National Health System: crisis management or crisis in management?

2020 began with a serious stress test for healthcare systems around the world due to the spread of a viral agent that was little known and highly contagious, which swiftly turned a local outbreak into pandemic, triggering a crisis on a global scale. This crisis has not spared our National Health System (Servizio Sanitario Nazionale or SSN), materializing as a multi-faceted phenomenon, which makes it worthwhile to explore at least one of the many contexts engaged in facing this emergency: management.

Specifically in relation to management, there are three different aspects of ‘crisis’.

First, the coronavirus epidemic is a clear-cut example of crisis management. Objectively speaking, we are facing a disruptive event that risks dramatically overwhelming our SSN, its internal stakeholders (e.g. doctors, nurses and other healthcare workers) and external stakeholders (e.g. citizens and suppliers), with fallout that could potentially erode people’s trust in the national health system itself. What is the way forward? We need to leverage two crisis management tools, one in the pre-crisis stage (stakeholder management) and the other when the crisis strikes (organizational communications). As regards the first, the levers that we can utilize are limited by the ongoing contingency. Yet we can acknowledge that the current system in this country is the result of tensions pulling in two different directions: on one hand is the pressing demand for territorial autonomy from the richer regions (at the moment the areas with the highest exposure to the Covid-19 crisis), and on the other a push toward centralization (consider compulsory administration enacted in regions with high healthcare debt, and the referendum on 4 December 2016), In reality, Italy found itself facing coronavirus with its vision of the SSN still under construction, to say the least, and with a distinct disconnect between central and regional administration.

With no well-defined stakeholder management ex ante, in itinere we are witnessing a complex reconfiguration of institutional interdependencies, a process that certainly does nothing to facilitate organizational communications. Much could be said on this point, but here it is worth underscoring that our country, knowingly or unknowingly, has opted to derogate from the principle of ‘speaking with one voice’. In reality, when a crisis is particularly complex, and Covid-19 undoubtedly qualifies, speaking with many voices could be a winning strategy, so as to be comprehensible to a wide range of stakeholders - as long as the message is unambiguous and leaves no room for contradictory interpretations. So to sum up, then, the key is for listeners to perceive that there is a single control center (Is there one?), that the causes of the crisis have been unmistakably identified and established (Is there a clear idea of the dimensions of the phenomenon?) and that there is a shared vision as to how to cope with these causes (What is the key to controlling the situation?).

Second, the pandemic has forced the SSN to take on management during a crisis, to find a way to take care of patients effectively with the resources that are available. This means first understanding which production factors are scarce and need to be protected, and then which are not and must be saturated effectively to capture all possible value added. In recent years our SSN has gradually seen available resources dwindle. In fact, the much-discussed 37 billion euro cut (or the absence of an increase) over the past decade was not simply a case of financial rationing. Instead the outcome was a progressive decline in skilled resources in the field (doctors, nurses, other healthcare workers and technologies). On average, the number of doctors and nurses has dipped by 6% and 4% respectively in the past ten years, in the face of ever-growing need. In addition, more than half of the doctors who work for the SSN are older than 55, and at least 45% of the nurses are over 50.

Similarly, the overall number of beds, both in regular wards and intensive care, is down to around 3.2 per 1,000 residents (compared to the EU average which is closer to 5 beds per 1,000 people). The onslaught of the emergency has freed up financial resources, but not skilled resources, which are harder to find. To activate new beds, hospitals require a variety of professionals, but new medical staff need time for training (unless they are retired medical professionals called back to action, as has happened here). So it is obvious that beyond additional financial resources, the system must resort to other less-scarce factors of production: local healthcare networks, for instance, with family doctors and pediatricians supported by the intermediate health care facilities and out-patient services, and a plethora of third-sector players, production concerns and entrepreneurial ventures which are capable of rapidly refocusing to provide assistance in this emergency (from telemedicine to the hotel sector).

Undoubtedly the more immediate the system response, the more effective it is (time is one of the scarcest resources during a crisis). But what can slow or stop the process of medical professionals working outside of hospitals as they take over care of patients? In this case too there is no single answer, but rather several depending on the different regional contexts. But there is one aspect that all the regions in our country - and indeed all the countries in the world impacted by the crisis - have in common: We have responded to the coronavirus with a risk management plan which can be greatly improved. Glaring proof can be seen in the general lack of even a minimal supply of personal protection equipment.

This leads us to the last of the three aspects of crisis: the apparent crisis in management. This third consideration leads to a more general reflection on where management is right now, and what it means to be a manager. What is management in a sector such as healthcare, which is replete with interconnections and interdependencies? What is management in the midst of an emergency like the one we are living through today? What can management do in concrete terms at times like these? The starting point must necessarily be reconstructing the managerial space that is actually available at this moment. Covid-19 has forcibly refocused our attention on the fact that in healthcare, there are other approaches to action beyond the managerial mindset: the technical-rational perspective and the political perspective. The former (typical of a healthcare context) aims to frame the phenomenon and offer insights into understanding it; the second must develop a vision and build the setting for enabling conditions. Management for its part should propose a synthesis, merging these two perspectives, formulating rapid solutions and rendering them actionable on the ground. Naturally the more precisely the phenomenon is framed and the vision is conveyed, the more effective the work of managers will be.

This was true before the crisis, and continues to be true as the crisis continues. If we look back, we can see that from a technical-rational viewpoint, this emergency was anything but unexpected. In fact, already in 2010 the World Health Organization invited all countries to set up a preparedness plan to mitigate epidemiological risk (to be updated every three years). WHO also recommended proactively establishing programming guidelines (vision) and enabling conditions. There is no sign of an updated plan in our country (nor in any other European country), and the effects of this are plain when we look at the situation we are in now. The decision-making dynamic, as least as far as what we hear in public debate, seems to be totally centered on the dialectic between the technical-rational dimension and the political dimension of the crisis. Management has seemingly disappeared, but perhaps to see management we need to go into the trenches and take a closer look. Or, since we need to respect the principle #iorestoacasa (I’m staying home), we should ask the people who are directly involved to speak for themselves.

Seeing management in action will help us move forward and create the conditions to face future challenges. As Albert Einstein said in his book The World As I See It, “A crisis can be a true blessing to any person, to any nation. For crisis brings progress. Creativity is born of anguish, just as the day is born of the dark night. It is in crisis that inventiveness, discoveries and great strategies arise. He who overcomes a crisis rises above himself, without being overcome.”