Ophthalmology objects to Italy’s health care changes

New provisions affecting ophthalmologists include a ban on private practice by hospital physicians.

ITALY — A new, controversial law issued by the Ministry of Health Care is at the center of public debate in Italy. The new provisions are aimed at giving a completely new structure to the health system, in force since 1968 and partially modified in 1992 and 1993.

Efficiency, higher standards and modernization of the National Health Service are the aims declared by the Minister of Health Care, Rosy Bindi, but not all physicians agree with the spirit of the new law, and believe that some of the provisions are undermining the medical profession.

Business-like hospital management

One point of controversy concerns the internal organization of state hospitals, which under the new law would be run with the same criteria as a private firm: flexibility, independent management, definition of strategies and evaluation of results. Physicians are given a new career structure; in the old system, the medical staff was employed by public competitive examination, which gave access to two pre-defined levels, “head of department” and “assistant.” The new provisions merge the two levels; all physicians will be employed at the same level, and duties, roles and salaries will be assigned by an internal scientific and managerial board according to the specific needs of each department and on the basis of personal abilities and merit. An internal examination board, chaired by the general manager of the hospital, will reassess the position of each staff member every 5 years on the basis of results and capabilities. The medical staff also will be involved in the general and financial management of the “firm.”

Professional training, specialization and follow-up courses, which were often left to private initiative, will now become an obligatory part of the medical profession, and will be provided by the National Health Service (NHS).

“It’s a more flexible system,” according to Giuseppe Montante, MD, regional secretary of Anaao-Assomed, one of the leading unions of the medical profession, “where the tasks and positions are based on abilities and performance, and not on fixed labels. The principles of continual assessment and professional training are an incentive to personal improvement and growth, as well as a guarantee of professional quality for the patients.”

The principle of the 5-year reassessment is particularly unpopular amongst heads of departments, which, in the old system, were guaranteed a lifelong position.

“A law should never be retroactive,” said Prof. Aldo Caporossi, MD, head of Siena University Eye Clinic. Alessandro Galan, MD, head of the ophthalmology department in Padua S. Antonio Hospital, agrees, and adds that “the career that I had been offered some years ago, and for which I have worked and qualified, has been changed ‘in progress,’ and this is not correct. You can’t shift one’s ground in this way!” He also asks: “Who will be assessing my results and professional skills? With what competence? On which criteria?”

On the same questions, some doubts also were expressed by former Minister of Health Care Guzzanti: “The principle is good,” he said in an interview in the national newspaper Il Corriere della Sera, “but I don’t believe we are ready to take this step. We have no experience of teamwork, and we are not yet ready to assess colleagues.”

From a different perspective, Giuseppe Tagariello, MD, assistant in the hematology department of Castelfranco Veneto Hospital, said, “We will be learning, and this is important. At present, no one acknowledges the good or bad work we do. We are afraid of internal competition and no incentives are given to those who deserve them. In other countries, this is perfectly normal.”

Incompatibility

An even more controversial issue is the new regulations concerning the relationship between public employment and private practice. To date, public employment in hospitals had been compatible with private practice by law, and a considerable number of physicians supplemented their work in public structures with work in their own surgery or other ambulatory or clinical structures. From now on, physicians will have to make a choice: either work exclusively for the NHS, or opt out and work only privately.

A certain amount of private consultation will be allowed inside hospitals, which, as the government promises, will be equipped with all the necessary structures, spaces and instruments to enable physicians to exercise the entire range of their professional skills. As an alternative, in case hospitals cannot offer the space and/or the equipment needed, physicians will be allowed to carry out their private consultations in accredited private surgeries, with signed special agreements with the NHS.

All private surgeries can apply for NHS subsidies, on condition that they satisfy the government’s quality standards and they are functional to the general planning of health services in the area. In the accredited private surgeries (as well as inside hospitals, as before), patients will be able to receive treatment that is completely or partially financed by the NHS.

Incompatibility affects ophthalmologists

Ophthalmologists are amongst the fiercest opponents of the new law. Very few of them, at present, work exclusively in hospitals and many have made massive investments to equip their private surgeries with the technology that their profession requires and that not all hospitals can afford.

“Most of the other specialists don’t have to deal with such a high public and private demand, so they won’t feel the problem with the same intensity,” said Prof. Emilio Balestrazzi, MD, president of the Italian ophthalmological professional society APIMO. “This law is a heavy limitation to professional freedom, thwarting the many years of effort and sacrifices that most of us put into the profession.”

Thanks to Prof. Balestrazzi, the ophthalmologists had the opportunity of a direct confrontation with Minister of Health Care Rosy Bindi at the APIMO congress in Montecatini last April.

On that occasion, Minister Bindi confirmed that the hospital physicians’ exclusive working relationship with the NHS was not to be discussed. “If we want a system to work properly, we cannot have its most important resource only to be there part-time,” she said. “What firm would want to rely on a manager who for half of his time works for somebody else?”

Among the many objections raised, both on this occasion and many others, is the financial aspect, which is a common concern, since the government has not yet quantified the incentives that would be given to those who choose to remain in hospitals, thus giving up a considerable part of their income. No one expects these incentives to be particularly generous.

“The truth is that the NHS used to rely on a compromise: I pay you very little, but once you have finished your hours, you can work outside,” Prof. Balestrazzi said. “Now the government still wants us to be paid very little, but not do any work outside, and this is frankly too much!”

The average salary of medical staff in hospitals is 20,000 to 30,000 euro a year, one of the lowest in Europe.

“If I divide my monthly salary by the number of surgical operations I do in a month, it comes out that for one operation, I earn as much as my housekeeper for an hour’s work,” said Prof. Giulio Baquis, MD, head of an eye clinic in Tuscany, at the APIMO congress.

Restructuring hospitals

Minister Bindi asserted that incentives and freelance work inside hospitals will add up to an acceptable amount, but the financial side of the new law is certainly the most obscure and problematic. The NHS is heavily in debt, and at present the policy of the government is that of reducing, rather than increasing, public spending.

Minister Bindi assured that “there will be no cuts in the NHS. In Italy, we already spend less than in other countries: 5.2% of the GIP, against the European average of 6%, and the 14% of the United States. We cannot spend less,” she added, “but can certainly spend better.”

Certainly the financial situation of the NHS collides with the increasing needs of most public hospitals, which have low budgets and are at present inadequately equipped.

“In most cases, hospitals need new operating rooms, more beds, more visiting rooms and more assisting personnel,” said Dr. Baldassarre Licata, MD, National Counselor of Anaao-Assomed. “Honestly, I don’t believe that Minister Bindi can keep her promises and offer the medical staff all that’s needed to exercise to the fullest their professional skills inside public hospitals.”

In this respect, ophthalmology is again in a slightly different but even more demanding position. As Minister Bindi pointed out at the APIMO congress, efficient eye care in hospitals requires “fewer beds, but more adequate structures for day hospital and day surgery, and more up-to-date technology.

“Our present government has made a considerable effort to accelerate plans for structural and technological innovation in the NHS,” she said. “We are allocating substantial resources to districts which submit to us good investment plans. The new lines of investment will have to take into account that one of the priorities in building a new hospital will be spaces and equipment for the private profession. In the meantime, the doctors who have chosen to work for the NHS will be using the structures and equipment of accredited private surgeries.”

“How can we make a tranquil choice on the basis of promises and hypothetical projects?” Dr. Galan said. “How can I make professional decisions on something that doesn’t exist?”

Such objections became the matter of a legal interrogation submitted to Milan magistrate’s court by a group of physicians of the Ospedale Maggiore, who asserted their right of postponing the choice required by the new law until the hospital is fully equipped for their profession. The judgement was in favor of the physicians.

“Freelance profession and hospital service have always lived well together, in a positive, synergic relationship,” Prof. Caporossi said. “Those who are committed to their work have always given their best both inside and outside the NHS. Physicians need support, not penalization.” He also pointed out that the extra income and the professional incentives coming from private activity stimulated the physicians to constant updating, which will now be jeopardized by a lack of time, money and motivation.

“Saying that no firm allows its managers to work for somebody else means nothing,” declares the manifesto of Libertà Medica, a recently born medical association. “We are not talking about competition between firms, but about freelance work. Any other state employee can do freelance work, and most professional categories, such as architects and lawyers, work both in state universities and in their private studies.”

Private, but under government control

Freelance practitioners have their own concerns. According to the new law, private surgeries and clinics can only be opened with government permission and are obliged to submit periodically to quality standard controls. Freelance practitioners also can apply to be accredited by the NHS.

“We believe that a public health service must have this kind of control over private practices,” said Minister Bindi, insisting on the necessity of a national system of regulations and constant monitoring of all medical activities.

“We are very worried about this threatening interference of government, local authorities and NHS in our surgeries,” said Costantino Bianchi, MD, freelance ophthalmologist and secretary of APIMO. “Freelance activities are bound to be suffocated by increasingly restrictive rules.”

The former Minister Guzzanti, in the interview cited above, also said that “the new law is strongly restrictive for the private profession,” and pointed out that “our hospitals need a lot of restructuring, and private medical care should therefore be taken into more consideration.”

A full-page press release published in the national newspaper Repubblica in June by the Italian Ophthalmologic Society, the SOI, which has more than 3,000 members, accuses the government of regarding “private medicine as a dangerous rival of public medicine, without taking into consideration the important role that competition plays in the improvement of the quality of services.” The association’s secretary, Matteo Piovella, MD, added that “the provisions taken by the government are based on purely political strategies. They are not in the interest of either physicians or patients.” Dr. Piovella highlighted how the peculiar professional situation in Italy is poorly represented by the usual medical unions, such as the Anao.

A more positive and optimistic opinion is expressed by Anaao-Assomed. The regional secretary, Dr. Montante, believes that the new provisions bring “a more balanced competition between public and private medical care. The latter is an important complement of the NHS, but must serve the real (and not fictitious) needs of the public. Above all, they must respond to the same criteria of quality and organization as public structures.”

He also said that “a market without rules is not right when dealing with an essential service such as health care. In such a market, people would be totally unprotected and in the power of somebody else’s interest.”

Before summarizing the position of his union, Dr. Licata noted the fact that “all discussions should bear in mind that we are talking about a National Health Service, which in this country is a solidarity system based on the constitutional principle of personal right to health care.” With regard to the medical profession, he said that “on the whole, the new law is not without limits and defects, and we will carry on our negotiations to correct them. Nevertheless, there have been some important achievements, and we know that mediation in politics is more effective than a fight to death.”

For Your Information:

• Prof. Aldo Caporossi, MD, can be reached at +(39) 0577-585604; fax: +(39) 0577-586162.
• Alessandro Galan, MD, can be reached at the Ospedale Civile Sant’Antonio, Via Facciolati 121, Padua, Italy; +(39) 049-8216780; fax: +(39) 049-8216541. Dr. Galan has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Giuseppe Tagariello, MD, can be reached by e-mail at G.Tagariello@sheffield.ac.uk. Dr. Tagariello did not disclose whether he has a direct financial interest in any of the products mentioned in this article, or if he is a paid consultant for any companies mentioned.
• Prof. Emilio Balestrazzi, MD, can be reached at L’Aquila University Eye Clinic, Ospedale Nuovo S. Salvatore di Coppito, Coppito 67100, L’Aquila, Italy, +(39) 0862-319671; fax: +(39) 0862-319672; e-mail: emibale@tin.it.
• Prof. Giulio Baquis, MD, can be reached at Via dei Bardi 48, 50125 Florence, Italy; phone and fax: +(39) 055-289935; e-mail: gabrielebaquis@lycosmail.com. Dr. Baquis did not disclose whether he has a direct financial interest in any of the products mentioned in this article, or if he is a paid consultant for any companies mentioned.
• Baldassarre Licata, MD, can be reached at fax: +(39) 049-8216541. Dr. Licata has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Costantino Bianchi, MD, can be reached at via Ciro Menotti 1/A, 20129 Milan, Italy; +(39) 02-740793; fax: +(39) 02-7386612; e-mail: cbianch@tin.it. Dr. Bianchi has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Matteo Piovella, MD, can be reached at via Donizetti 24, 20052 Monza, Italy; +(39) 039-389498; fax: +(39) 039-2300964. Dr. Piovella has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.