Including mental health care in a model of European health system.

The management of a health system is a matter of economics and business administration because of the costs induced by goods and services delivered. Economics teaches us that the positive effects induced by competition in free markets cannot be expected in health care, which is a classic example of market failure from both demand and supply sides. The most sensible key concepts to refer for managing a health system are funding and provision. While the logical solution for the first variable is universal coverage through general taxation, the second one requires a deeper understanding. Integrated care is the modern approach that better supports the choice in favour of the public sector also for service provision. A major threat against this approach is dual practice legally allowed for health professionals, which inevitably raises financial conflicts of interest. An exclusive contract of employment for civil servants should be the sine qua non for providing public services effectively and efficiently. Integrated care is particularly important for long-term chronic illnesses associated with high levels of disability, such as neurodegenerative diseases and mental disorders, where the mix of health and social services needed can be very complex. Nowadays the growing number of community-dwelling patients with multiple physical and mental health needs is the major challenge for the European health systems. This happens also in public health systems, which should provide universal health coverage in principle, and the case of mental disorders is striking. In the light of this theoretical exercise, we strongly believe that a public National Health and Social Service should be the most indicated model for both funding and providing health and social care in modern societies. The big challenge of the common model of European health system here envisaged would be to limit the negative influences of politics and bureaucracy.

The role of general practitioners in the EU: time to draw lessons from a too wide range?

Although the role played by general practitioners (GPs) is historically consolidated, continuous changes have been recently introduced in Europe because of the increasing multimorbidity and complexity of patients. Here we try to compare the roles played by GPs in the four major countries of Europe. In France GPs are self-employed medical doctors, and their remuneration consists of a payment scheme for the services provided. The weekly opening hours of French GPs are on average approximately 48. In Germany primary care is mainly provided by GPs and outpatient internists, and patients are free to choose the facility and the professional. German GPs are self-employed professionals mainly remunerated for each consultation, who work for an average of 50 opening hours per week. In Italy GPs are self-employed professionals mainly paid on per capita basis, who have their own list of patients and must guarantee a minimum number of clinical opening hours per week, which has often become the average number in practice. Accordingly, the patients' weekly access to Italian GPs' clinics is very limited. In Spain GPs are civil servants who work in multifunctional facilities with multi-professional teams. The weekly hours worked by Spanish GPs are 38 hours, as for any other civil servant. Trying to draw positive lessons from the comparison, the Spanish facilities seem to be the most advanced examples of horizontal-integrated organizations able to fulfil the expectations of a growing population of ageing people. The range of generalist professionals could be enlarged beyond GPs, as the German example shows.

[The European mosaic of specialty training programmes in general practice.] / Il mosaico europeo dei programmi di formazione specialistica in medicina generale.

During last decades, general practice has been internationally recognized as an independent and essential medical specialization, with specific skills and tasks. This inevitably created the need to widely implement an organized specialty training programmes to allow future general practitioners to acquire all the skills and knowledge necessary to work within the world of primary care. However, this process has not led to homogeneous applications in European countries, mainly due to the profound and structural differences of each national health system. In our contribution we have tried to make a synoptic comparison of specialty training programmes in general practice in the main European countries (England, Italy, Spain, France and Germany).

[The European enigma of pharmaceutical pricing: still solvable?] / L'enigma europeo dei prezzi dei farmaci: è ancora risolvibile?

The attempt to regulate pharmaceutical pricing has a long tradition in Western European countries and various solutions have been experienced in recent decades to try to control public pharmaceutical spending. Nonetheless, drug prices have become increasingly out of control and unsustainable even in the richest European countries. In a situation of "market failure" such as the pharmaceutical one, in fact, two totally opposite needs collide: the main objective of the health authorities of universal access to essential drugs, versus the aim of the pharmaceutical industry to maximize turnover in order to guarantee high returns on investments. We are therefore convinced that the growing threat of drug prices that are too high must be solved with drastic solutions. The goal of this contribution is therefore to first summarize the current situation of pharmaceutical pricing in Western European countries, then debate the main issues currently discussed and finally propose a radically alternative scenario that moves from prices to the budget.

[What future for the pharmaceutical patenting in europe: reforming or getting rid of it?] / Quale futuro per i brevetti farmaceutici in Europa: riformarli o eliminarli?

The covid-19 pandemic and the anti-SARS-CoV-2 vaccines have once again brought to the fore the issue of patents in the health sector. The current European panorama on the patenting of pharmaceuticals is rather confused and difficult to understand, characterized by a precarious (dis)balance between the commercial incentives guaranteed to the industry by supply-side patents and the regulatory framework in support of public interests on the demand side. Here, we first focus on a regulatory analysis of pharmaceutical patenting and more in general on market exclusivity within the European Union, and then set out some proposals for a radical reform of European legislation. In particular, we believe that there are three major critical issues on the subject that must be addressed and reformed as soon as possible: 1. the management of pharmaceutical patents through the European Patent Office and the parallel network of national offices, 2. the excess of discretion of pharmaceutical companies in the filing of patents and 3. the short duration of market exclusivity on drugs. In fact, the right moment has come to definitively reform the European legislation on pharmaceutical patents in line with the tradition of continental welfare.

Pharmaceutical pricing in Europe: time to take the right direction.

A price stems from the intersection between supply and demand curves in any common market. However, there are special markets where consumers do not pay for goods directly, and prescription drugs are a well-known example in healthcare. Drugs are mainly funded by public expenditure in well-established welfare systems like those of the Western European countries. However, the present era of austerity in public funding has made financial resources scarce in most European nations. Currently, the leading tendency for pharmaceutical pricing in Europe is direct negotiation with pharma companies. However, these negotiations are administratively burdensome, with costs not necessarily offsetting savings. Moreover, since any trade negotiation implies some degree of confidentiality to be effective these strategies are scantily transparent. When prices are set for many products through unavoidably arbitrary decisions, the final consequence is an irrational allocation of financial resources. Here, we raise a proposal to restore a reasonable balance between public equity objectives of health authorities and private profit incentives of the pharma industry in Europe, switching from pricing to budgeting. The underlying rationale of our proposal is to stop setting arbitrary prices in a context of market failure.

Integrated care in Western Europe: a wise solution for the future?

INTRODUCTION: IC is a term commonly adopted across the world underpinning a positive attitude against fragmentation of healthcare service provision. While the principles supporting IC are simple, their implementation is more controversial. AREAS COVERED: The growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by aging multi-morbid patients. A comprehensive definition of IC should now include the coordination of health and social services useful to deliver continuous care across organizational boundaries. The recent debate on IC is largely influenced by the mismatch between the increasing burden of health and social needs for chronic conditions from the demand side, and the design of health-care systems still focused on acute care from the supply side. EXPERT OPINION: The major reasons of persisting IC weakness in European countries stem from arguable choices of health policy taken in the recent past. The political creed in 'market competition' is probably the most emblematic. All initiatives encouraging health-care providers to compete with each other are likely to discourage IC. Since most European GPs are still self-employed professionals working in their own cabinets, the anachronistic professional status of GPs is another historically rooted reason of IC weakness.