R ATIONALE FOR THE ANALYSIS

4. COMPOSITION AND PAY LEVELS OF THE ITALIAN NHS

62 A second major wave of reforms started in 1992 has led to an increase of managerial responsibilities to the Local Health Authorities (LHAs) and public Independent Hospital Trusts (IHTs), that is, to the organisations providing healthcare services to patients and to the general population, in coherence with the general principles and framework supplied by the New Public Management theories (Marcon and Panozzo, 1998; Anessi Pessina et al., 2004; Anessi Pessina and Cantù, 2006; Mattei, 2006).

However, the national Ministry of Health maintains a broad responsibility over the results of the system and specific prerogatives, especially in the personnel area. Here, at least two dimensions have a major importance:

- the professional regulation: the national parliament and Ministries of Health and of Education produce most laws and rules regarding professions³⁰. They refer to (see also De Pietro, 2005a: 37-82, and Tousijn, 2000):

o the identification/recognition of health professions;

o the definition of the so called “professional profiles”, stating responsibilities and competences of each of them;

o the regulation of orders and colleges³¹;

o the definition of numeri clausi for the university courses, both at the bachelor, master, and specialty levels³²;

two independent bodies as refer to NHS activities. Furthermore, for the same reasons also the Ministry of health statistics consider two autonomous bodies.

30 Major exceptions, with the main responsibilities assigned to Regions, refer to:

- the definition of professional skills and competences of supporting staff (for instance the definition of activities permitted to aides) and the regulation/provision of their education;

- the definition of regional norms that improve/specify the national regulation regarding the minimal staffing requirements for authorising healthcare organisations to provide services and/or to get public funding as NHS private providers;

- the role of Regions in the process defining numeri clausi for bachelor, master and specialisation university education (while the final decision is taken by the national Ministry of education);

- the organisation and provision of specialisation curricula for family doctors;

- the possible development of a “continuous education in medicine” programme integrating or substituting the national one (note that while named “continuous education in medicine”, it applies and requires mandatory education to all health professions).

31 In Italy Orders and Colleges are semi-public bodies subject to public law. All professionals must be enrolled with them in order to practise. Usually they are organised at a provincial bases (in Italy provinces are 107) with a national federation.

o requirement of minimal staffing for healthcare organisations;

o requirement of minimal continuous professional education;

o etc.;

- the collective labour agreements: the labour conditions for employed staff in Italy are set by national agreements signed by employers and workers organisations for each industry. In the case of organisations providing healthcare services, public staff of the NHS are regulated by three national agreements, regarding respectively: 1) medical doctors, dentists, and veterinary doctors; 2) biologists, pharmacists, chemists, psychologists, physics degrees, and other technical, administrative and legal staff with managerial responsibilities; 3) other staff (nurses, aides, laboratory and radiology technicians, administrative employees, etc.). Other staff working for private organisations providing healthcare services is regulated by other collective agreements always signed at a national level by employers and workers organisations, the most important among them being the agreement adopted by the main federation of private hospitals (AOIP). These national agreements are then integrated by “second level”

agreements signed at the level of each single healthcare organisation, but without major consequences or changes of the national agreements (that in any case state conditions that can only be improved – i.e. with advantages for employees – upgraded by the

“second level” agreements). In this framework, almost no role is left to Regions (while they have the main responsibility for organising, funding and running the system): this is a peculiar characteristic of the Italian labour market and legal setting, that guarantees a high level of homogeneity of labour conditions across Regions, despite the major inter-regional differences in terms of socio-economic development, cost of living, etc.

The analysis presented in the following pages refers to the positioning of Italian Regions along two main dimensions:

- the occupational composition of NHS staff, referring to ratios between the different occupational figures such as medical doctors, nurses, aides, etc.;

- the average pay of each occupational group.

In addition, the analysis will look at the economic consequences of these differences.

32 Numerus clausus (“closed number” in Latin; plural numeri clausi) consists of setting a limit to yearly

64 In particular, we define “composition effect” the economic consequences of the occupational composition of the staff of a certain RHS compared with the average composition of the NHS.

In the same way, we define “pay effect” the economic consequences of the average pay level for each figure in a certain RHS compared with the average pays in the NHS.

It is then possible to define a “total effect”, summing up the two effects referred above. The

“total effect” measures the savings (or greater expenditures) that the Region could obtain if it adopted the national average occupational composition among different figures (composition effect), and the national average pay levels for each of them (pay effect).

Figure 4.1 summarizes the basic definitions given above.

Figure 4.1. The elements of the positioning analysis.

The analysis can finally position RHSs on the matrix of Figure 4.2, where percentages on the axes gives us a measure of possible savings (with positive or negative sign) that Regions could obtain adopting national averages for occupational composition and/or pay levels, measured as percentage of the total regional expenditure for RHS salaried staff. It is then possible to highlight four areas of the matrix, combining compositions “light” and “heavy/expensive” with pay levels “high” and “low”.

COMPOSITION EFFECT

PAY EFFECT

+

=

TOTAL EFFECT

Figure 4.2. Matrix of regional positioning.

In the same figure, Regions that will position themselves above the diagonal (dotted line) have a combination composition/pay levels more expensive (and so they would obtain economic savings if adopting the national averages). Regions below the diagonal have a combination less expensive (therefore, they would spend more if adopting the national averages).

Finally, as already said it is possible to measure the economic consequences of the composition and of the pay levels effects for each Region, measured as percentage of potential decrease/increase of their expenditure for salaried staff pays compared with current spending.

In the following section the staff composition will be analysed not only referring to the occupational composition (measured by indicators such as the ratio between nurses and doctors), but also referring to what we define “organisational composition”. This second dimension of the staff composition refers to the managerial choices of each organisation of the NHS providing healthcare services. In this case, the management of the LHAs or IHTs will define their own organisational structure, with crucial choices about the number of clinical services, of coordinating jobs for nurses, etc. Left aside the organisational consequences of these choices (for example in terms of equilibriums between specialisations and integration needs), they also have strong economic consequences in terms of pay levels. In fact, the head of clinical units or the nurses coordinator receive higher pays than their colleagues (i.e., respectively, consultants or collaborating doctors, and team nurses).

Finally, a very important specification should be done about the “normative” utilisation of such COMPOSITION EFFECT

PAY EFFECT

-15% -10% -5% 5% 10% 15%

-15%

-10%

-5%

5%

10%

15%

High pay levels

“Heavy” composition

Low pay levels

“Heavy” composition High pay levels

“Light” composition

Low pay levels

“Light” composition

66 the performances of LHAs and IHTs (or of RHSs at large) should be evaluated for their effectiveness in pursuing their public mission and so a broader set of indicators should be adopted, while in a framework that should promote an efficient use of the public funding.

Moreover, the regional characteristics of the labour market can explain some decisions. Just as an example, in areas suffering nursing “shortages” LHAs and IHTs could effectively decide to increase the pay levels in order to retain or attract nurses.