it will still have to be implemented after the crisis, as well as resources will be needed for investments aimed at bringing health structures back to efficiency”.
The accounting magistrate then recalls that “the decisive factor in territorial assistance is the role of general practitioners and pediatricians of free choice affiliated with the Ssn which is responsible for assess the health need citizen by guiding access to other services. ” But “also in this case the number of doctors has decreased in the last five years: by 3.8% in the case of general practitioners and 1% for pediatricians. A decline that was stronger in the regions not planning to return “, to which must be added” the progressive aging the workforce and the difficulty, therefore, of ensuring an adequate replacement “.
In addition, the staff of the service was down emergency medical Service, which should guarantee the continuity of care for the whole day and for all days of the week. Between 2012 and 2017, although the number of medical guard points increased overall, the number of doctors decreased by 2.8%.
ESCAPE OF DOCTORS ABROAD – The analysis also speaks of a real “flight” of doctors from Italy for lack of places and low wages. So doctors leave the peninsula in search of fortune abroad. Based on the data OECD in the past 8 years, they are over 9,000 doctors trained in Italy who went to work abroad. UK, Germany, Switzerland is France are the markets that more than the others have represented a solution “to legitimate employment needs and adequate remuneration when not met by the national private sector “. A condition which, underline the accounting magistrates, “while arguing in favor of the quality of the training system national, is likely to make the measures taken for the increase in specializations not very effective, unless accompanied by a incentive system that allows you to effectively combat the distortions highlighted “.
The accounting judiciary, however, stresses that often these are not real stable transfers, but of temporary requests . “As observed by the Ministry of Health – the Report reads – the increase in certifications issued each year by the administration for the purpose of the free movement of doctors and medical specialists graduated in Italy to the countries of the European Union does not necessarily correspond to the number of the doctors who actually move permanently abroad “. The vast majority of cases continue to remain registered with an Italian Order, moreover these certifications can be requested exclusively for perform occasional and occasional services in a Member State, “as happens in the case of doctors residing in regions bordering the Italian border”. In some cases, “the certifications are not used, the hypothesis of a job abroad is lost and in others they are used to follow training coursesabroad with the intent to return to Italy “.