The pandemic has exposed all the holes in the National Health Service (SSN). Not only that, he also drew attention to possible reforms. Then, nothing more. Despite the launch of the National Recovery and Resilience Plan (PNRR), the reforms of the NHS have disappeared from public discussion to remain confined to a corner. Yet, Mission 6 of the PNRR redesigns the NHS of the future, for example by introducing Community Homes and Hospitals precisely for the purpose of building territorial healthcare; therefore, the issue should return to the center of public debate.
But what reforms does the NHS really need? What are the perceptions of Italians on the NHS? Are these perceptions correct? What health care would they like for the future? These are the questions that theObservatory for Italian Public Accounts led by Giampaolo Galli, starting from the results of a survey conducted specifically by Ipsos for Laboratorio Futuro, in his analysis "The dilemmas of the present and future National Health Service“. However, before looking to the future, to understand today's problems and to identify the choices we should make, for the Observatory, it is appropriate - write Massimo Bordignon and Gilberto Turati - to reconstruct the reasons for some choices that have been made in the past and others that have always been postponed.
The perceptions of citizens and the reality of the NHS
During the pandemic there was much talk of "definancing" public health, in particular the controversy surrounding the alleged 37 billion taken from the NHS by governments in the decade 2010-2019 is well known, so much so that perhaps more than one Italian thinks that the system health has been progressively crumbled and public spending on health reduced to a minimum. But how has public health expenditure evolved over the years?
Public health expenditure
Figure 1 shows the evolution of public health expenditure per capita, i.e. how much the public administration spends on average for every Italian, including children. As can be seen, since 1995 spending has grown both in real (ie, adjusted for inflation) and nominal terms. This was at least until the financial crisis of 2008, with the attempt by the governments that have succeeded one another to lead the country to stabilize spending in a very difficult macroeconomic framework in which, on the one hand, the GDP falls heavily with the crises and on the other other, economic growth after the crises fails to recover the lost ground. From 2000 to 2019, the nominal expenditure has grown from 1.179 to 1.904 euros per capita (+61%), that real (based on 2015 prices) from 1.547 to 1.856 euros per capita (+20%).
The quality of the service offered
At the request of the Observatory, Ipsos consulted a sample of Italians from which an erroneous perception emerges, especially among the elderly and (surprise) among the more educated. But why? According to the Observatory, this perception could depend on quality of services offered. The Italian population has aged a lot in the last 20 years and the older groups are also the ones most in need of health services.
But quality is a complex concept to define, even more so in the health sector; therefore difficult to measure. An indicator that is often used is the result of the “LEA monitoring”: a series of indicators (mostly of structure and process) aimed at understanding compliance with the Essential Levels of Assistance in the Italian Regions. And from 2012 to 2019 (the pre-Covid year), the "LEA score" improved significantly in all Regions with Ordinary Statute, with the exception of Calabria (which had a drop from 133 to 125), and in all Special Statute Regions, with the exception of Sardinia (for which data has been collected since 2017 and which has seen a drop from 140 to 111 in three years). On the basis of this indicator it would therefore not be rash to conclude that the quality of care has improved in our country, a figure in contrast with the perception of most Italians.
Ordinary SSN financing
Another interesting aspect to contextualize perceptions of spending is to think about financing. Between 2002 and 2010, the funding is increased in nominal terms by 39% and in real terms by just under 20%. With 2010, funding begins to grow by about 1 billion euros per year, with the sole exception of 2013 (also due to the economic recession of 2012). Then with the pandemic, the resources committed to the NHS grow even more: for 2020 they will reach 120 billion euros.
And what is the perception of Italians? For 49% public health funding before Covid has steadily decreased, 32% neither agree nor disagree and only 6% disagree. Also in this case, the percentage of those who fairly or strongly agree grows with age, reaching 60% for the 55-64 age group. And even here it is the more educated who have the most distorted perceptions.
The European comparison
At European level, France e Germany spend more than our country over the entire period from 1988 to 2020. Another interesting comparison is with the UK, who spent less than us until the beginning of the new millennium and then surpassed us, spending 25% more than us in the pre-Covid year. As for the Spain, which has the closest health system to ours, spending has always been lower than ours. As well as for the Greece. The conclusion is that the level of expenditure for the NHS is higher than that of the Mediterranean countries, but also that with the years of crisis in the second part of the decade 2000-2010, Italy has lost positions vis-à-vis the economically stronger countries and with public finances in better shape, such as France and Germany.
What do Italians think about it? One out of two Italians thinks that our country spends less or even much less than the European average. Consistently with the other answers, also for the European comparison, we note an increase in erroneous perceptions with age: 51% in the 55-64 age group. While this time it is the least educated who have erroneous perceptions, even if 43% of the most educated think that Italy has a lower expenditure than the European average.
The productive structure of the SSN: from the hospital to the territory
However, these perceptions aren't exactly far-fetched. The main reference is the chiusura , reduction of the weight of hospital principals. In fact, several hospitals have been closed (between public and private they were 1165 in 2010, we reached 992 in 2019), although in some cases rather than closure we should speak of reconversion into long-term care and rehabilitation facilities (the "Community hospitals" of the PNRR), and yes they are reduced beds for treble. It is a process that has been going on for decades, which must not be read in direct relationship with the financing and health expenditure, common to all Western countries, which goes by the name of de-hospitalization: the attempt to limit hospital stays and offer services that do not require hospitalization through territorial structures.
But why reduce the production capacity of hospitals? The reasons are not only (or mainly) a cost problem. The reduction in hospital beds should above all be read as a major one restructuring operation of the hospital services industry, carried out in all health systems, to make them more appropriate and therefore to improve the services to be offered. What has happened however is that while the number of hospital beds has decreased, hospital staff has reduced much less and investments in territorial services were less than expected, in the latter case above all due to the strong resistance of general practitioners to adapt their role to the changes in the role of the hospital.
What is the perception of Italians of de-hospitalization? Again perceptions are skewed, but less so with respect to funding and spending.
The role of private individuals and hospital care
The Ipsos survey tried to investigate perceptions on role of private individuals: about one Italian out of three thinks that the private sector plays a fairly or clearly greater role both in hospital and territorial care.
With regard to hospital care strictly speaking, despite the de-hospitalization, the production of the service is largely in public hand. Naturally the regional variations are consistent: but Lombardy, which in the collective imagination follows the region where the private sector triumphs, is exactly on the national average, surpassed even by Emilia Romagna. The extremes are represented by Basilicata on one side, where the private sector is almost non-existent, and by Calabria and Campania, where the accredited private sector reaches market shares of over 30%.
This picture helps clarify two issues for the Observatory: first, despite the de-hospitalization, hospital services are still largely in public hands; secondly, where hospital services are similar to social services (long-term care) and even more where the social aspect of the service is more prominent than the health one (welfare residences), the private sector plays an important role because the public has historically renounced to intervene in the production of the service. Furthermore, private individuals also play an important role in local healthcare and this probably reflects the coordination difficulties that the reforming action encounters in terms of local services.
In short, the production structures are there but someone is needed to link them and transform them into a network of services for users. It seems inevitable to associate this role with general practitioners, but again these are private professionals.
Dilemmas for the future
But what is the future of the NHS after years of substantial immobility? The PNRR has clearly indicated the route. However, some major dilemmas remain. Here are which ones:
- The first is the question of decentralization. The majority of those interviewed are in favor of the current system II (decentralized solution at regional level, with the state in the role of director setting the rules of the game for all regions). It's just about making it work. It is also interesting to note that one in four Italians in the 18-24 age group would prefer to have a private insurance system parallel to the NHS.
- The second the role of hospitals and local care. 54% of those interviewed opt for a reform of local medicine which aims to involve more in patient care a category (general practitioners) who have so far preferred to strenuously defend the status quo.
- A final question concerns the role of the private hospitals. The majority of those interviewed (43%) point to an alignment of private hospitals with public ones, especially on the Emergency Department front, for access to funding. While 31% (in the 55-64 age group) believe in the exclusion of the private sector from public funding. On the other hand, young people (40% in the 18-24 age group) believe that private hospitals should be focused on quality care and innovative pathways.
The scenarios
So what lies ahead for the NHS? The Observatory dares three scenarios considering that compared to 40 years ago, Italian society has changed a lot (especially in terms of demographics and the aging of the population). This figure brings with it at least three consequences: the requests for long-term care services will increase, aging is a synonym of chronicity and the increase in chronicity is the main reason that supports the rethinking of health systems.
Institutional setting
Let's start with the institutional structure of the NHS: healthcare management will remain the same. However, it is necessary to fully implement thearticle 119 of the Constitution, bringing spending decisions in the health field closer to those of financing, to increase the responsibility of regional decision makers. This calls for a new discussion about tributes own that can be assigned to regions; the probable future elimination of IRAP (a tax that by now has no juridical sense, after the subtraction of the main component of its taxable base) could offer an opportunity for a general reflection. Naturally without hiding, whatever the financing model, both the administrative difficulties induced by the dimensional differences between the Italian regions, and the differences in income levels, which in any case require the maintenance of large transfers in favor of the poorest regions. It is within this framework that the discussion on the differentiated federalism, pursuant to art. 116 of the Constitution.
Resources
In terms of resources, it will be difficult to make the increase in demand compatible with the financing difficulties. Our NHS, like the other sectors of social spending, is in fact financed with a pay-as-you-go system: today's workers pay taxes and social contributions to finance the production of services and the payment of transfers to those in need today. The aging of the population reminds us that the imbalance between those who work (and pay) and those who use services is not only relevant for pensions, it is also relevant for other sectors of expenditure, including healthcare, given that the elderly (who do not work) are the major users of health services. The equation will require or a profound revision of the tax system, so as to also associate income and assets that are now totally or partially excluded from the tax burden to the levy (for example by reviewing the taxation of consumption and assets and also the myriad of subsidy mechanisms existing in the Irpef and in the other taxes), or the renunciation of universalism, that is, one of the founding characteristics of the NHS. The alternative of further increasing the tax burden on income from work, particularly employment (84% of income currently subject to Irpef) does not seem feasible, in the light of the fact that it is already very high in Italy (the tax wedge on labour, inclusive of taxes and contributions, is among the highest in Europe, 6 percentage points more than the European average) and which already imposes strong distortions, including a low demand for regular work.
Universalism can be renounced in two ways: either by reducing the space of public insurance, the LEA now guaranteed by the Constitution; or by introducing one greater selectivity in the services offered, choosing for which services and/or for which categories of citizens to preserve the free public service and for which to instead introduce a system of greater sharing of costs. In both cases, it is necessary to think about the role that private insurers should play, recognizing that in reality the process has already begun and that it needs to be more regulated. It has been at least since the early nineties, in fact, that the theme of supplementary health insurance it is on the table: however, no serious attempt has been made to discuss it, further confirmation of the difficulties of reforming the current NHS and deciding its route. But the knots will inevitably end up coming home to roost.
Organization
As far as the organizational aspects, any assessment of what the "necessary" relationship between beds and population is cannot be detached from the integration of the role of the hospital with the local structures. The route, in this case, has been traced by the PNRR until at least 2026: there is already a plan to build "Community Hospitals" and "Community Houses"; it is on this project that the assessments on the adequate level of hospital beds must be inserted. Naturally, the beds must then be made operational through the staff. As far as healthcare personnel are concerned, again on the basis of data from the latest NHS yearbook, there has been an increase in the number of doctors but above all in the number of nurses, who have returned to the level of ten years ago. This is a comforting fact, while the lack of personnel for i is disheartening territorial services, precisely those on which the PNRR focuses the most. In particular, it will be necessary to reform local medicine, to make it more attractive to young doctors.
If private insurance companies can lend a hand on the financial front, it is finally necessary to understand what to do with the private producer of services. Will the investment of the PNRR be able to shift the weight of the public producer in areas traditionally dominated by private individuals, through hospitals and community homes? It is possible to think of a new way of doing territorial medicine that is not that of contracts with independent professionals such as current general practitioners? These questions, concludes the Observatory, are the same ones we have been asking ourselves for at least twenty years and without an adequate answer it will be difficult to see what will become of the NHS of the future.
