Rationing or Reorganization?

REDUCED FUNDING, HIGHER INFLATION AND GROWTH OF NEEDS ARE PUTTING ITALIAN HEALTH CARE UNDER STRESS. ADD TO THIS THE AGING OF DOCTORS AND THE SHORTAGE OF NURSES. THERE ARE NOW TWO OPTIONS REGIONS AND COMPANIES MUST EVALUATE

by Francesco Longo and Alberto Ricci, Associate Professor at the Department of Social and Political Sciences and SDA Bocconi Professor of Practice

The OASI 2023 Report looks the Italian National Health Service and finds a scenario of great stress caused by three major elements. The first is financing, which in the coming years will reach between 6% and 6.5% of GDP, which is at least three percentage points below France, Germany and the United Kingdom. The second, it’s high inflation. The third is the growth of needs, inevitable in the country of Europe that has the oldest population: Italian statistical agency ISTAT forecasts a growth in the population over 65 from 14 to 19 million in the next twenty years, of which 6 million will live alone. In addition to these, there are two other crucial factors of tension: the aging and the shortage of the Italian health service personnel. Aging affects all medical occupations: doctors have an average age of 51 and nurses 47, while general directors of regional health management organization are 60 years old on average. Labor shortage, although attenuated in the two-year period of the pandemic (+3 % of new medical employees between 2019 and 2021), is exacerbated by trends in internal imbalances for which there are no signs of reversals.
Italy has medical staff that is in line with the rest of Europe and is growing after the recent expansion of admissions to medical schools in Italian universities. Some significant deficiencies concern specific disciplines such as emergency medicines, anesthesiologists intensive care, or laboratory medicine. However, the most macroscopic critical issue today is the dearth of nurses: there are 62 per 1,000 inhabitants, comparable to Spain (63) but far below France (85), the United Kingdom (87) and Germany (121). The problem here is the growing shortage of people wanted to embrace the nursing profession: for the 2023-24 school year, Italian nursing schools recorded on average 1.2 applications for each position. In 2012-13 the corresponding value was 2.7. In 2023, medical schools have supplied the health industry with as many doctors as nurses (around 10,000), when the need for the latter is approximately 2.5-3 times that of the former, even when considering only replacement rates.
Faced with this scenario, two different responses are possible on the part of those who, be they Italian regions or companies, have no way of determining the level of spending, which is set by the central government: health rationing or reorganization.
Rationing reduces the cost of individual items at the margin, or at least slows down their growth, while trying to maintain the same volume of supply. This approach can fight economic waste in health, but this will never be reduced to zero. The criteria for evaluating managerial work are simple: a better relationship and economic balance between health service volumes and the resources provided define success. As the budgetary constraint becomes more severe, staffing levels, the breadth of support services and the intensity of care are progressively reduced, increasing waiting times and dissatisfaction of users. However, the latter continue to flow without filters towards service models that have now revealed themselves deeply inadequate.
Reorganization, on the other hand, is a deeper process of change, which acts on multiple fronts. It is first of all a question of analyzing consumption of services and identify areas of inappropriateness (the patient receives more than necessary) and of inadequacy (the patient receives less than necessary), trying to equalize treatment provided to patients with homogeneous profiles. It then involves defining intervention priorities, studying access paths, reallocating resources, rejigging professional roles, developing and disseminating new technical and managerial skills. The key often lies in creating more appropriate and diversified settings in relation to patients' needs, also by using digital resources. This approach evaluates its success through dimensions that are more difficult to measure: the coverage rate of medical needs, equity in access, and the quality of health services provided.