Dear minister, the choice between addiction or convention for MMG “is” the heart of the matter

by Antonio Panti

This is why I disagree with what was said yesterday at the Fimmg da Speranza congress. Common sense requires starting any discussion on the new structure of local medicine having this point, or dependence or convention, very clear. The legal status influences the organization and affects the operating model. Certainly not on the ethical or deontological aspects, which are identical for all doctors, but on the behavior of the operators

08 OTT – “The dependence of general practitioners is not the heart of the story, it is a topic to be discussed at a later time, whoever insists on it now wants to fuel the conflict”. These are the statements of Minister Speranza at the National Congress of the FIMMG, as reported by the newspapers.

I disagree even as a rhetorical point in a congressional speech. Common sense requires starting any discussion on the new structure of local medicine having this point, or dependence or convention, very clear. The legal status influences the organization and affects the operating model. Certainly not on the ethical or deontological aspects, which are identical for all doctors, but on the behavior of the operators.

The transition to dependence poses such and many problems as to make it practically impossible and just think, for example, of the payment of existing ENPAM pensions, should the contributions of the assets, paid to INPS and no longer to ENPAM, fail. But the problems for citizens would be very different, first of all the question of trust and the possibility of changing doctors – the only freedom still allowed by the system – which I do not know how it could be maintained if the relationship of trust were to be transferred from the doctor to the structure.

But the most relevant issues are two, the proximity and the capillarity of the assistance. The public documents approved so far provide for the establishment of a health house (or whatever it will be called) for every 30,000 inhabitants, taking into account geography. In these health houses, many services are offered, the fundamental ones of general doctors, then of the family nurse, the social worker, the secretariat and some specialists. It is expected to open at least 12h and availability 24h. We will therefore have health houses that respond to city districts up to those that will cover vast territories.

One thing is not clear: do the thousands of medical offices in the hamlets, substitutes for the main doctor’s office, remain alive or not? The question is decisive for citizens, in particular the chronically elderly. Will the general practitioners all have an outpatient clinic in the home of health or will they maintain the current geographical distribution which responds to criteria of internal competition and therefore to the advantage of citizens?

Proximity can be a simpler problem even if the distance between the health house and many hamlets can be tens of km through difficult roads. Is the car a work tool, will the employed doctor use his own? And how many does the ASL have? The car must be available for each doctor because home visits can overlap. Furthermore, a simple accounting and budgetary system must be invented.

The real problem, however, is the capillarity of outpatient services. If all the doctors work in the health house, it can be calculated that 30 MGs per 30,000 inhabitants require, albeit alternating, 10/15 furnished rooms, at least 3 waiting rooms and that about 200 people will enter the building in the morning and the same number in the afternoon, together with those who need the other services present.

And what if they wanted to keep the peripheral clinics instead? Which seems like an obligatory choice because you can’t even remotely think that your doctor’s surgery is half an hour away by car. Then these clinics must be acquired and managed. This poses administrative and practical problems. Is management entrusted to doctors? In short, how do they deal with the thousand problems of everyday life which everyone repairs for themselves?

Capillarity is fundamental both for citizens, who in this way are better assisted on a proactive level than their own medicine and will make less use of specialist services, and for the service which, as demonstrated, spends less and better the more they are widespread and peripheral the offer points.

But working in your own clinic or in that of the service is different. And the behavior of contract staff with an accredited private manager would still be different, as shown in the State Regions document on home services.

The Minister thinks about it well. Any legal status, employee or freelance, brings advantages and disadvantages to workers but the concrete problems are not doctors but citizens and the health service.

Antonio Panti

08 October 2021
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