Subsidiarity or complementarity between public and private healthcare? Sharing – interview with Massimo Castoldi

I would kindly ask you to introduce yourself.

I am Massimo Castoldi, medical director of Humanitas Gavezzini in Bergamo since 1 January 2017. I have always worked in the healthcare management of numerous hospital groups in Lombardy, first as assistant and then as director. I started in about 1990 in the San Donato Group, then I was medical director of the Galeazzi in Milan, the Istituti Clinici Zucchi in Monza, the Cardiologico Monzino, and then superintendent of the IEO. I am a specialist in hygiene and hospital medicine. I have always carried out my career within hospitals. I therefore have direct experience of the private sector and of working with the public sector.

There are those who speak of ‘partnership’ and those who speak of ‘subsidiarity’ of private versus public healthcare. What do you think about this?

All healthcare that we call ‘private’ is nothing more than a corporate way of managing the public health service.

For about 75% of its needs, the Italian healthcare system responds to citizens through public-law hospitals, and for about 25% through private-law entities. Thus, the public service is unique, it is that which the citizen accesses through the public reimbursement system – co-payment or otherwise. The entities providing this service can be private or public law entities.

This, I believe, is a fundamental distinction since service must be measured by output: what does a private hospital offer? What does a public one? Always a service to the citizen. Obviously there are also services that the citizen pays for out of his or her own pocket, but this happens in both the private and the public sector.

Subsidiarity is a concept that we have only recently rediscovered but which was already contained in our constitution. Subsidiarity is basically offering services to the citizen as close as possible to where the citizen is. Whoever is in the closest place is subsidiary to the fact that the state responds to the citizen’s need. So, in this sense, private healthcare is subsidiary.
A similar term, but only apparently and perhaps therefore to be avoided, is ‘complementary‘. Complementarity to the healthcare offered by a private entity would indicate that the healthcare system responds to the needs of citizens through the public, and if something remains to be done, it relies on the private system, it buys it. So, in this sense, in my opinion, some problems arise.

Another thing, in Italy, the health system is regionalised, i.e. the regions respond differently to these concepts of subsidiarity/complementarity. In some regions the private sector is really complementary and provides at most 10 per cent of the services, in others it is much more integrated and therefore much more subsidiary.

What was the situation before the pandemic and what has changed with it?

The pandemic exposed the shortcomings of one or the other system, introducing the concept of a national emergency. However much we tried to integrate in Lombardy and the other regions, it soon became clear: either the whole system, public and private, made itself available to the needs of the citizen for the pandemic, or we would not get out of it.

In my hospital, to give an example, we have 230 beds. Since we are in Bergamo, which was the epicentre of the first wave, of my 230 beds I saved practically none for the pathologies that always afflict us. I had 260 beds open, 250 of which were for covid.

The pandemic taught us, in my opinion, a beautiful collaboration between public and private. Every week I used to meet on Teams with all the other medical directors of public and private hospitals and the ATS and ASL, to discuss problems together and find shared solutions. This system has now been somewhat sidelined because of the problems with hospital funding and the hunt for employees. Once the wave of emergency has passed, the collaboration has been lost a little, but it should be recovered in redesigning services to citizens.

What are the best points of public-private collaboration? What, on the other hand, needs to be improved?

There are examples that are being carried out in the Lombardy region. For example, right here in the province of Bergamo, a project called PROFUMO (‘Oncological Patient Follow-Up Project’) is being launched. This is a project to build a continuous follow-up pathway for cancer patients. All cancer patients resident in the province of Bergamo and public and private hospitals participate in this project. This was made possible by sharing the agendas for the needs of citizens in the province of Bergamo.

In my opinion, this is the way to collaborate: to do upstream planning of needs, having seen the needs of the territory and seeing who can give what, to what extent each can contribute to the fulfilment of the need, because, in the end, the issue is unfortunately that the health system in fact has a budget. Either we make the system efficient and try to give the answers to those who need them, or else in a contingent system, economically capped, someone risks taking services at a lower level and someone who has urgent needs instead remains cut off. Therefore, sharing care pathways between the public and private sectors offers a better response to the needs of citizens. It is necessary to provide useful and appropriate services by having a quota of resources, both in public and private hospitals.

How do you run a private hospital? Is it different from a public one?

There are substantial differences. If you go into the details, however, the problems are the same. What is a hospital? Walls, structural requirement; machines, technological requirement; people, organisational requirement. A hospital is labour intensive, i.e. it takes a lot of people to make it work, but it is also technologically very intensive, i.e. the combination of technologies makes the hospital one of the most advanced places in terms of machinery and structure.

As for the differences between public and private, the latter gets its money from the rates and bills it issues, the money it makes is from the services it provides. Public hospitals, on the other hand, get their funding from a state budget. So the private sector has more agility in management, it can direct resources better by having faster management mechanisms. For example, I do not need to take part in a public competition to hire a doctor. This is certainly the first important difference: in personnel we go for direct recruitment, whereas in a public hospital any person enters by competition.

However, the public is more attractive because it seems more stable, as opposed to the private which seems more friable. Technologically, a public hospital has to make a European call for tenders in order to buy high-tech machines, a private one, if it has the necessary funds resulting from an investment plan, can buy whatever it wants – obviously then there are all the public authorisations, but it does not need a call for tenders.

And the same is true for the structure: if I want to build a new pavilion, I build it and then get it authorised; in the public sector, the approval has to come before the investment since the resources are public.

In the private sector, we can in short be ‘quicker’, even though we have our own constraints, the management choices are certainly easier to implement. Apart from that, it is true that it is easier for the private sector to lose personnel to the public sector than vice versa: the workforce of a hospital, i.e. nurses, doctors, etc., go more towards the public sector.

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