" Foundation yes, foundation no. The Hospital's Future. Any innovation is useful in the healthcare field, provided it is intelligent. The organisation of healthcare systems is given a high priority, and involves equally high difficulties, in all countries with a high standard of living, where equally high is the number of elderly people and health demands, expectations and costs. One aspect of my life as a medical practitioner is that of having worked for years (45 in my case), as Prof. Sirchia, “in large metropolitan public hospitals”, as well as having had lots of experience in Italy and abroad. I have always found, on all occasions, within each system and each hospital, that there are situations which differ substantially from one case to the other, and that these dissimilarities are often due to the human factor, and I am referring here to qualification and professional ethics.
This is why I wrote to the Minister Bindi and to the Government of those days, expressing the opinion that the so-called non-selective “Intramural” system had disqualifying and demagogic aspects; it represented a generalised award, which medical practitioners had been entitled to for some time, but it had been smuggled in as an innovation and improvement of the system, which of course has not materialised at all. But all the positive aspects of public hospitals are contained in a healthcare reform, which unfortunately has not been entirely enforced. Now I would like to refer to the letter written by the present Minister of Health to the daily paper Repubblica on the day of Epiphany, which was entitled “The Future of Hospitals is in Foundations”.
I am not questioning objectives or proposed remedies, here, but rather the diagnosis. The objectives are excellent and desirable: ”re-launching our great public Hospitals and their inestimable professional values”, by making them “comfortable, efficient, aimed at fully meeting people’s needs”.
Ensuring that “patients are not subject to selection, that there is no discrimination among pathologies, that research and development are not given up, that education and training are strengthened”. I would add a comment on both medical and paramedical staff quality of life and working conditions, and on incentives and awards to repay professionalism, which is one of the two most important resources of modern hospitals, the other one being organisation and technology.
But I wonder why a Foundation-Hospital should necessarily produce all these results, without however creating vacancies. Therefore, the diagnosis (hospital decline) and its pathogenesis (the Enterprise- Hospital public system) don’t really convince me. I shall start from the “vacancies”: hospitals, whether large or small, assist everyone, from the most disparate and serious emergencies to resuscitations, to the most “costly” diseases and patients and the most “profitable” pathologies. It is within large public hospitals and University Policlinics that the highest quality assistance techniques have developed, thanks to public and private funds. Italian healthcare has often been acknowledged to be in the forefront.
Still, hospitals are old, they no longer meet patients’ residential quality-of-life requirements, waiting lists are often intolerable and there certainly are pockets of inefficiency. But why not everywhere? Why are there a number of “happy oases”? In my opinion, those who have succeeded in combining “entrepreneurial” skills with their professional commitment are capable of assigning a major role to the human factor: but all this is already provided for by the current system. I shall therefore come back to the point I made at the beginning. We are going through an uneven development, with costs that are too high, because positive results have to coexist with pockets of unproductive inefficiency. Obviously, the system allows this, it allows the good and the not so good, and what’s more, it is individual people who are responsible for both.
Now this is no longer bearable, it is too expensive and (I couldn’t agree more!) it has to be changed, but the point is: “let us not throw out the baby with the bathwater”. The bathwater, in my opinion, is the way in which hospitals are (or often are not) run: and I am not only referring to questionable administration behaviours that apparently continue to cause damages in certain cases. What I am strongly referring to and strongly convinced about is the fact that at times General Managers do not live up to the expectations of the users they should be serving, by making hospitals and enterprises efficient and competitive, but rather to those of their political connections, or to their own. If privatisation is able to resolve this unaccomplished part of the reform, then that is fine; a board of directors which managers are to report to and account to for their activity would be a concrete organ, made of flesh and blood (and brain), and not an abstract controller, the public power of the regional authority, in fact its political majority which can make use of the hospital rather than serving it as a precious organ, a means of essential public functions: qualified assistance, innovatory research, university and postgraduate education and training.
As we know, this already happens in some Italian regions, which are more efficiently managed, but something similar also takes place in the IRCCS scientific nursing homes (Istituti di Ricovero e Cura a Carattere Scientifico), which are also directly funded by the Ministry of Health. Does this mean that these are all a model of excellence in healthcare? Or does it mean that financial profitability sometimes does not take precedence over the public service?
Are they availing themselves of too many or even illegitimate advertising means? But let us have a look at the best ones, and luckily there are quite a number: unfortunately even the best nursing homes prevalently select patients, have no urgency routines, produce quality assistance but choose their own development lines rather than epidemiological requirements: therefore, they do not comply with part of the objectives listed in the Minister’s letter to Repubblica. Besides, they have provided positive and important examples for our healthcare system, but they only represent a small part of it and, as I have just mentioned, they do not replace, nor would they (especially the private IRCCS) accept to replace, in my opinion, a public system that treats everyone.
This remains an open issue.
Let us therefore come back to the not yet detailed proposals of our present Minister, who has the whole situation very clear in mind. Indeed, the general policy statement produced by Mr Sirchia before the Social Affairs Committee of the Chamber of Deputies contains unquestionable rules and objectives, which however are not applied very much; these do not relate to selected facilities but to the entire system: quality control, health workers’ continuing education, information to the population, reorganisation of the hospital network (by giving priority to chronic or disabling pathologies) and reorganisation of the urgency networks.
That is, only things that a public authority can impose or, in other words, that can only be enforced if a public planning of supply exists, which both enterprise-hospitals and foundation-hospitals, all size healthcare facilities, both private and public, are to report to and abide by. If this actually takes place, it will be all very well, but this is not privatisation of healthcare: we therefore need a public power that is answerable for everybody, whilst we do not want discriminated patients and selected pathologies.
This was Mr Sirchia’s statement in his article on Repubblica.
And we shall, with a positive attitude, attend to him in this trial stage."

prof. Cesare Fieschi

Roma, 15 January 2002

(trad.Interpres-Giussano)