November 2008
By G. Passerini and A. Campanini
The evolution of the Italian GE, in the N.H.S is towards a more aggregated way of delivering care. This is what new GP’s contracts aim at, to limit the access to hospitals, facing themselves with problems of resources’ limitation.
The problem of GP is actually different in large/ medium size cities, compared to small ones/ villages, where many GPs still work single- handed.
Different options are offered ( and remunerated, when established):
- Net Practice: single- handed GPs operating in different surgeries, but in internet connection with others, so that they can enter other GP patients’ computerized clinical records while patients can consult a GP, other then theirs, in out of consultation hours of their GP.
- Group Practice: as above, but practicing in the same surgery and with Staff.
- Primary Care Centres: open at least 8 hours per day, involving more GPs with staff (Secretaries and Nurses), with availability of first level instrumental tests ( ecg, spirometry, audiometry etc)
- Territorial Unit of Primary Care: open 24 hours a day, including staff ( Secretaries and Nurses), firs level Pathology Lab and Ultrasound Services, as well as Specialists directly working in between the same TUPC.
At the moment PCC and TUPC are only very few and experimental.
With the aim of reducing the burden of First Aid& Casualty Hospital Depts, currently overloaded of work, and mainly used and forced to increase the number of admittances, some proposals have been set in the Agenda of the next Contract for GPs.
The main one deals with the possibility of returning ( it was abolished in 1980) to the system in which out of hours ( night-time and Sundays) calls be dealt with by GPs in the near future.
Others proposals include:
- Creating a closer continuity ( by Internet connection) between GPs and Doctors working in the N.H.S. Deputising Service.
- Involving GPs in First Aid& Casualty Hospital Depts ( to treat lower risk cases after triage)
- (In larger cities) Creating GP Centres, where GPs ( on a rota system) could operate 24 hours per day, including Sundays, on a free access system.
Some experiences could start in 2009 ( in the New Contract). Only GPs in First Aid& Casualty Hospital Depts have already been experienced, with positive results, in a few little areas ( the first ones in the Piemonte Region).
On the national level the organization and running of GPs depends more and more by Regions than from the Central Government, so different policies are applied in different Regions.
Some ongoing projects
In some Regions agreements have been signed among Local Health Authorities, Regions and GPs’ trade Unions to involve GPs in care programs. The philosophy is that, if GPs help limiting overall expenses in some specific field, a part of saved money is redirected to them.
A couple of experiences are presented as examples.
OAT (Chronic Oral Anticoagulant Treatment)
In Italy OAT is still mainly carried out in Hospitals, in the so called Anti Coagulation Centres, mainly located in Clinical Pathology&Laboratory Departments.
In the Emilia Romagna Region an agreement has been signed between the Region and GPs.
Each GP ( the participation is not compulsory) can accept to follow up Chronic OAT ( quick strip authomatized system).
The agreement consists of:
- Preliminary Teaching Course ( one full day)
- Yearly periodic re-evaluation of results ( days in range) and refresher course
- Payment of € 214/ pt/ year ( plus strips supplied by the region)
Provided that the whole project reaches the aim of reducing overall expense ( including indirect expenses depending on the intervention of Hospital based Anti coagulation Centres ( very frequent in Italy) from € 4 to 1 million/ year.
During the first 6 months an evaluation has been done on the percentage of days in range, comparing Anti Coagulation Centres vs Participating GPs. The result is: 57% for the former and 61% for the latter.
Diabetic Care ( type 2) Integrated Management
Diabetic Care is carried out in very different ways in Italy: in some Regions it’s totally carried out in Hospitals, where as in others it’s shared between GPs and Hospital Diabetologic Centres.
In some Regions ( Lombardia, Campania, Emilia- Romagna, Marche) projects ( with free possible participation) of Integrated Care of Diabetes have been carried out.
The agreement consists of ( with differences either in protocols and tasks or in payments and payments):
- Preliminary Teaching Course
- Yearly periodic re-evaluation of results ( quality indicators, mainly HbA1c and BP, but with differences)
- Yearly ( or biennal) overall re- evaluation by Hospital based Diabetologic Centres, for heart/ kidney/ eye/ etc supervision and instrumental tests, where/ if required
- Payment of € 200-250/ pt/ year.
Global c-v Risk Measuring with High Risk People Detection and Intervention Programs
In some areas ( different places in various Regions) GPs have been involved in filling in data- bases with the aim to detect high risk patients.
In a second phase these have been followed to help reducing their global risk ( giving up smoking or reducing weight or treating BP or DM etc).
Some currently updated figures
In Italy ( 56 million population) we are about ( free contractors with the N.H.S.):
- 50,000 GPs
- 8,000 General Pediatricians
- 18,000 doctors working in the national Deputysing Service ( on call overnigh and on Sundays).
So far we haven’t any possibility of University based career nor half time job.
Quality and drug prescription in the Italian NHS
A strong effort has been made by Local health Authorities to force GPs to prescribe generic drugs ( it’s not compulsory).
The problem of quality has been advertised by The Ministry of Health, stating that generic means equivalent.
Official figures declare that 12-17% of all prescribed drugs are generic.
The main reason for the shift to them has been a matter of prices.
During a first phase drug companies didn’t lower the price of the branded drug, so patients had to pay the difference ( sometimes € 5-10 or more per box) between it and that of the generic. For this reason the some patients asked GPs to prescribe generics.
In a second phase drug companies lowered prices, at most just a little ( usually less than € 1), of branded drugs.
This balanced the shifting to generics.
Future Close Meeting in Italy?
We have got in touch with the Italian Society of Quality Assurance, asking their patronage, to cover expenses. We have suggested to hold it jointly with the National Congress of the Society. At the moment we don’t have any official reply.
