Policy responses for Italy - HSRM


Policy responses for Italy

2.2 Workforce

Measures towards maintaining or increasing the health workforce
The ‘Relaunch Decree’ of 19th May (n° 34), together with its latest amendments of 28th June, established that healthcare professionals who by the 31st December 2020 have been in service with precarious work contracts for 36 months will switch to an open-ended employment contract. This deadline was set in order to guarantee that those on the front line during the Covid emergency will be included. Furthermore, healthcare workers active on the Covid-19 frontline will be awarded a bonus up to EUR 2,000.

In parallel, a new amendment inserted into the ‘School Decree’ approved on Thursday 28th May, awards 50 Continuing Medical Education (CME) credits for the year 2020 to doctors, dentists, nurses and pharmacists who continued working during the Covid-19, as a compensation for the knowledge and skills acquired while dealing with the pandemic.

At 2nd November 2020, a total of 453 doctors and 868 nurses from the Armed Forces have been working alongside the National Health Service throughout the country. Military health personnel have been employed in 200 testing drive-throughs and are also available to collaborate in other emergency activities in several Italian provinces.

It appears that, for the second wave, Italy is suffering from a shortage in anesthetists by almost 2000 workers. Methods to respond to workforce capacity shortage are part of processes that can seldomly be shortened as not all newly recruited physicians are skilled for certain specialties. Thus, available anesthetists will be required to work longer hours until newly trained staff becomes available.

The Stability Law 2021 has increased funds for economic incentives for healthcare personnel employed in the COVID-19 emergency by EUR 40 million. Frontline healthcare professionals have been experiencing an increased burden of stress, faced daily with severe illness or death. In the Italian context, the risk of acute stress disorder, burn-out syndrome, and full psychiatric disorders is very high, highlighting the importance of providing the necessary mental health support. So far, a few mental health professionals are directly involved in the direct management of the crisis. However, many independent and mainly on-line initiatives have been launched at facility level rather than as national or regional initiatives.
- https://www.nurse24.it/dossier/covid19/riconosciuti-50-crediti-ecm-infermieri-emendamento-campari-dl-scuola.html
- Law Decree 19th May 2020, n. 34  - Urgent measures in the field of health, support for work and the economy, as well as social policies connected to the epidemiological emergency caused by COVID-19. [Available at https://www.gazzettaufficiale.it/eli/id/2020/05/19/20G00052/sg]
- Amendments to Law Decree 19th May 2020, n. 34 of 28th June – [Available at http://www.quotidianosanita.it/allegati/allegato8651425.pdf]
- http://www.quotidianosanita.it/m/governo-e-parlamento/articolo.php?articolo_id=89508
- Alwan NA, Burgess RA, Ashworth S, et al. Scientific consensus on the COVID-19 pandemic: we need to act now. Lancet 2020; published online Oct 14. http://dx.doi.org/10.1016/S0140-6736(20)32153-X.
- Paterlini, M. (2020). Covid:19: Italy has wasted the sacrifices of the first wave, say experts. BMJ, m4279. doi: 10.1136/bmj.m4279
- https://www.quotidianosanita.it/governo-e-parlamento/articolo.php?articolo_id=91256
- Sani G, Janiri D, Di Nicola M, Janiri L, Ferretti S, Chieffo D. Mental health during and after the COVID-19 emergency in Italy. Psychiatry Clin Neurosci. 2020 Jun;74(6):372. doi: 10.1111/pcn.13004. Epub 2020 Apr 24. PMID: 32248608.

The shortage of healthcare professionals has been an on-going public health issue of great relevance for Italy and, now more than ever, the matter has come to the fore.

According to a 2019 OECD report, tying with Russia and Denmark, Italy ranks 9th and above average in terms of the patient- to-doctor ratio among OECD countries (3.5) with 4 doctors per 1000 inhabitants, with a total of 92 855 employed in hospitals. In contrast, the patient-to-nurses ratio is among the lowest in the group (5.8), ranking 24th and considerably below the OECD country average (8.8) with a total of 233 053 nurses employed in hospitals.

Consequently, Italy has one of the lowest doctor-to-nurse ratios in the OECD at 1.4 nurses per doctor. In response to the imbalance, while the number of medical graduates has stayed relatively constant at 6 500 per year, the country had already been working on increasing the number of nurses in training (yearly graduates went from 3 100 in 2000 to over 13 000 in 2014). The challenge, however, has remained to create enough positions to absorb the growing number of a potentially active workforce.

Measures towards maintaining or increasing the health workforce
To face the emergency, several measures have been applied, creating faster recruitment tracks or allowing more freelance contracts to be released. Decrees 9/03/2020 and 17/03/2020 have implemented a series of measures to increase the availability of health workers for a total of EUR 660 million. Among these, the government approved the hiring of 20 000 healthcare professionals, allocated EUR 250 million for staff overtime, authorized the possibility for healthcare facilities to hold back their staff eligible for pension, offered retired doctors and nurses the opportunity to volunteer to practice and requested temporary enrolment of doctors and nurses from the armed forces. In addition, freelance contracts for doctors and nurses are permitted for those who are not yet listed in the Medical Register and temporary practice in Italy is allowed for those who have been practising abroad under EU directives.

On the 20th and 28th of March, the Department of Civil Protection issued two Ordinances (N° 654 and 656, respectively) to establish a Specialist Medical Unit and a Technical-Nursing Unit through online calls. A total of 300 physicians and 500 nurses (from the National Health Service, private clinics and freelancers) have been selected on the basis of specific requirements by the Head of the Department of Civil Protection. Participation is voluntary and volunteers will be sent to areas facing greater difficulty in the COVID-19 emergency. The hosting regions reimburse transfer and accommodation. In addition to their normal salary, each professional will receive a flat-rate solidarity premium of EUR 200 for each day of work, paid by the Department of Civil Protection. Almost 7,000 doctors and 10,000 nurses have applied as candidates.
Since the beginning of the outbreak, several regions have been increasing their workforce capacity. In absolute numbers, by 8th May, Lombardy has hired 589 additional doctors (+ 3.8%) and 1,016 nurses (+ 2.6%) whereas Emilia Romagna hired 421 doctors (+ 4.7%) and 1032 nurses (+ 4.0%). The biggest effort was made by Marche, which increased its capacity of clinicians by 15.8% and of nurses by 7.3%.

Safeguarding health workers’ mental health
Following the advice of the Scientific and Technical Committee, the National Institute for Insurance against Accidents at Work (INAIL) has established collaboration with the National Council of the Order of Psychologists (Cnop) to jointly promote the activation of psychological support services in aid of healthcare professionals during the emergency. They are developing and providing directives and tools to enable all healthcare facilities to provide services for stress management and burnout prevention of their health workers. Health facilities are, in fact, advised to set up task forces of psychologists even through distance counselling. INAIL has provided links to training materials specific for dealing with the Covid-19 emergency and has designed a triage system for psychologists to timely assess their patients’ situation and monitor them over time. A dedicated e-mail account ([email protected]) has also been created to encourage the establishment of a national network of healthcare facilities and sector operators.

Ukraine has sent over 16 doctors and 4 nurses in support of Marche region and Albania has sent 30 medical personnel to Lombardy.

On 9th April 86 volunteers (medical doctors) from the south of Italy were deployed in the most affected regions in the north (Lombardia, Emilia Romagna, Marche and Liguria) and were assigned to the hospitals of most affected cities to support COVID-19 clinical response. Moreover, integrated doctors-nurses teams from Albania, Tunisia, Cina, Cuba, Poland and Russia have come to serve in the most affected areas of Lombardy such as Bergamo, Brescia and Cremona.

A team of 19 medical doctors from Norway and another team of 11 doctors and 4 nurses from Romania have been deployed to Lombardy through the European Civil Protection mechanism.

The Della Valle family, owner of the luxury brand Tod’s Group, has donated EUR 5 million to the families of health professionals who have lost their lives in the battle against Covid-19. The fund is being administered by the Civil Protection and is called "Always with you" and the account is open to donations on behalf of anyone who wishes to contribute.

- https://www.oecd-ilibrary.org/docserver/4dd50c09-en.pdf?expires=1585588812&id=id&accname=guest&checksum=38C2E9718F8893844D29E997755F0EAB 
- Ministry of Health, 2017. Statistical SSN Yearbook – Organizational framework, activities and productive factors of the SSN. http://www.salute.gov.it/imgs/C_17_pubblicazioni_2879_allegato.pdf 

- OECD, European Observatory on Health Systems and Policies and European Commission. State of Health in the EU, Italy, Country Profile 2017. http://www.euro.who.int/__data/assets/pdf_file/0008/355985/Health-Profile-Italy-Eng.pdf?ua=1 

- http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioNotizieNuovoCoronavirus.jsp?lingua=italiano&id=4188 

- http://www.protezionecivile.gov.it/amministrazione-trasparente/provvedimenti/dettaglio/-/asset_publisher/default/content/ocdpc-n-654-del-20-marzo-2020-ulteriori-interventi-urgenti-di-protezione-civile-in-relazione-all-emergenza-relativa-al-rischio-sanitario-connesso-all-

- Department of Civil Protection Order n° 656, 26th March 2020 – “Ulterior emergency interventions for health risks linked to the insurgence of pathologies deriving from transmissible viral agents” https://www.gazzettaufficiale.it/eli/id/2020/03/28/20A01917/sg 

- https://www.inail.it/cs/internet/comunicazione/news-ed-eventi/news/news-covid-19-supporto-psicologico-operatori-sanitari-2020.html
- ALTEMS Covid-19 working group - Instant REPORT#6: 8 Maggio 2020  - Analisi dei modelli organizzativi di risposta al Covid-19, available at https://altems.unicatt.it/altems-6REPORT%20ALTEMS.pdf