Strikes and a healthcare system on its knees: Italy’s start to 2024

Principles betrayed

The Italian health service is allocated €48.8bn less than the average European health budget, says Nino Cartabellotta, founder of the Gimbe Foundation, a non-profit organisation working on healthcare.

“The principles of the INHS—universality, equality, solidarity—have been betrayed,” he told The BMJ. “For at least 20 years, governments have deliberately planned the health system’s failure—to the advantage of the private sector.”

Italian doctors also have among the lowest salaries in Europe.2 The average annual salary is €86 000 before tax, and doctors The BMJ spoke to believe an increase of 5-6% is long overdue.

Cartabellotta blames a limit of 14% of the total budget for staffing that was placed on health spending in 2004 and has remained in place. The Italian health system is region based and healthcare tends to be around 80% of any regional government’s budget. The spending ceiling directly limits the number of doctors and nurses that can be hired.

The latest financial bill, signed on 22 December 2023, states that, of the €2.15bn yearly budget, over half (€1.4m) is to cover the rising cost of energy. Around €200m is allocated for increasing the pay of all healthcare workers, but its dispersal is complicated. It includes an overdue pay rise promised by the previous government in 2019 but never enacted. Not all health workers—or even all doctors—will get the pay rise at the same time, however. For most doctors the increase will begin only in the first months of 2024.

One of the few payouts that did start in 2023 was for emergency department staff. A bonus of €100 per hour for any doctor—not just emergency medicine specialists—who volunteers to do extra shifts in the emergency department of their hospital. Emergency medical specialists, meanwhile, also received a two year pension concession that would allow them to retire at 65 instead of 67—though only for doctors born after 1996.

There are further pledges to pay for other overtime, but unions say that this is impractical given that most physicians’ working weeks are already over 60 hours.

Gettonisti

The bill allocates €600m to contract private clinics to help reduce waiting lists—a measure unions say “will not produce concrete results” and uses public money to pay the private sector.

Public hospitals are already heavily reliant on “gettonisti”—locum workers—a stop gap that became widespread during the pandemic. Di Silverio says it’s not ideal, but they have been left with little choice. “There is an expenditure ceiling for hiring staff, which prevents hospitals from hiring permanent staff even if they wanted to,” he says. Gettonisti fall under the “goods and services” category, which means they are not subjected to the budget limitations.

Gettonisti are paid by the hour to cover several consecutive shifts in emergency departments as well as hospital wards. The BMJ was told that salaries can range from €100 to €120 an hour. But one gettonista, speaking under condition of anonymity, said, “I earn more than a doctor who works in the INHS. Compared with an INHS employee, however, I do not have some protections—such as sickness and accident cover or holiday insurance—which I have to pay for myself. Furthermore, the amount is gross, and tax is more than 50%. So out of €100 I have €45 left.”

Even after tax, the average is double what many INHS doctors earn, says di Silverio. Some INHS doctors have also outlined concerns over hiring—some gettonisti may have been long retired, others have only recently graduated, some might be posted to a department and role outside their specialty. Again, di Silverio says this is not ideal, but in times of crisis it’s better than nothing.

Burnout

Over the past decade, 111 hospitals and 113 emergency departments have closed across Italy, with 37 000 beds cut. In contrast, the number of accredited private hospitals has remained stable. There are now almost the same number of private centres as public—of 995 healthcare centres, 51.4% are public and 48.6% private.3

As citizens struggle to access public services, those who can afford it are turning to private care. The crunch of patients in public hospitals is particularly bad in emergency departments, where there are often reports of difficulties admitting patients with chronic conditions as well as those needing acute treatment. This has led to increased physical assaults from patients or their relatives.

Fabio De Iaco, president of the Italian Society of Emergency Medicine and head of the emergency department at a Turin hospital, says the emergency department is “the last true barrier of the health system,” filled with patients with minor problems who should be seen elsewhere and an increasing number of chronically ill people, mainly elderly. “An oncology patient who can’t access treatment often comes to the emergency department, where they can finally be seen by a doctor,” says De Iaco, who estimates that around 50% of cancer diagnoses are made in emergency departments.

The quality of life for both patients and doctors in emergency departments is poor, he says, and does not correspond to the value of the profession. “Our doctors are sick, three out of four experience burnout, anxiety, or depression.,” he told The BMJ. At the time of interview, he had just worked 18 hours in a row over Christmas Eve and Christmas Day because of staff shortages, despite contractually not being supposed, as head of the department, to be working nights or holidays.

Italy’s public hospitals need more secondary care specialists, but increasing numbers of younger doctors are opting to avoid stressful career paths. “In the past two years, almost 50% of positions in emergency medicine remained vacant, and many of those who fill these positions eventually decide to leave. Emergency physicians will soon be a rarity,” says De Iaco.

Other specialties have even worse gaps. According to Anaao Assomed, 74% of microbiology posts are unfilled, as are 63% of clinical pathology roles and 63% of radiotherapy roles.4 But specialties popular in the private sector—such as dermatology, ophthalmology, and cosmetic surgery—are booming.

Stop gap policies

Italy’s youth no longer see healthcare as an attractive career option. Younger people do not want to enter a stressful profession with low remuneration, limited career prospects, unacceptable working conditions, and increasing risk of physical attacks. “New generations have different goals, and I can’t blame them,” di Silverio says.

Under the previous government, there were some attempts to stem the gap, such as a 2020 pandemic decree that allowed resident doctors to work more widely before they were officially given their medical licence (licence training now takes place before graduation rather than after it). The then government also pledged €7bn—funded by the EU’s post-pandemic national recovery and resilience plan—to a five year project introducing “community homes.”

These homes are local health centres where general practice is combined with facilities for laboratory testing and diagnostics, plus community hospitals (which include primary and secondary care, alongside social workers and labs), with the aim of relieving emergency departments and hospitals. But progress has been extremely slow in some regions and not started in others.

Since then the Italian government has changed. The recently approved financial bill is part of prime minister Giorgia Meloni’s plans for 2024, but the unions say it does not contain enough funding to provide the resources needed. Moreover, such a bill cannot tackle the structural reforms that unions are demanding—such as the decriminalisation of liability in the medical act to give doctors better protection against legal complaints—with no real interventions to ameliorate working conditions.

And even the concessions that were provided were only temporary—the government postponed the effects of pension cuts for INHS doctors until 2027, when originally the cuts were to start in 2024. “This will only encourage, over the next three years, the drain of personnel from public healthcare,” di Silverio says. As a result, the unions continue to plan strikes for this year.1