Who will pay for territorial healthcare when the Pnrr funds have run out?

6 May 20231 year ago babelfish

The doubts of the Parliamentary Budget Office and the unknowns about the future of the territorial health care reform once the resources of the Pnrr have run out

What will remain of the innovations introduced by the PNRR once the resources of the PNRR have run out? This question was asked by the Parliamentary Budget Office in reference to national health care. The PBO in the focus " Territorial health care: a challenge for the National Health Service " analyzes the impact on the National Health Service of the component of the PNRR dedicated to territorial health, for which 7 billion of investments and 500 million of the Complementary Fund (FoC).

THE CAPACITY DOWNSIZING OF ITALIAN HOSPITALS

The report, edited by Stefania Gabriele , focuses on the first component of Mission 6 of the PNRR called " Proximity networks, structures and telemedicine for territorial health care ". The shift of care from the hospital to the community level has been one of the most widespread policies in European countries to improve health services. In our country this trend has collided with the downsizing of hospital capacity, which is already lower than in other EU countries (in Italy the number of beds per 1,000 people is 3.2, while the European average is 5.3).

THE REFORM OF THE TERRITORIAL ASSISTANCE NETWORK

The innovations, analyzed in the focus of the PBO, converge in the reform that aims to revolutionize the organizational model for the territorial healthcare network "with the determination of the relative structural, technological and organizational standards, to be combined with those, defined for some time, of the hospital care". There are three levels of treatment that give substance to the reform:

the community houses , which have the task of directing patients towards primary health care, socio-health and social care services, as well as promoting health and ensuring the care of chronic patients. These structures are assigned 2 billion euros;
home assistance , which is expected to be strengthened and whose goal is to take care of at least 800,000 new patients over 65. Furthermore, by June 2024, more than 600 territorial operations centers (TOCs), interconnected and equipped with special devices for patient telemonitoring, aimed at coordinating health and social-health structures to improve accessibility, continuity and integration of care and at spreading telemedicine. The resources allocated for home care are divided as follows: 1 billion for telemedicine, 2.72 billion to increase the number of over-65 clients and another 280 million for the activation of the 600 territorial operations centers (TOCs);
community hospitals, with short-term stays, for a maximum of 15-20 days, for the development of intermediate care between hospital and outpatient clinic. These structures have the task of relieving hospitals of low-complexity services and limiting access to the emergency room. The numerical goal is to achieve or upgrade 400 community hospitals by mid-2026. Resources of 1 billion euro have been allocated for community hospitals.

THE DIVISION OF FUNDS BETWEEN THE DIFFERENT TERRITORIAL LEVELS

Of the 7 billion envisaged, no less than 6.675 were to be divided between Regions and autonomous Provinces. “The loans distributed up to now amount to 5.9 billion, of which 42.8 per cent went to the South – reads the focus -. An attempt has been made to make the 40 per cent constraint to the South more flexible by applying specific criteria for the various investments”. In reality, many Regions, especially in southern Italy, do not have intermediate structures for hospitalizations with low clinical intensity . And even the diffusion of home care is overall limited and very different between the Regions "both in terms of care taken in relation to the population and in terms of aid intensity". The picture that emerges is that of a multi-speed Italy.

THE UNKNOWN OF THE REFORM

The Parliamentary Budget Office points out the existence of several unknowns. First of all the construction times for the works, which should be very quick to comply with the roadmap of the PNRR, then " the ability to ensure a territorial rebalancing of services , the availability of financial and human resources to make the new territorial assistance, the involvement of general practitioners (GPs), the adaptation of the reform to the various regional models”.

WHO WILL PAY FOR THE REFORM WHEN THE FUNDS OF THE PNRR HAVE RUN OUT?

The PBO identifies three major criticalities of the territorial health reform as envisaged by Ministerial Decree 77/2022. First of all the economic resources. If it is true that, for the construction phases, the national health system will be able to draw from the funds of the PNRR, it is in the management of the new structures of the reform that the problems will emerge. When the resources of the PNRR are exhausted " more than one billion will have to be found in the funding to the NHS to give continuity to home care services and when the community hospitals will be available, 239 million will have to be found for the related personnel". And this is in stark contrast to the financial planning for the three-year period that began in 2023 which provides for “a reduction in the share of the product allocated to public health, which would make it difficult to enhance services, even in the presence of a reorganization of the same. The need to allocate further funding to local health care will plausibly emerge; among other things, the Government has undertaken with the Regions to find additional resources where necessary, compatibly with public finance constraints”.

THE LOSS OF ATTRACTIVENESS OF THE NHS AND THE UNCERTAINTIES FOR GPs

Another very hot topic concerns the recruitment of human resources for the NHS. The UPB underlines that the "difficulty in finding personnel and the loss of attractiveness of the NHS are becoming an emergency, above all as regards nurses and some categories of doctors, to be faced with adequate personnel planning, the increase of training offer, the adoption of measures aimed at restoring the attractiveness of work in the NHS in terms of social and economic recognition". This criticality is intertwined with another. " The involvement of general practitioners (GPs) in the implementation of the reform would require a clear regulation of the forms and methods of participation in the various structures and a revision of the training courses to strengthen them and adapt them to the new setting of primary care in the area – yes law in focus -. The hypothesis of transforming general practitioners from contracted freelancers into employees of the NHS at the moment seems to have been shelved ". The Policy Act for the agreement with general practitioners 2019-21, on the other hand, limits itself to assuming that "the reorganization that emerged from the previous agreements is already consistent with the provisions of the PNRR", to which is added the delay in the negotiation which "ends up being the cause and effect of the difficulties in introducing, and financing, more relevant innovations, which are also necessary from the point of view of the reform".

THE CENTRAL ROLE OF THE HEALTH CARE DISTRICT

The last aspect concerns the spaces for intervention that private healthcare will be able to find. If one of the objectives of the territorial healthcare regulation is "to ensure uniform standards throughout the national territory ", on the other "institutional innovations will have to be incorporated into the individual regional models", and with these, and with their interactions with the private system, interface. The PBO technicians point out that "to ensure priority to the planning function, maintaining on the one hand control over expenditure and on the other hand the commitment to appropriateness and equity in the provision of services" the role will be central of the Health District "emphasized in the descriptive part of the Regulation and strengthened by recent provisions".

This is a machine translation from Italian language of a post published on Start Magazine at the URL https://www.startmag.it/economia/chi-paghera-lassistenza-sanitaria-territoriale-quando-saranno-finiti-i-fondi-del-pnrr/ on Sat, 06 May 2023 05:05:11 +0000.