The coronavirus epidemic forces us to rethink the future of public healthcare starting from now. We cannot consider healthcare spaces without looking at the emergency situation we are dealing with: the present pushes us towards a global reset. Tomorrow, once the emergency is over, what will the relationship be between regions? Who will have to make decisions regarding the health of the Italian citizens- the Government or the individual Regions? Additionally, we will have to search for new planning models and also offer spaces to reflect on what we want our National Health Service (NHS) to be from now on, in light of the gaps and flaws of the system. It is not enough and perhaps it doesn’t even make sense to feel pleased when saying we have the best healthcare system in the world: everything we once considered “adequate” for healthcare, seemingly appropriate and fair up to roughly two months ago, now suddenly seems old, even obsolete.
Appropriateness is something to reason on in new terms.
Therefore, also healthcare construction, the concept of healthcare space, suddenly becomes something that goes beyond the resources, the wards and the projects that we must continue carrying out. In recent weeks the healthcare emergency of the country has highlighted the need for a new innovative conception of healthcare spaces. The hospital and the regional offices will have to follow more adaptable and flexible criteria. The wards will have to be partly redesigned, in modular form, with beds spaces that can be converted based on the needs of the moment. The hospital is no longer a sacred totem but rather a living organism. That’s already happening by force in the areas most affected by the viral epidemics of the recent weeks. In just a few days entire wards were emptied- their “normal” patients were safely transferred away- and refilled with Covid-19 patients.
The context we knew completely transformed in the span of a few hours. It was the product of reforms, cuts and planning attempts. Hospitals born and restructured with the organizational adjustments of the past few years found themselves changing skin to face an emergency and doing it “empty handed”. Healthcare workers were forced to improvise the role of a trench troop, ready to crawl through the mud, trying to gain a meter and respond to the attack of an unknown and unexpected enemy.
What has happened
The rock-solid certainties of the “healthcare company” system we knew were shattered; it was designed to focus on the monetary balance, based on the number of beds, with renovations that targeted more financial than health outcomes. Interventions were based on contingency plans –forced by increasingly less sustainable costs – that now seem incomplete.
The philosophy behind the 2015 DM (Ministerial Decree) no. 70 crumbled. It was a measure “born old”, as several experts in the sector labelled it since the beginning, and it was never fully implemented, making it even clearer that the creation of a new healthcare world is now not only feasible but a must.
The DM no. 70 was the most recent attempt to reorganise the national healthcare network identifying similar standards throughout the territory. However, those criteria proved inadequate in light of what has been happening with the pandemic. The policy applied the bed-per-inhabitant parameter provided by the spending review of the Monti Government, with a reduction of 3,000 beds according to the new standards of 3 beds per 1,000 inhabitants for acute care and 0.7 beds per 1,000 for long-term care and rehabilitation.
We cannot retrace the complexity of the last twenty years of health policies, starting from the reform that turned local healthcare departments into local health agencies, that drastically modified the Title V (section of the Italian Constitution related to establishing authority over healthcare management between the Regions and the State [N.d.T.]), the funding, the hospital standards, and the complex architecture, product of a continuous conflict between the Regions and the central Government. So, we will just consider the tip of the iceberg represented by the criteria of the DM no. 70.
In face of the tragedy in Lombardy the rigor of the decree just seems like an ideological waste. The logic behind these years of conflicts between hospitals that, armed one against the other, tried to defend their bed places and functions, suddenly becomes something intolerable.
The coronavirus will leave its mark, not just on our skins – happy, hopefully, to have escaped it – but also on the model of healthcare that the country must rethink; a model ensuring that what is happening on the hot front of the northern regions never happens again. We would need a new think-tank made of the best available experts, administrators and trade unions, in order to create a reform that’s really looking to the future and to system efficiency, with new modalities able to put healthcare at the centre of politics, rather than viewing it as a crouch or, worse, as a cash machine to plunder. Healthcare planning must be reorganised.
The greedy approach that “scissors hands politicians” displayed towards healthcare policies is no longer sustainable.
In recent years the number of beds, just like the number of hospitals, dropped. They were around 311,000 in 1998; they decreased by 90,000 units in 2007 reaching about 225,000, and then about 191,000 in 2017, the last available data.
The ratio with the number of inhabitants went from 5.8 beds per 1,000 inhabitants in 1998, to 4.3 in 2007, and 3.6 in 2017.
The guidelines are partly outlined in the new Pact for Health between the Government and the Regions that was launched in December. The document presents many points, that took long months of negotiations and discussions between two governments, and among the measures there is also the speeding up of the admission process to the 32-billion fund for healthcare construction, with a clause allowing the Ministry of Health to run checks on the state of the approved interventions. Moreover – in line with our reasoning – the Pact includes the option to overrun the ordinary legislation in cases of emergency or potential extraordinary needs so that emergency healthcare construction interventions can take place.
How to start again
Maybe we will need a sort of Pact-bis in order to reassess the more urgent emergencies. Starting again means rethinking the relationship with technology and with innovation, especially in light of what is happening during the coronavirus emergency, which highlighted a strong necessity for intensive and non-intensive care equipment for wards.
Let’s go back to our totem hospital, referring to the types of beds that are in line with the regional funds. The equipment meant for ordinary beds and that intended for the beds of intensive or non-intensive units is significantly different. Perhaps we should design a flexible area to locate next to the standard provision of units and beds. Lorenzo Leogrande, the President of the Italian Association of Clinical Engineers (AIIC)- comprising of more than 2,000 clinical engineers- explains, “What we are facing, and what we have been partly subjected to, is teaching us that it can become necessary to convert, overnight, a large number normal inpatients beds into intensive care beds. Nowadays getting a supply of technological equipment has become ‘the’ number one problem because the market has been literally ransacked, so there is no availability. Everything is linked to the production capacity of the companies, which now declare waiting times that are too long to meet our needs. During past emergencies the technological difficulty used to be a minor issue, yet today we are part of a global struggle to purchase equipment, and that changes everything.” Aside from the equipment, in order to restructure a ward, you need to also consider the plant engineering. You cannot convert all the beds, as that would not be sustainable, yet that is already happening today, with great difficulty, in the red zones.
Several hospitals in northern and central Italy are dedicating entire wards to Covid-19 patients. Part of them is in critical conditions and requires intubation but the vast majority needs ordinary assistance from an infection ward. The emergency caused the demand of beds in intensive and sub intensive care units to explode, tripling and quadrupling the associated needs. In the future we could experience another type of emergency so having modular wards then might be a feasible solution.
“We need to find the correct mix of intensive care beds, those regularly required for healthcare routine use and a certain number that can be easily reconverted in a future emergency. Obviously, we need a technological and plant engineering reorganisation, and the future healthcare will have to give more space to the technical expertise that can manage and implement this change,” explains Leogrande.
The construction of intensive care units has to follow precise standards, in terms of the plant engineering, mechanical and even the air recirculation design, especially when dealing with infectious patients. “Intensive care units must also be properly designed so that by acting on the plant engineering and all its relevant aspects, and on the filters, you can change its way of functioning. This way you can optimize the microenvironment of the space where these patients are located, providing greater safety for the healthcare workers.”
According to the President of the AIIC: “In light of this emergency, our convictions need to be reviewed, starting from the logic behind management, in terms of human and economic resources. Merging local health agencies made them lose relevant expertise, at the expense of their service efficiency.” It is the same as saying that if there is a problem on a ship the engineers need to be onboard to conduct the repairs. Healthcare spaces are an innovative ground that we will have to focus on facing more than just the technicalities, that originate from the multi-year investment program in healthcare construction and technologies proposed by article 20, of Law 67/1988. This has always been the guiding star for the redevelopment of the construction and technological public heritage.
Healthcare spaces are an innovative ground that we will have to focus on facing more than just the technicalities.