4.2 Human resources
4.2.1 Health workforce trends
In 2010 the SSN employed a total of 646 236 health-care personnel, of which 70.2% are health staff, 18.1% technical staff and 11.7% administrative staff. Among health staff, 23.7% are physicians and dentists, 58.3% are nurses and the remaining 18% include other health professionals (pharmacists, biologists, physiologists and veterinarians22) (Ministero della Salute, 2013b). Almost 64% of SSN employees are women, with a marked concentration in nursing, rehabilitation and administration (Ministero della Salute, 2013). Overall, the number of health-care professionals increased from 1990 to 2011, especially with regard to practising nurses and midwives. In the last ten years an increase of 18% in the number of nurses and midwives has been registered (Table4.3).
The number of active physicians grew during the 1990s and early 2000s, declining to the minimum of 3.65 physicians for every 1000 population in 2006. The trend is now stable at around 4 active physicians per 1000 population. Over the same period, dentists also increased with a peak in 2006 (0.63 per 1000 population). The number of active pharmacists is available from 2004 only and here too there is an increase up to 2008 followed by a small decline.
By way of comparison Fig4.5 shows OECD data on the number of active physicians per 1000 population in Italy and selected European countries in 2012 or the latest available year. The rate in Italy (4.1) is on a par with that of Sweden and Germany and higher than the rates in France, Spain and the United Kingdom. (Other OECD data on practising physicians shows 3.7 practising doctors per 1000 people in Italy, which is slightly above the EU average of 3.4.)
Conversely, compared to these countries the number of nurses (not including midwives) per 1000 population is considerably lower in Italy, with the exception of Spain (Fig4.6). Interestingly, the nursing profession in Italy is currently experiencing an enhancement of its role, especially with regard to the management of patients with chronic conditions with the introduction of formal or informal nurse-led professional groups in primary settings (see Chapter 5). In terms of the combined number of physicians and nurses per 100 000 population, WHO data show that Italy is roughly in line with the EU average with around 1092 of these health-care professionals compared with an average of 1182 (Fig.4.7).
Fig4.8 shows in greater detail the trend in the number of dentists per 100 000 population over the last 20 years or so in a selection of countries. Europe registers a steady increase in the available number of dentists over time, with the exception of France and Sweden. In Italy the trend is rather unstable with peaks (1999 and 2006) and declines (1995, 2003 and 2008).
Fig4.9 provides a snapshot of the trend in number of pharmacists per 100 000 population across Europe. On average, for EU15 countries, the number has increased but the trend is not steady for all the countries featured, particularly Spain and Italy. The few data available for Italy indicate a sharp reduction in 2006 (−12 professionals available per 100 000 population in one year) followed by a significant increase in 2008 (+25 professionals available per 100 000 population in two years), and then a decline again before a new rise. These fluctuations are the outcome of intermittent employment freezes on public pharmacists imposed by national and regional level cost-containment measures and possibly of poor quality of available data (see Chapter 3).
4.2.2 Professional mobility of health workers
Few data at national level map the mobility (outflows and inflows) of health workers in Italy, especially with regard to personnel working outside hospital settings (e.g. informal care workers). Since 2007 the National Federation of Nurses (Federazione Nazionale Collegi Infermieri – IPASVI) has been monitoring the flow of nurses and reporting on the composition of the workforce; there are no reliable national data on the mobility of medical doctors or care workers.
Estimates report that Italy has a relatively low reliance on foreign medical doctors – less than 5%, when compared to the United Kingdom, Ireland and Switzerland where such rates range between 22.5% and 36.8% (Wismar et al., 2011). Currently, the country is facing a freeze on medical doctor turnover as well as health care-professionals turnover in general. In addition, it is difficult for both foreign-trained and domestically trained foreign medical doctors to find stable employment. Consequently, medical doctors tend to leave, rather than enter, the country. On the other hand, nursing shortages have led to high inflows of foreign nurses. In fact, one in ten nurses is of foreign origin. The largest groups are from the European free-movement area, including Romania (25%), Poland (10.7%), Switzerland (7%), Germany (5.6%), France and Spain (around 3.5% each), and a significant number are from south America (Peru 5.3%) (Wismar et al., 2011). The majority of foreign nurses have migrated to central and northern Italy. In addition, the elderly care and home-care sectors rely heavily on foreign carers, who nevertheless are mainly undocumented workers working in the grey economy. The demand for informal care workers (badanti) is estimated to be three times higher than the demand for nurses (Chaloff, 2008). The increasing demand for assistance for elderly people is the main driver influencing international health professional mobility. Recent legislation has sought to regularize the immigration status of care workers and partly reflects the needs of the health and long-term care systems; entry requirements for nurses also have been eased. However, health professionals from non-EU countries cannot hold permanent public sector positions and are thus disproportionally affected by less favourable working conditions.
To encourage health workforce mobility and strengthen education and capacity-building within the health professions, bilateral agreements have been developed at regional and local level. Regions and health-care units have primarily agreed bilateral programmes with foreign nursing institutes, especially with eastern European partners, to guarantee the recruitment of qualified professionals (e.g. through distance learning programmes).
4.2.3 Training of health workers
The educational pathway to achieving and maintaining professional status for doctors includes basic medical training, which occurs primarily at a public university (5–6 years). The initial years are dedicated to pre-clinical/basic science and later years to clinical rotation (university based). Before entering postgraduate specialization, medical graduates take a state examination in order to be listed in the national register and be granted the authorization to practise as physicians. Postgraduate education consists of a minimum two years of residency depending on specialty and is often much longer. Physicians wishing to become GPs must be registered on a national list. Ranking on the list depends not only on the number of educational and academic qualifications achieved but also, as of 1 January 1995, on successful participation in a two-year GP training course. Legislative Decree No. 256/1991, which implemented the EU directive on GP training, made participation in this two-year course compulsory to practise family medicine.23 There are lifelong continuing medical education (CME) requirements for public and private sector employees.
Since 1999, to limit the number of training positions available in the medical field, enrolment in university medical education programmes (medicine and surgery, veterinary science and dentistry) has been based on a competitive assessment exam. For the 2013–2014 cycle, there are 9897 slots available for medicine and surgery training, 825 slots for veterinary science and 984 slots for dentistry. There are also restrictions on advancement to postgraduate levels. However, it is worth noting that despite these efforts to control the national supply of medical doctors, there is still an oversupply in the country, resulting in an outflow to other EU countries, especially the United Kingdom and Germany, where they find more stable employment conditions (Wismar et al., 2011).
In 2001 the training programmes for qualified nurses changed to encourage more qualified personnel to enter the health-care workforce. Currently, nursing training occurs at university level (3 years) and includes foundation courses and clinical rotation at the end of which candidates are required to take a national examination. This is in line with EU Directive 85/595/ECC on the upgrading of the nursing profession. Some nurses continue with specialization programmes in fields such as public health, paediatrics, mental health and psychiatry, and geriatrics, taking a first or second level Masters degree or a two-year graduate degree. Doctoral programmes are also available.
Both doctors (GPs and specialists) and qualified nurses are registered in their national registries (Albo Porfessionale) that are available by specialties. Moreover, there is mutual recognition of medical qualifications gained in other EU Member States, Switzerland, Norway, Iceland and Liechtenstein for the purpose of practising in Italy.
In general, CME is recommended for continuing certification and career development for all health professionals. The National Programme on Continuing Education in Medicine (NPCEM) was established by the Ministry of Health in 2002 and from 2008 its coordinating body is the National Agency for Regional Health Services – AGENAS (see Chapter 2). All health professionals are currently required to earn 150 CME credits every three years (minimum 25 and maximum 75 credits per year), including comprehensive knowledge upgrades in management and leadership skills. Regardless of the profession or training level, in order to offer CME credits, institutions typically require accreditation by central or regional governments as part of quality assurance requirements.
Ancillary staff, such as laboratory technicians or nurses’ aids, are often trained through some specialized courses not associated with a university.
In July 2019, about 130 000 NHS physicians, veterinarians and healthcare managers started benefiting from the new agreement signed by the Italian Minister of Health, Giulia Grillo. The agreement resulted in a remuneration increase for medical personnel equal to 3.48% of their salary, which on average corresponds to EUR 190 more per month.
The fee paid to physicians for out-of-hours emergency medical services has also increased from EUR 50 to 100, and to EUR 120 for doctors working in the emergency room. Additionally, doctors over 62 years of age are eligible to ask for an exemption from Emergency Service. Furthermore, for those with 5 years of service within an hospital, remuneration has risen by EUR 2000 per year. The trade unions who signed the agreement were: Anaao Assomed, Aaroi-Emac, Fassid (Aipac-Aupi-Simet-Sinafo-Snr), Fp Cgil medici e dirigenti SSN, FVM Federazione veterinari e medici, Uil Fpl, Cisl medici, Cosmed, Codirp, Cgil, Cisl, Uil.