from Leadership Medica n. 2/2001

In recent years, federalism has taken shape to the point that more consideration is now given to the Italian regions. In the health sector, progress is also being made along these lines with countless national and regional laws granting responsibility for public health to the regions. As far as general medicine is concerned, a succession of conventions over the past three years has shifted the onus of national agreements to the regional authorities. It is true that negotiations to renew contracts take place in Rome, but now doctors no longer find themselves face to face with the Ministry for Health but regional authorities. The various regional health councillors nominate a delegation of councillors with a president, also appointed by the regions, who conducts negotiations in the name and on behalf of the twenty Italian regions plus the provinces of Trent and Bolzano. The last two agreements to have been stipulated included additional regional agreements to be stipulated at local level. Calling the respective parties and finding an agreement can prove to be an inordinately long process. This is undoubtedly the reason why deadlines and dates have now become an optional feature. The result? Official Journal n°230 of 2nd October 2000 published a collective national agreement governing relations with general practitioners with effect from 1st January 1998 and expiring on 31st December 2000. Hence, a convention with a validity of three years is decreed exactly three months before the end of the term. Times change for sure and the author of this article has himself taken part in negotiations for conventions governing general medicine first with INAM, ENPAS, INADEL, then with the Ministry representing SAUB, then with the Minister again but this time representing USL, then yet again with the Ministry representing the regions and finally with regional delegations. Without a shadow of doubt, things have gone from bad to worse: the timescale is longer and the contents of the agreements themselves are encumbered with laws and bureaucratic cavils that effectively deprive doctors of professionalism so that patients are faced with a more bureaucratic, less sympathetic medic. At this stage, in view of the new legislature that places even greater emphasis on federalism, we may well question ourselves on the point of a national agreement for general medicine. Since responsibility for health has now been handed to the regions, since negotiations must be conducted by the regions and then integrated with regional agreements, it would seem more logical for each region to stipulate a regional agreement locally, without even troubling the woolly inter-regional authorities in Rome. This would undoubtedly accelerate negotiations and agreements and make it possible to stick to deadlines so that doctors are no longer forced to take important decisions retrospectively. Above all, it would ensure that appropriate assistance is given to citizens in a particular region since their needs do not necessarily correspond with the needs of citizens in another region. It obvious that local authorities know more about the needs of citizens and the best way to organise services than a central authority where even the State seems to be distant, even though somehow or other, it should know everything that goes on. At this stage, there is little point in discussing the merits of the type of federalism that needs to be introduced in Italy. What cannot be tolerated is the current hybrid situation whereby merely for political reasons, laws are passed and the State fails to shoulder its responsibilities for fear of being accused of anti-federalism, yet fails to delegate power federally. A similar situation can only damage doctors and lead to poor medical assistance for citizens and disorganised health authorities.

Amedeo Pavone

(traduzione Interpres sas-Giussano)