I have to stress the point that the Italian government is trying to combine general practice and emergency service and out-of-hours services into single primary care units that provide 24-hour cover.
From outside Italy, it could be read as the way forward for primary care groups or primary care trusts, because we see in the UK that GPs work in partnerships in the NHS.
In Italy it will be totally different because single primary care units are not financially and contractually going to be trusts, but that every GP would remain in a quasi-subordinated profile with the local health service as the real decision makers for their future professional contract. GPs' careers would depend upon local health service strategies and expenses profiles.
GPs provide 24-hour cover and this is thought to be good for all patients and for quality of care, despite a lack of evidence and experimental research.
Take in mind this: when the new contract in the UK abolishes out-of-hours care … here we see, after 25 years of emergency services, that GPs, some approaching retirement age, are asked to work nights and weekends … or are pushed to ask for early retirement — if pensions will be still paid to physicians …1
Also, this big change proposed may force GPs to close their solo practices after years of work spent managing them.
Again, there are no plans (apparently … or an underground network of interests could be in gestation) to consider structured places where to put these groups of doctors who are really pushed (obliged for survival) to work together and to change their style of work and life in such a strong and quick way.
This ‘investment’ in changes is being made in a national context without an apparent new contract for years, with an economic downturn and increasing burn-out, as indicated in the international research (only Hungary and Bulgaria got worse results in this, according to a presentation by Petrazzuoli et al at the WONCA European Congress in Amsterdam in June 2004). An increasing number of GPs are looking at the UK's NHS International Recruitment going around Italy and collecting GPs who are free to leave the country.
Substantially, this change is going to be imposed without total consultation of GPs. This lack of consultation is taking place despite a national economic recession and without any real financing of the public primary care setting unlike other countries such as the UK, because the political powers don't believe in a real professional relevance and leadership for general practice. In Italy not one research department of general practice exists.
The new kind of general practice created by the forthcoming changes (anonymous and without continuity care for patients) would be a local sub-product of hospitals. Devolution of local trusts with different speeds and different contractual powers is the way to kill (slowly but inexorably) GPs as free contractors and advocates for their patients, along with the public health system.
- © British Journal of General Practice, 2005.