Introduction
Italy was the first European country to be dramatically hit by the COVID-19 pandemic,
recording the highest official number of victims in the world up to Easter 2020. Of
course, this catastrophic event has put under pressure the Italian National Health
Service (INHS), a Beveridge-type healthcare system characterized by universal coverage.
Here, we first summarize the main characteristics of the INHS at an institutional
level. Then we focus on the three health services most affected by the pandemic: (1)
general practitioners (GPs), who were put under intense pressure by the population
as a front-line service; (2) accident and emergency services (AEs) in hospitals, which
were put under strain at the onset of the pandemic and were the sites of the first
outbreaks; and (3) intensive care units (ICUs), which were overcrowded by severely
ill patients at a later stage. Finally, we try to draw some lessons from this epochal
experience, envisaging changes that could be potentially useful for improving the
INHS performance, and hopefully that could be relevant to other European countries
too.
Institutional Framework
Italy has around 60 million inhabitants and a population density higher than that
of most Western European countries, although unevenly distributed throughout its very
extensive landmass, which includes the two large islands of Sardinia and Sicily. Italy
is geographically divided into 20 regions (Fig. 1) governed by elected politicians,
which vary a lot in terms of both size—from 3261 (Aosta Valley) to 25,832 (Sicily)
square kilometres—and population—from around 130,000 (Aosta Valley) to 10,000,000
inhabitants (Lombardy) [1].
Fig. 1
Population of Italian regions (2017).
Source: ISTAT. Annuario Statistico Italiano (ASI) (2017) [1]
Introduced in 1978, the INHS is a public service mainly funded by general taxation
that provides universal coverage and comprehensive healthcare free at the point of
use [2]. Unlike the UK NHS, the system is highly decentralized and the 20 regions
are each legally responsible for planning services and allocating financial resources—health
is by far the most important item of all regional budgets. Local autonomy implies
financial accountability, which allows regions to develop substantially different
health strategies without national endorsement [3]; it is a common view among experts
that Italy has 20 NHSs. Conversely, a national policy is not necessarily applied by
all regions homogeneously. So, the central and regional tasks have been intertwined
in the last few decades on account of many piecemeal legislative measures issued by
the quite numerous governments over time.
General Practice
Unlike in other Western countries, there are two kinds of GPs in Italy: one for adults
and one for children. Altogether there are around 52,000 GPs fairly homogeneously
distributed throughout the country’s areas, ranging from 1.3/1000 inhabitants in the
north-west area to 1.1/1000 in the islands [1]. As yet there is no national academic
specialty in general practice in Italy, only 3-year postgraduate training courses
that vary substantially in content by region [4]. Similar to the UK, GPs are self-employed
physicians mainly paid on a capitation basis under national contracts, although additional
financial incentives and fees for service can be agreed at a regional level. Unlike
the majority of their British counterparts, many Italian GPs still work single-handedly,
somewhat isolated within the INHS [4], despite several regional efforts to financially
incentivize group practices since the late 1990s [5]. Patients are still registered
with one GP, which is a major obstacle to them working in group practice. As a consequence,
the weekly access to GP practices is limited. According to a survey we conducted 5 years
ago on 731 GPs in three large northern regions [6], the average opening hours to the
public were 3.5 per weekday, confirming the disappointing results of a previous survey
conducted a decade before throughout the country [7]. So, the political slogan “24-h
access target” of a recent reform—drawn from the British experience—proved unsurprisingly
unrealistic [4]. Last but not least, since around half the Italian GPs are over 55 years
old, an aging workforce is a further barrier to change in the culture of care.
In addition to GP practices, many other facilities provide primary-care services in
local health districts [6], i.e., the operational units of the local health authorities
(the third tier of the INHS). Although their mix can vary a lot at the point of delivery
even within the same region, the most important health services are: outpatient specialist
consultations, infant vaccinations and population screenings, counseling for family
planning, and home-care services. In general, this fragmentation makes primary care
hard to manage, and its piecemeal delivery still disorients patients and their caregivers.
Accident and Emergency Services
Accident and emergency services (AEs) are the “pillar” of emergency care in the INHS,
as in the UK NHS [8]. Around 80% of public hospitals have AEs [1], which generate
a high rate of trust by Italian people and are perceived as the most appropriate place
to attend for receiving reliable emergency care. However, overcrowding has increasingly
become a major issue for the Italian AEs in the new millennium [9]. Because of the
aforementioned weaknesses, GPs have great difficulty in playing their “gate-keeping”
role in primary care, a crucial limitation in the aim of minimizing unjustified access
to AEs for problems that could potentially be treated in the community. According
to a recent INHS survey [10], more than 70% of the total access to public AEs was
inappropriate, and empty AEs after the outbreak (for fear of contagion) may be considered
indirect evidence of usual inappropriate use.
Another crucial issue for Italian AEs is that they are located in many public hospitals
that are of a small size—around 30% with < 120 beds, and only 15% with > 600 beds
[1]. Many efforts to make public hospital networks more rational have failed, eventually
leading to questionable reorganizations at local level [11]. For instance, the two
AEs in which the first and second outbreaks started in Lombardy are both located in
very small hospitals. Lacking alternatives in primary care, a widespread (justified)
sentiment in people living outside big cities is that increasing the distance to acute
hospital services undermines easy access to healthcare, especially to emergency care
[6]. This feature has traditionally fostered the political resistance to closing AEs
in local hospitals despite their limited spectrum of clinical competences and technological
equipment.
Few private hospitals (less than 10%) have AEs in Italy [1], just like in other European
countries [12]. This is not surprising, since private hospitals concentrate on profitable
services, a real challenge for AEs, which are very expensive services where many health
professionals have to be available full-time regardless of daily demand.
Intensive Care Units
Intensive care units (ICUs) are historically relatively recent departments introduced
into acute hospitals for critical care [13], involving dedicated teams and equipment
specialized in treating very vulnerable patients. The major goals of ICUs are monitoring
and supporting vital functions in critically ill patients, who may present very different
pathologies but share the potential for reversibility of their life-threatening conditions
[14]—a very demanding challenge for the ICU health professionals, as highlighted by
the media during the COVID-19 pandemic.
The density of ICU beds is quite homogeneous throughout Italy, ranging from 9.4/100,000
inhabitants in the central area to 7.8/100,000 in the islands (national mean value
8.7) [1]. The majority of beds are in public hospitals (92%), with an occupancy rate
of around 50%—slightly lower than that in private hospitals (around 60%). Similar
to AEs, the reason for the overwhelmingly high public proportion seems to be the low
profitability of ICU beds, characterized by high costs involving both personnel and
equipment [15].
It is difficult to compare the supply of ICU beds between different countries [16].
Since the demand for ICUs is greatly affected by the organization of the other hospital
services, such as the high-dependency beds as an interim facility, the density of
ICU beds can vary a lot from one country to another, and an international standard
is difficult to establish [17]. According to the last European survey [18], the variation
in number of ICU beds was really substantial between countries. Of the main Western
countries, the lowest figures were recorded in Sweden and the UK, the highest in Austria
and Germany. Since both the former countries also have a low density of total acute
care beds, whereas the latter two have a high density [18], the idea that the number
of ICU beds is tightly related to the domestic planning and funding of the other acute
hospital services is strongly supported [19].
Future Prospects
In line with our analysis, we think it is time to radically address the major INHS
issues so glaringly highlighted by the COVID-19 pandemic.
The first issue is institutional, which needs a political reform, since Italy can
no longer afford to have 20 different regions. There are too many regions, which are
too heterogeneous, with populations varying from an average-sized European country
down to a modest-sized county. This makes it impossible for all of them to be equally
organized for managing and providing the same kinds of health services. Moreover,
the regional institutional autonomy makes the INHS too open to influence from local
politics, undermining its technical governance [3]. In practice, regions can launch
local policies without national endorsement. Besides working out a few but clear-cut
“rules of the game” at a central level to coordinate regional health authorities,
the first bold and inevitable step to harmonize the INHS is to drastically reduce
their number. For instance, assuming a minimum threshold of 5,000,000 inhabitants
and taking account of the Italian geography, the number of regions could easily be
halved or even reduced further – two each (West and East) for Northern, Central, and
Southern Italy in addition to Lombardy (by far the most populated) and the two major
islands (isolated by definition). Although politically challenging, this reform cannot
be considered an insurmountable hurdle, especially after the catastrophic event we
have just witnessed. For instance, Denmark achieved this kind of reform 13 years ago—moving
from 13 counties to five (new) regions—despite tough political resistance [20]. The
management of the Danish health service has benefited a lot from this reduction.
The second issue is mainly organizational and concerns the “upstream” piecemeal situation
of primary care in the community and the “downstream” (partly consequential) overcrowded
access to emergency care in hospitals. Improving the consistency of non-hospital healthcare
services at a local level is vital, starting from general practice. An initial rational
step would be to merge all the existing sites providing different services in districts
into single “health services” open at least 12 h per week day [4]. These single facilities
should bring together all the health professionals who work in primary care, GPs as
well, who should become employees of the INHS like their colleagues in hospitals.
Much easier to plan and supervise, these organizations would extend daily access to
services in the community and appropriately filter minor ailments away from AEs in
hospitals. A co-location of a wide range of health professionals in large-scale organizations
open on a daily basis would also improve the provision of home services for elderly
people who are unable to travel [6], besides facilitating their informal care-givers
(e.g., relatives). Moreover, this would help people appreciate that the INHS does
not consist only of hospitals, the hitherto easily identifiable health facilities
that they often inappropriately attend as a consequence. It is not by chance that
low levels of AE crowding are reported in countries with strong outpatient healthcare
services, such as in the Scandinavian case [9]. Last but not least, this should help
politicians close small and inefficient acute hospitals, as the above-mentioned Danish
reforms have done successively [20], and as occurred with the closure of cottage hospitals
many years ago in the UK.
The third and final issue concerns critical care, on the forefront of pandemics, and
should be easier to tackle once the two previous issues are addressed. The outfit
of ICUs in public hospitals is rather homogeneous throughout Italy and their average
occupancy rate is acceptable during “normal” times, so an increase of public beds
could lead to long-term inefficiencies. Conversely, the sudden influx caused by a
pandemic like COVID-19 quickly puts under strain any critical-care capacity. Therefore,
the best strategy in such circumstances is an emergency national plan, which should
allow prompt central intervention, and coordination of regions, and involve the national
network of civil volunteers and the army for building up new ICU beds if necessary.
Finally, it seems obvious to recommend assigning the management of pandemics to a
special unit of a national health authority charged with ensuring national preparedness.
This has not been the case for COVID-19.
In conclusion, COVID-19 has tested the fabric of the INHS and highlighted the importance
of rational planning and coherent national and regional strategy. These findings may
not be surprising, but other countries may learn from them.