Will the treatment of allergies be possible only by individuals?

by Riccardo Asero and Roberto Polillo

From what we read in the proposals for reform of territorial medicine and hospital standards, it is clear that an irresponsible health planning policy is in place which tends to relegate allergology and clinical immunology to a role. residual and not essential for health protection. If at the level of the Ministry of Health it has been decided to completely privatize the therapy of allergic diseases, we must have the courage to declare it publicly.

October 28 – The COVID 19 epidemic has revealed the extreme weakness of our NHS, where the policies of linear cuts, implemented in response to the great financial crisis of the mid-2000s, have reduced and reduced health and organic structures, seriously compromising the ability to respond to pandemic events.

The poor performance of our country inevitably forced a change of strategy on the part of the public decision-maker and the Recovery and Resilience Plan (PNRR) has become the tool for relaunching our NHS. An ambitious project characterized by the provision, in the specific chapter of the document “Mission 6” dedicated to health, of specific funding for health, quantifiable at 15.63 billion and by the definition of two macro-areas of priority intervention.

The two intervention zones denoted M6C1 and M6C2, as we know, concern respectively:

• Local networks, intermediary structures and telemedicine for territorial health care: the interventions of this component aim to strengthen the services provided in the territory through the strengthening and creation of territorial structures and equipment (such as Community Foyers and Community Hospitals), the strengthening of home care, the development of telemedicine and more effective integration with all social and • health services (allocation of 7 billion euros).

• Innovation, research and digitization of the national health service: the measures included in this component will allow the renewal and modernization of existing technological and digital structures, the completion and dissemination of the Electronic Health Record (ESF), better capacity to provision and monitoring of Essential Levels of Assistance (LEA) thanks to more efficient information systems. Significant resources are also allocated to scientific research and the promotion of technology transfer, as well as to strengthening the skills and human capital of the NHS also through the improvement of staff training (allocation of 8.6 billion euros).

In parallel with the PNRR, the Ministry of Health and Agenas have prepared a text amending the ministerial decree 70 on hospital standards and a proposal for reform of primary care.

These are coordinated measures that have a dual objective:
• redefine the organization of hospital care with the promotion of a model based on the intensity of care, on the establishment of intensive and sub-intensive care places, on the expansion of clinical networks with the dual objective of give a system that is too rigid, criteria of flexibility, resilience and priority of intervention and promote the reference disciplines of clinical networks by investing in these technologies and human resources.

• strengthen the primary care system with the creation, within the framework of a precise timetable, of community homes, community hospitals and home care with the aim of ensuring the care, monitoring and assistance of patients with acute / chronic illnesses not requiring hospitalization; define protocols for implementing hospital and territorial continuity through the creation of operational centers in each district dedicated to this.

In this great reform process which will involve the overall structure of our NHS, the major absentees are the allergological-immunological (and to a lesser extent rheumatological) disciplines which risk becoming totally residual and not essential for the needs of functioning and functionality. of the two branches. . assistance (hospital and regional).

Proceeding in order, we highlight some critical elements that emerge from reading the documents:
1) Hospital assistance (Amendment of Ministerial Decree 70)

• For the discipline of allergology and immunology, the old standards relating to the number of structures / services without beds per population pool are confirmed: By allergology: one structure (indifferently complex, departmental or simple) per watershed between 2 million and one million inhabitants ; for immunology, the numerical parameter is between 4 and 2 million. This means that for a region like Lazio, the maximum number of structures that can be activated would be between 5 and 3 for the first and between one and two for the second.

• For the discipline of rheumatology, structures with beds are reconfirmed (1 for 1.5 million -700,000 inhabitants) and those without beds (1 million-500,000 inhabitants) are introduced as an alternative.

• In pulmonology, only structures with beds are planned and the reference parameters are lowered (one for 600,000 to 300,000 inhabitants).

• The number of clinical networks (three previously) is set up, strengthening their functional characteristics. In the document “Clinical networks represent an organizational method for the coordinated management of the entire chain of care for specific pathologies or services within the framework of population basins and the distribution of specialties. The clinical network is based on a system of close relationships between centers (nodes) organized according to the Hub and spoke model…. In the definition of networks, the integration of acute and post-acute activities with territorial activity must be considered …

• The networks defined in the document are:
1) time-dependent networks (emergency-emergency, cardiology, stroke, trauma, birth points);
2) specialized medical networks (infectious diseases and response to epidemic emergencies);
3) oncological networks (oncohematology and rare tumors)
4) pediatric networks;
5) neurodegenerative disease networks
6) transplant network;
7) network of diagnostic and treatment services;
8) pain therapy network;
9) rare diseases network;
10) rehabilitation and hospitalization network.

It is quite obvious that the absence of any reference to an allergological and / or immunological network acquires a clear meaning; indeed, the legislator does not consider these disciplines as essential for the purposes of health care and therefore does not define standards such as quantities capable of guaranteeing universality of access and uniformity of levels of supply. An unacceptable position both for the complexity, gravity and chronic evolution of pathologies that fall within the discipline (ADR of drugs, allergy to hymenoptera venom, severe food allergy, severe asthma, etc.) and for the increasing spread of allergic diseases.

• In the amendment text of MD 70, the standards of hospital structures are also redefined (basic equipment, first aid and first and second level DEA practices) and none of these include the figure of the allergist while almost all other specialties with varying degrees of structuring within the Presidium. The same considerations as above apply to this part of the document.

2) Territorial assistance “Models and standards for the development of territorial assistance in the national health service”

Agenas and the Ministry of Health have prepared a new version of the document “Models and standards for the development of Territorial Assistance in the National Health Service” in order to completely rethink primary care and address the main issues strictly related to health. interventions envisaged in the Mission 6 Component 1 “Networks, local structures and telemedicine for territorial health” of the National Recovery and Resilience Plan “.

• In the document, a central role is given to the District which will have the mission of coordinating various services including the Hub and Spoke Community Houses, the Community Hospitals, the Usca, the Hospices, the family nurses, the home care and the implementation of the toll-free number 116117 for non-urgent care.

• The characteristics of the Hub and Spoke structures are redefined with the indications of the related specialty disciplines.
• In this case also no reference is made to the allergist, while the presence of a spirometer is one of the obligatory instruments which inevitably requires the presence / opinion of a specialist pulmonologist, favoring the replacement process already. ongoing in various regional situations.

Final considerations

It is clear that an irresponsible policy of health planning is in place which tends to relegate allergology and clinical immunology to a residual and non-essential role for the purposes of health protection.

An irresponsible choice which will deprive citizens of essential and irreplaceable services also in relation to the provisions of the new LEA which have remained inapplicable, in which certain services are, on the contrary, the exclusive responsibility of the allergist.
The consequences will be the impossibility of adequate treatment by citizens suffering from serious pathologies and mortification for professionals who have devoted their professional life to allergology or who after having obtained a regular qualification will not have access to the world of job. .

The scenario that emerges is therefore that of a dramatic impoverishment of our NHS ‘ability to respond to growing health needs and the liquidation of a tradition which in our country has relied and can count on world-class excellence.
We need a clear and strong response from the scientific societies concerned and a spirit of service which has been lacking until now.

It is therefore a terrible challenge that awaits us that we can only win by joining forces and aiming for a strong and convinced dialogue with all the institutions involved by the Ministry of Health, at the State-regions conference, by Agenas. and the representative bodies of the category.
It should not be forgotten that in industrialized countries (including Italy) about 25% of the general population suffers from allergic diseases. One wonders which structures these citizens will have to turn to in the future for treatment, given the situations described above. We must define a territorial network of allergists who take care of this mass of patients / citizens who otherwise would end up turning to a few hospitals (obviously totally insufficient to meet the needs of all these people) or to private centers that have judiciously the allergy specialist.

The recent SARS-Cov-2 pandemic has led to the rediscovery of the indispensable character of the allergist specialist for the diagnosis and adequate treatment of adverse effects of vaccines, while in future health planning this professional figure is surprisingly completely ignored. Allergic reactions to drugs, foods, hymenoptera venoms, to name but a few, are frequent and only the specialist in allergology and clinical immunology has the necessary skills to be able to take care of patients suffering from these pathologies.

If at the level of the Ministry of Health it has been decided to completely privatize the treatment of allergic diseases, we must have the courage to declare it publicly. There is only one alternative and is to put the above programming back to work to remedy this serious flaw.

Riccardo Asero
President of the Italian Association of Territorial and Hospital Allergists and Immunologists (AAIITO)

Roberto Polillo
Member of the National Council of the AAIITO

28 October 2021
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