Chapter 2

This measure seems advisable both in order to encourage the organizations to pay greater
attention to overall efficiency, and in order to allow patient/consumer empowerment,
finally providing an incentive for continuous improvements in quality.
The integration of policies of management in the hospital sector is a necessary but not
sufficient condition for rationalization of the system. In fact hospitals certainly cannot be
changed if effective primary care does not develop in parallel.
From this point of view, both hospital and primary care suffer from the failure to develop
new, or at least to update their own, organizational models.
As is well known, most of the hospitals in the Italian network adopt an organizational
structure developed in the 1920s, which has come down to us with few modifications: we
think that it is certainly weak in terms of that integration of treatments which is increasingly
an imperative.
At the primary care level, emphasis has hitherto been placed on the commitment and
supply (creation of districts, more beds in nursing facilities, development of “Health
Houses”, etc), without much attention to which care models lead to the best clinical outcomes
and greatest customer satisfaction (attention that we do find at the international
level).
In the field of primary care, we observe an initial attempt to move from objectives of rationing
demand to a real taking in hand of the patient’s problems (see chapter 1.6 Barrella,
Rebba). In the most recent regional agreements, one finds less reference to expenditure
ceilings and/or limits to the services that can be provided, and more attention to the
design of diagnostic therapeutic pathways.
According to Barrella and Rebba, however, we are still far from attaining the objective of
real promotion and evaluation of the health outcome, in part because the variable part of
the remuneration of general practitioner managed at the decentralized level, where it is
easier to measure and check results is still very small.
Management of the system of primary care should be conducted through a multi-dimensional
set of interventions: the creation of integrated local information systems, network
connection and computerization of practices, the adoption of evidence based models
and integration of therapies, with testing of pay per performance mechanisms.
The attention to organizational aspects is shared by Tanese (chapter 3.4) who states that
«… the dynamism that has characterized the structure of health care organizations in
these ten years has been the tangible sign of the absolute importance of the organizational
dimension, and proof of the margins of manoeuvre created by the condition of organizational
autonomy in which they operate. However, the question is, on the one hand, about
the actual effectiveness of the changes induced by these processes and on the other
about the degree of real autonomy in which the organizations operate. The hypothesis is
that there are endogenous elements within the SSN that may condition and greatly limit
both the effectiveness of the change and the degree of autonomy of the organizations».
Tanese identifies some risks: first of all that the processes of change may become more
rigid as a result of an erroneous identification of the organization with the statutory item;
secondly, a mistaken identification of the organization with the organigram, and in consequence
with the positions in respect of which management appointments should be
[27]
CEIS Health Report 2006