Analysis and perspectives of GPs gathering models in Italy according to the latest Italian National GPs Joint Agreements Mazzeo M.C.*, Ceccarelli A.* °, Cicchetti A.* °, Le Rose C.*, Milillo G.* * GISAP – Independent Group for the Study of Primary Health Care ° Catholic University of Sacred Heart - Rome Pisa, August 2010

Gruppo Indipendente per lo Studio dell’Assistenza Primaria Independent Group for the Study of Primary Health Care Established in 2009, currently its members are: Maria Concetta Mazzeo: President Elio Guzzanti: President of the Scientific Committee Americo Cicchetti: Founding member Giacomo Milillo: Founding member Goals: Promotion and fulfillment of research and study activities on the organization, economics and healthcare policy, particularly with regard to an in-depth examination of problems related to the promotion and development of Primary Health Care, also through the organization of educational activities. For more information, visit our website GISAP

Purpose of the study This study analyzes the collaboration between GPs and other Primary Health Care (PHC) professionals compared to what Italian National GPs Joint Agreements plan and according to some Regions’ experiences.

Background New trends : in demographyin demography →significant increase of population aged >65 years in healthcare needsin healthcare needs Need to rethink the Primary Health Care providing mechanisms Evolution of the context : Institutional →Constitutional Law 3/2001 and Law 42/2009 Organizational Financial →severe constraints on the Italian budget Source: Eurostat ( )

Background General Practice has been working for several years to define health care providing models: based on the gathering of different professionals and skills; in which the GP is responsible of the achievement of a “professional integration”; which are aimed at proposing to citizens a more complete and qualified service. Effectiveness – Efficiency - Accountability

“Functions” to be realized by GPs Clinical : activities of prevention, diagnosis, care and rehabilitation (h24; 7 days out 7; 365 days per year); Organizational : creation of adequate information flows and contribution to services planning; Educational : promotion of healthy life styles and assignment of responsabilities to patients and citizens. Background

Methods A perspective analysis of gathering models was performed and compared to those experienced in some Italian Regions through Regional GPs Joint Agreements.

Findings Italian National Joint Agreements considered voluntary forms of collaboration between GPs linked to financial incentives diversified according to the organizational complexity of gathering

Findings Simple Association (Associazione Semplice): Simple Association (Associazione Semplice): 3 to 10 GPs in their own studies Regular peer-review meetings Network Association (Medicina in rete): Network Association (Medicina in rete): 3 to 10 GPs in their own studies Network computer connection to allow each GP to access patients’ medical files GPs Group (Medicina in gruppo): GPs Group (Medicina in gruppo): 3 to 8 GPs in a single building Possibility to share assistants, nurses, medical and computer technologies National GPs Joint Agreements

Complex models of GPs gathering The “ Equipe” proposal (2000) Several regional models “Local structure characterized by a multidisciplinary and interprofessional integration, able to provide complete answers to population health needs.” (National GPs Joint Agreement, 2000)

Gathering of GPs, Paediatricians, and other professionals aimed at ensuring the integration of social and health interventions in a determined area. Equipe

Local Primary Care Units (UTAP): 2005 Experimental gathering models Experimental gathering models defined as: “Integrated structures for the supply of Primary Health Care, formed by the gathering of several doctors (GPs, Paediatricians, Specialists) who work in a single building, ensuring a high level of integration between general practice and secondary care.” (National GPs Joint Agreement, 2005) Complex models of GPs gathering

Local Primary Care Units Structured in a single building Have a basic organizational structure Have a basic technological equipment Purpose: To ensure a full continuity of care; an appropriate management of clinical pathways; To provide home and institutional care; some secondary care.

Primary Health Center (Casa della Salute) New experimental model provided by the Ministry of Health Programme “A new Deal for Health”, presented to the Parliament in June Main Goal: To promote, through the contiguity of facilities and of professionals, the integration between essential levels of health and social care. Complex models of GPs gathering

Primary Health Center Polyvalent structure able to supply the and to ensure Continuity of Care and activites of prevention to a catchment area of inhabitants. multidisciplinary approach to population care needs

Findings Although these models developped among GPs the attitude towards teamwork, time highlighted their limits. In few cases these models succeeded in minimizing negative effects of GPs competition, which is still the main obstacle to a full GPs collaboration. Limits of the voluntary models of GPs gathering

Findings Multidisciplinary Primary Care Units - PCUs Introduction of the Multidisciplinary Primary Care Units - PCUs (Unità Complesse di Cure Primarie - UCCP): mandatory; described as an “extended team” of professionals; each professional performs different and integrated functions each professional performs different and integrated functions FUTURE

Gathering of GPs, Paediatricians, and Specialists ; Can be defined as an “ extended team ” of professionals having their own tasks but the same mission; Don’t have a predetermined configuration: can be a single building or a network structure with headquarters in which some activities, technologies and services are concentrated. Multidisciplinary Primary Care Units Findings

Discussion more complete and qualified answer to population needs support of nurses and other professionals clinical functions Multidisciplinary Primary Care Units should provide a more complete and qualified answer to population needs through the provide of a 7/7d and 24/24h care by professionals who, thanks to the support of nurses and other professionals, could be appropriately concentrated on their clinical functions.

Conclusions The new Multidisciplinary Primary Care Unit model provided by the 2009 Italian National GPs Joint Agreement must be: tested in some Regions in order to be validated; implemented at the national level taking into account the singularities of each territory.

How to make the “dream come true”? How to share out work? How to define tasks and roles? Who has the power (or the duty) to take decisions? What kind of (and how much) hierarchy? How to manage new and specific situations? Conclusions