One of our reports on the quality of life in healthcare organisations shows that healthcare professionals draw their energy and find their motivation in their relationships with colleagues and patients, while the real problem seems to be the confrontation with the management structure. How could it be useful to act to try to remedy this problem?
First of all, you have to divide the public world from the private world, because if you put the two together, in my opinion, you don’t really understand this situation. The public world is made up of rules largely undetermined by the managers of the individual hospital, of the individual ASL, interpreted by these managers, so obviously interpretation plays a decisive role.
Then the doctor, when dealing with the management of the structure within which he works, believes that the management does not know the problems of relations with patients, does not know the real life that the individual doctor, the individual nurse, lives every day. Consequently, it is like those dialogues you have with people who talk to you about things they don’t know in your head, and consequently are not even able to tell you what to do or what not to do.
These are, in my opinion, the psychological premises underlying the existing conflictuality. Which is a conflict that exists (I dare say almost everywhere) and which has grown in the post-Covid period. For a very simple reason, which is that there is a shortage of health personnel due to demographics. There are demographic humps on the way out, not enough people coming in: the result is that there are few people so these few people work more, and at this point some differences in, for example, salaries between Italy and other countries have become in the minds of these professionals unsustainable differences. And the market also allows them to quit one side and go to work in another, because there is demand there is no supply; and so this has created an increase in conflict, this is what I have seen so far.
It would be interesting to go deeper into this discourse you just mentioned on the shortage of health personnel, in the sense that it seems to me to be one of the key points of the issue. In our report, we also found a problem related to working hours, too much time pressure: there is an exasperated efficiencyism which, however, sometimes clashes with the chronic lack of staff.
So, in essence, the planning done by the Italian state on the health professions is completely wrong. It has been so for forty years: at times it has been out of phase in excess, while it has been out of phase in defect in the period from 2000 to about 2019. So these twenty years of scarcity of entry into medical schools and specialties are now leading to a situation where there is a lack of generational change. So if you look at the historical trend you will see that graphically it is a kind of sine wave. This sine wave is largely determined on the one hand by the doctors’ lobbies above all, who want as few doctors as possible in the market because the fewer doctors there are, the higher the remuneration; and on the other hand there is pressure from society, as at the moment, which says that there are no general practitioners, there are no emergency-medicine specialists, so emergency rooms must be closed and so on. So this is the situation and this is the main reason, i.e. beyond the fact that the individual ASL, the individual hospital, etc., puts out calls for tenders, but right now the calls for tenders are going out. So it’s also not a question of will, unless you say that they go unfilled because the salaries and working conditions are not adequate in relation to what the doctors want.
How important is economic leverage in all this?
Clearly it is a major aspect. For example on salary aspects there is little to be done. That is, if a public hospital manager has a very good doctor under him and wants to reward him in some way, he cannot in fact do so. Because by rule he has limits, strict constraints. The situation in the private sector is very different because each private individual has a certain freedom of action, so in theory he can do it. After that, of course the private individual also has budget constraints to undergo. Consequently it would be nice to pay everyone more; but if you paid everyone more, then afterwards the budget would go bad, and when the budget goes bad, after a while that manager or managing director stops being a manager or managing director.
After that, in my experience, what happens is that most health workers do not know exactly what the management problems of health facilities are, so they create in their minds a false image of things that can and cannot be done.
And faced with this perspective, what is your vision for the future? That is, on the one hand what do you expect and on the other hand what do you think should be done?
What I expect is the boiled frog, that is, I expect that the state will not address the problem, it will patch it up as it has done now with the retirement age for doctors. That is, it will try to minimise the problems in the short term without solving them at a strategic level with the mirage of maintaining the same system as in 1978. Politicians do not have the courage or the vision to deal with a re-establishment of the national health system, and so eventually there will be a slow decline that will lead in part to the privatisation of health care delivery and in part to pieces starting to fall off. That is, banally in six years from now the number of general practitioners will be half. So the policy will not address the problem, it will simply raise the ceilings (it raised them from 1500 to 1800, then raised them to 2000, then to 2500 and so on), obviously making the situation worse.
What should be done is a long list of reforms, in short reforms in the public-private relationship. So how do you allocate public services to private providers? One piece of the reforms would certainly go in the direction of deregulating some things that are regulated today without there being any improvement in people’s health.
I give a concrete example. Today, where there is a radiology machine, it is necessary to have the physical presence of a radiologist, which is madness because the presence of a radiology technician is quite sufficient. The radiologist actually does the referencing of that image, but the referencing can be done remotely, and so you can have an increase in the productivity of the system simply by saying that you no longer need the physical presence and radiologist at the machine, and this would produce you, for example, the ability to do as many mammograms as you want throughout the country; and there is a long plethora of these deregulations that would produce an improvement in the situation.
Then there is the relationship with technologies, which is a very complicated relationship because doctors tend to be conservative, so they tend to want to use them up to a certain point. Patients themselves are conservative, so the patient sometimes prefers the low-tech mode. But because he was used to the old-style national health system, where low-tech was possible, i.e. the doctor’s time was available to the patient, today this is no longer possible for numerical reasons.
These are some of the reforms, there are many others that should be done, but all these reforms touch on the interests of pieces of lobbies within the system and obviously politics does not want to get involved in this kind of conflict.
In your professional work experience, how would you define your relationship with your team?
Well, my professional experience means my 14 years at the Centro Medico Santagostino, so when we talk about a team we mainly talk about a non-clinical team: that is, I had a team of administrative staff who dealt with technology, communication and so on. With this team the relationship was fantastic and I have nothing to say, also because I actually built the company and I chose the people, we worked together from the beginning, so everything was easy from this point of view.
On the other hand, when it comes to the relationship with the clinical team, i.e. with the clinical providers, I must say that over the years the relationship has been very fruitful in terms of confrontation and dialogue, but with some misunderstandings and conflicts. In any case always with great mutual respect. A doctor’s objective is to make a person well, and I respect that, while over the years they have learnt to respect the objective of keeping a company healthy from the point of view of accounts, organisation, safety at work, the quality of all the machines we provided, and so on.
So in my experience, the correct approach is to set up different roles, because everyone has to be a leader in their own role: the doctor has to be a leader as a doctor and the manager a leader as a manager. And this approach I have to say has led to very good results in the 14 years I have been at Santagostino.