Primary Care in Italy

Introduction – the Health National Service

Italy has a National Health Service since 1978. Before there was a service based insurance system for different professional categories. Since 1978 article N° 32 of the Italian Constitution was fully implemented by the Italian Government, which provides the health as a right for each citizen and a duty for the whole community.

The Italian National Health Service is divided into three different levels:

1.   The Ministry of Health coordinates the activities of Regions. Particularly through its department and services, it is responsible for five different functions:

  1. Health care planning,
  2. Health care financing,
  3. Framework regulation,
  4. Monitoring,
  5. General governance of the National Institutes for Scientific Research.

Since 1999, and as a consequence of the process of decentralisation within the National Health System, Italian regions are fully responsible for governing, regulating, financing and monitoring the regional health care systems.

2.   19 Italian Regions plus 2 autonomous provinces are responsible for:

A) the regulations for organizing health care providers and for providing health care services;

B) the criteria for financing health care organizations which provide services financed through the Regional Health Fund (accredited public and private organizations, i.e. Local Health Authorities, Teaching Hospitals and accredited private providers);

C) the strategic planning process both at regional and local level;

D) the technical and management guidelines for providing services in the regional health departments, including assessing the need to build new hospitals, accreditation schemes and accounting systems.

3. 145 Local Health Authorities (LHAs) are geographically based organizations responsible for assessing needs and providing comprehensive care to a defined population. LHAs provide care directly through their own facilities (districts, departments, hospitals, diagnostic laboratories, hospices, nursing homes, rehabilitation centres) or through services supplied by teaching hospitals, research hospitals and accredited private providers (e.g. outpatient specialists, general practitioners, long term hospitals).

The social care in Italy is free of charge for citizens. State funding goes directly from the Italian State to the municipalities. Sometimes municipalities themselves manage their own social services through these funds. Or the municipalities or groups of municipalities entrust these funds directly to the LHA, which also manages the social and health care on behalf of the municipalities.

Primary Care in Italy.

Primary care in Italy has many different actors:

1) First there are 46.000 General Practitioners (GPs) and 7.700 Family Paediatricians (FPs) in the whole nation. The Italian population is around 62 million and about 10 % are immigrants. Every citizen above the age of 18 can choose a GP which is registered in a list of the municipality or another territorial area. FPs treat children up to the age of 6 or if parents wish, up to the ages of 14–16) The healthcare provided from GPs and FPs is free of charge for all citizens. The salary of GPs / FPs is per capita, based on the number of citizens registered with a GP or FP. The maximum number of citizens registered for each GP is 1500 and 800 babies or children for each FP. These physicians have a gatekeeping role. They are responsible for prescribing medication and, after diagnosing a health problem, referring patients to specialist consultations or further levels of care if needed.

2) The whole Italian territory is divided into 708 health districts. Most of them are covered with the presence of GPs and FPs. But in some districts primary healthcare is provided without the presence of  a GP or FP. In these locations nurses, social workers, administrative personnel, other medical specialists like cardiologist, neurologist, gynaecologist are providing care. Many of these services are free of charge for the population but not always. Sometimes a payment is needed and often the amount is different from region to region which lead to the problem of inequity between the citizens of different regions.

There is a separate employment contract for GPs and FPs, which is renewed at national level every 3 - 5 years. The current contract is in force since 2009. Based on this national agreement each of the 19 Italian regions and 2 autonomous provinces can carry out a regional agreement with GPs and FPs. In order to become a GP and to practise, a physician must complete specialist training consisting of a three-year professional training course in general medicine. This professional training is managed and organized  by the regional authorities.

Changes in primary care

Something is changing now in primary care. In the latest national agreement all GPs and FPs must be, mandatory, subscribed to a Functional Territorial Aggregation (FTA). This is a group of about 30 GPs with one GP as coordinator. This organization is in contrast with the previous situation, where a GP (or FP) worked alone in his or her clinic, detached from other professionals and care provision.

In the acronym “FTA” the word “functional” means that each GP remains in his or her own office, but  is part of a group only functionally connected: they can share a budget with the same objectives, meetings and if needed also can share the clinical data.

Nowadays there are also more complex primary care structures (PCCS or UCCP = Unità Complesse di Cure Primarie = Complex Primary Care Unit): these are groups of GPs (and sometimes FPs) that work in the same building in an integrated way with nurses, administrative staff, social workers and medical specialists.

These structures have different names depending on the region. For instance the name is Territorial Unit for Primary Care in north Italy (UTAP = Unità Territoriali di Assistenza Primaria), or Health Clinic or House in central Italy (CDS = Case della Salute) and territorial building for assistance (PTA = Presidio Territoriale di Assistenza) in southern Italy.

So social workers, allied health professionals and physicians collaborate in providing care at community level. This allows them to keep the facility open for 12 hours a day or sometimes even up to 24 hours a day, 7 days a week (with a medical service for the night emergencies and holidays).

Finally

The PCCS/UCCP are very similar to the Community Health Centers in other parts of the world. These structures are the future of primary care.

In Tuscany, the Case della Salute (CDS) has proved to be able to reduce hospitalization (inpatient hospital admission) by 6% with a saving of around 18 euro per inhabitant per year. Practically, if all the inhabitants of Tuscany were covered by a CDS, savings could mount up to approximately € 50 million. And last but not least, all surveys show that people are happy to be treated and cared for by a CDS. We hope to motivate other regions to follow our initiative and let the whole Italian population profit from this health system improvement.

Author:

Piero Salvadori, MD, Local Health Authority of Empoli, Florence, Primary Care Department. p.salvadori@usl11.toscana.it

Links:

http://www.observatorysummerschool.org/materiale2012/240/italy_france.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1960619/ 

http://link.springer.com/article/10.1007%2Fs10389-013-0563-x#page-1 

http://www.euro.who.int/__data/assets/pdf_file/0006/87225/E93666.pdf

http://www.euro.who.int/__data/assets/pdf_file/0003/263253/HiT-Italy.pdf

Case della Salute:

http://portale.usl11.net/pagina_0.php?pag=casasalute|english&casasalutepag=casasalute_1&casasalutepos=9