With the final approval of the health expenditure budgeting Law, which will come into force on 1 December 2001, in actual fact the entire health expenditure is handed over to the Regional Authorities, with a programme that provides for the transfer of as much as 241 billion Euro (465 thousand billion of the former Lira) from the State to the Regional Authorities, for the 2002 – 2004 three-year period. This Law will be starting off the devolution of healthcare, to be followed by that of the other two sectors (school and safety), which will be subsequently transferred, thus finally ratifying the autonomy of Regions from the Central Government. With the actual transfer of power to decide on health expenditure, the various Italian Regional Authorities will be invested with their own share of responsibility as regards the need for greater control over expenditure ceilings. Regional Authorities will indeed have to answer for any failure to keep within the budget limits; they will be entitled to either act directly on expenditure itself, or request a participation in expenditure, with prescription charges, additional Irpef (personal income tax) charges or local taxes. However this will all have to remain within the so-called “essential assistance levels” (in Italian: L. E. A.), which will have to be reviewed within 60 days of the Law coming into force. This is indeed a new concept, which replaces the old cost-benefit clause applied by the previous legislatures with the new cost-quality clause, essential in order reshape, through the L.E.A.s, the new healthcare programme. Constant expenditure monitoring, both at a regional and at a national level, will in any case have to be the primary objective of the new system; indeed it would not be conceivable that in an age in which the large trading chains are able to know, in real time and on a daily basis, the exact takings at a national level for their points of sale thought the territory, including individual entries for sold and unsold goods, our National Healthcare Service is to struggle with a bureaucracy that does not allow its left hand to know what its right hand is doing. Regional Authorities will have complete organisational and managerial autonomy, it being understood that assistance will continue to be provided in a uniform manner throughout the country. Certain Hospital-Enterprises will be selected with the purpose of giving these the necessary autonomy required for managerial testing. With respect to hospital reorganisation, the Regional Authorities will adopt a new beds-inhabitants reference parameter, providing for a standard average supply of 5 beds per 1000 inhabitants, of which 0.1% set aside for post-acute rehabilitation and long-term care. Surplus staff resulting from the reorganisation, besides being taken in within the facilities created from the reconversion of those no longer in use, will also be employed for the replacement of resigning or retiring staff within the same Enterprise, and for the arrangement of domiciliary medical and nursing services for chronic or terminal patients. The great problem of employment contracts and of NHS conventions will be dealt with on two levels: a national level and a regional/enterprise level, although, on the issue of contracts and conventions, we may end up playing a double game of ‘table tennis’, with a regional autonomy subject in fact to the surveillance of the other Regional Authorities. Besides, by ‘national level’ we shall as usual mean an interregional level in which representatives delegated by the Regions’ Conference will be having dealings in the name and on behalf of all Regional Authorities, in an assembly climate which will in fact empty regional autonomy of its meaning, by setting bounds and restrictions which will make it impossible to comply with that flexibility of contracts that is absolutely indispensable in a service which is to guarantee continuity 24 hours a day and 365 days a year. We then have all the regulations relating to the reclassification of drugs into categories, and the replaceability of patented drugs with their homologous generic drugs, with the possibility of paying for the price difference in the event of declared irreplaceability, as already mentioned in previous issues of Leadership Medica. In addition, the system provides for direct purchase and subsequent distribution by the Healthcare Enterprises and the Hospital Enterprises of the drugs required for the first course of treatment following hospitalisation or specialistic outpatient examinations. A concept that deserves to be dealt with separately is represented by the savings forecasted on the disposal of special waste, which will have to be subject to disinfection or to sterilisation in an autoclave, in order to assimilate them to ordinary urban waste, which will allow significant cuts on waste disposal expenditure. But the real step forward involved by the Law, which falls within the economic stability agreement planned for the next three-year period, has to do with the Health Service technological and telematic innovations. In our country we have Hospital Enterprises offering excellent qualifications and top professionalism, which coexist with Hospital Enterprises that are irrational, elephantine and chaotic, both from a practical assistance and from a management point of view. The control over health expenditure must therefore operate on quality, with a policy that is not only made of spending cuts but above all of investments, with the purpose of improving assistance and management standards. The crucial point of this development is represented by telematics and by the networking of the entire Health Service, so as to obtain tangible service integration (involving medical staff, chemists, Hospital and Healthcare Enterprises and welfare facilities), with an actual and effective transmission of information meant for health workers, with new communication possibilities and, at the same time, an overall control on the administration of health expenditure. This Law does not introduce computers from scratch, since, as we know, informatics already operates within the health facilities, even though it is in fact made inefficient owing to its complete fragmentation: all the realities operating within the Health Service in Italy have faced the problem of computerisation according to locally agreed parameters, but they are kept jealously private and disconnected from the rest of the system. The result is that, with an enormous expense, we are not even able to know what is happening next door, because everybody wants to equip themselves with sophisticated systems which, however, are not to communicate with each other. The technological challenge involved by this Law is to equip the National Health Service with a network that may make it possible to: 1) know every detail of the service, in order to better programme it; 2) allow communication among the various access points, with the purpose of improving the services offered; 3) start off a real integration of services among the various components operating within the organisation; all this with the purpose of supplying satisfactory healthcare assistance to the patient, who is after all the real object of the service. The last point that can be significantly developed in future, thanks to the availability of a suitable interconnecting network, is online educational activity for health workers through ultramodern teledidactics. This is a multimedia technology made possible by a functional integration of data-processing equipment and telecommunication systems, which are capable of putting teachers and learners in touch through teleseminars, videoconferences and multimedia hypertexts, offering the possibility of surfing through the various sections of the text. Of course, telematics will not be sufficient; it will also be necessary to get the doctors to go and see the patients at their bedside and discuss real cases with their direct involvement, in order to become aware of the various realities that coexist in hospital wards, if we really want our medical staff to embark on a programme that will keep it constantly abreast of the times. (Trad. Interpres sas, Giussano)