The Covid crisis has revealed a shortage of doctors in public structures. More and more graduates and doctors, while fewer professionals get assimilated in public health. The paradox became explosive with the Covid-19 pandemic, the emergency that highlighted a fragility evident for years: the lack of resources in the National Health Service, the set of services and activities for public health of citizens. Even darker scenarios are expected in the short term: the national health system risks facing a deficit of between 10,000 and 24,000 doctors over a four-year period. Is it really the shortage of doctors in Italy? Compared to European standards, Italy is not without doctors. On the contrary a research led by the Eurostat agency in August 2020 shows that Italy is the second country with the most doctors in the EU: Germany is in the first place with 357000 doctors (thousand) and on the third place is France followed by Spain. The figure has grown over the years. The balance becomes less striking by looking at the relationship within the population: 3.1 doctors per 1000 inhabitants according to Istat. A proportion that still places Italy above the European average.
The problem is that the overall availability of doctors is not reflected in the public health staff. In 2017, the Ministry of Health counted 1.7 doctors per 1000 inhabitants employed permanently in the national health service. The scenario has worsened with the arrival of Covid, given that the pandemic has exploded at the same time as the highest point of the pension curve for doctors employed by the NHS; which has now reached about 6,000-7,000 retired people per year. In this sense, it does not help that the average age of staff is among the highest in Europe. Italy has the leading position in the oldest age group of doctors with an age exceeding 55 years, which corresponds to 56% of the total: a figure that places us at the top of the ranking of EU countries with 16% above the European (OECD) average. The result is that in this four-year period from 2019-2023 there could be a deficit of over 10000 (thousand) doctors, which is the resulting imbalance between pensioners and new specialists who will opt for the NHS, which is 66% of the annual total. (32500 pensioners and approximately 22300 new specialist). That is a conservative estimate. If then, we consider the past shortage of more than 6000 (thousand) doctors and the need for at least 4000 (thousand) specialists to deal with the Covid emergency, the shortage can increase to over 200000 (thousand) doctors by 2023.
The problem arises from a decade of failure in the planning of specialist needs, with an imbalanced relationship between retired doctors and the number of contracts for doctors in specialised fields. Therefore, the outflow of retired doctors is not accompanied by an adequate number of training contracts that take into account both the needs of the system and the total number of new graduates arriving from universities. The so-called “training funnel”: in the last ten years about 12000 recent graduates have been excluded, found in limbo made of precariousness and professional debasement, hence prefer to emigrate. The gap is destined to widen, given that over the years access to the limited number of the medical degree courses has grown at a much faster rate than that of specialization contracts.
A second problem is represented by the fact that only 66% of specialists opt for the public sector. The rest work in private healthcare in structures equivalent to the public, affiliated and non with the NHS.
A third problem is that the deficiency can sometimes be qualitative. In the sense that some specializations are missing, they are even more vital in a period of health emergency like the one that exploded a year ago. The most evident case is that of anaesthesiologists. Before the pandemic, a shortage of at least 4 thousand anesthesiologists, was estimated in Italian hospitals. Today the shortage would seem to have been reduced with emergency measures, such as the recourse to postgraduates found in their penultimate year of their degrees, but there remains a shortage of placements for anaesthesiologists as well as for specialists in Emergency Medicine. Even in this case, the inadequacy of scholarships reveals only part of a larger problem: the discipline is anything but at the top of the choices of new doctors, who are allured by more profitable and less exhausting branches. On average a quota equal to at least 10-15% of trainees drop out after the first year to try again the competition in other fields. This is due to a number of factors; Firstly, the type of work, particularly stressful, which requires, in addition to professional skills, a special aptitude to face emergencies on a daily basis, and secondly the working conditions. Working for over ten years in staff shortages has resulted in decidedly difficult working conditions, which negatively affect private and family life more than in any other specialist area. The effort is not rewarded economically, if it is true that Italian anaesthesiologists are paid on average 30% less than their European colleagues.
There are 9000 professionals who in the last 8 years have chosen to leave our country to go to work abroad. In 10 years, there have been over 11000 emigrants (2008-2018). The reasons, once again, are essentially two: the low appeal of our offer – both from a remuneration point of view and from the prospects for the future, as well as the cuts in healthcare. Most doctors choose to go to the UK (4,274 out of a total of 11,024 expats in 10 years), but also to Germany, Switzerland, Belgium and France. Countries that represented a “solution to the legitimate needs of employment and adequate remuneration when not met by the national private sector”.
We must certainly avoid brain drain.
The vast majority of professionals who choose to move out of the country remain members of their corresponding medical union. All is therefore not lost, and doctors may be willing to return if conditions begin to improve.
A solution to attract doctors again in this sector is to make specific contractual changes, also from an economic point of view, for professionals who in fact dedicate their entire life in hospitals for people’s wellbeing.
Now there is an opportunity but a lot will depend on how they choose to use the European financing options (Mes light, but also Recovery Fund).
In accordance with the new National Plan of Recovery and Resilience, the resources distributed for health are only 19.7 billion, but for example the sector of green revolution and ecological transition is getting nearly 70 billion of euros or infrastructure for sustainable mobility 32 billion.
Although the funding for healthcare in Italy is one of the lowest in comparison to other sectors,
I believe that the proposals for using these funds are the following: 1. a necessary permanent hiring plan for healthcare personnel 2. the strengthening of the Prevention of Disease Departments; 3. an increase in activities related to district medicine; 4. the establishment of the Health Centres with multidisciplinary teams that also intervene at home and function 24/7; 5. the relaunch of the service for Health & Safety in the workplace; 6. the monitoring of production of toxic-harmful pollutants for the environment. 7. the strengthening of local services for mental health; 8. the relaunch of social healthcare: family clinics adapted to the new needs of services for women (from adolescence to menopause, to the elderly); 9. the overcoming of the current model of hospices and the conversion of these structures through the creation of alternative services.
A last consideration about the ageing societies:
we have to change
- how we think, feel and act towards age and aging;
- develop communities in ways that foster the abilities of older people;
- deliver person-cantered, integrated care and primary health services that are responsive to older people; and provide older people access to long-term care when they need it.
All Initiatives undertaken should seek the participation of older people, who will be central to and fully engaged in this multi stakeholder collaboration.
Regarding COVID-19 and older people: older people face a significant risk of developing severe illness due to physiological changes that come with aging and existing underlying health conditions.
People in the second half of their lives are bearing the brunt of the COVID-19 pandemic, which is exposing the flaws and shortcomings of various systems, including health, long-term care and support, social protection, finance, and information-sharing.
As mentioned in the European programme of work from the WHO (World Health Organization):
“We must better protect the people against health emergencies, we must ensure that older people and other potentially vulnerable groups are not left behind and many of the public health measures that ensure healthy lives and well-being for all at all ages are highly effective up to the oldest age groups.”
(Reference: Decade of Healthy Ageing 2021 – 2030)
