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Italy
The National Health Service (NHS) was first established in 1978 (Law
833) and subsequently partly amended in 1992 (DL. 502) and 1993 (DL.
517). It is a comprehensive universal NHS providing free care for
all citizens from birth to death. A new law is now being
discussed.It is based on a National Minister of Health, with
national capitation funding through the direct control of the 20
regional health authorities.
Direct financial responsibility is held
by the local district authorities, now transformed into trusts. Most
hospitals are directly managed by the district authorities. The
biggest hospitals, though, are now Trusts themselves with financial
autonomy.Apart from publicly owned health resorts, care is also
provided by agreement with private hospitals and specialists.General
practice is granted free of charge to all citizens. All district
inhabitants must choose their general practitioner (GP). Italian
general practice is list-based.
Almost all prescriptions and
referrals are decided by GPs who hold the entire clinical
responsibility for the patients. There are more than 56,000 GPs in
Italy.GPs are independent unsupervised medical practitioners paid by
the district authority on capitation (80 per cent) fee-for-service
and allowances (20 per cent). Terms of service are contracted and
agreed between GPs and the regional authorities every three years,
on a national basis.A new general practitioner's agreement is now
being negotiated.GPs are in charge between Sam and 8pm in private
practices.Out-of-hours services are performed by the National
Deputising Service with more than 20,000 doctors. They provide
urgent primary care during night hours, Saturday afternoons and
Sundays and holidays.
The new agreement provides possibilities of
innovation, eg, there is the possibility to create associations
between GPs.Terms of service for GPs include office and home visits,
diagnoses and treatment, prevention and screening as well as health
education. Working in general practice excludes any other medical
appointment by the NHS. Private medical activity is
allowed.Vocational training is now well established.The Ordine dei
Medici (FNOMCeO) exercises compulsory control on issues related to
deontology and medical ethics.Hospital care is also provided free of
charge. The Government introduced a new Diagnostic Related Groups (DRG)
system whose application is at the beginning.On the basis of income,
patients pay a contribution (co-payments) for specialist services
and for diagnostic procedure.The drug formulary includes free drugs
(first choice) drug with co-payments (second choice drugs) and
marginally effective drugs (entirely charged to patients).Authority
on capitation (80 percent) and with an overall medical population of
more than 31 5,000 doctors.Group work and team practices are rapidly
developing in general practice.
The remuneration of general practitioners
A GP is allowed a maximum of 1,500 (1,800 in some special cases)
patients on his or her list. This effectively places a constraint on
NHS income, since the payment system is a capitation one. NHS
earnings are therefore around £60,000 per annum and include around
20 per cent as reimbursement for expenses. All doctors are allowed
to work privately with limitations, except for GPs who are not free
to work privately with the patients on their list.
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