[Effect of hospital policies on patient mobility: Siennese experience]. Programmazione ospedaliera e flussi di pazienti: esperienza senese

The Italian National Health Service (S.S.N.), adopted in 1978 (Law n 833) and based on Beveridge's model, emphasises the citizens freedom to choose and the equal opportunity in accessing health care structures. Local Health Authorities--L.H.A. (U.S.L.--Unità Sanitarie Locali) become owners of almost all the structures in their territories and directly responsible for the satisfaction of all residents health needs. The former hospitals' network, based on independent first, second and third level public hospitals, in potential competition, was dismantled. Hospitals' financing, the main economic role of the S.S.N., was based on the documented running expenses: therefore the hospital interest to attract patients diminished and expenses increased in a uncontrolled way. In 1992, the Italian Government, (re)introduced (Law n 502) the quasi-market administered competition between Italian hospitals, making the major ones independent (Aziende Ospedaliere--A.O.) from the L.H.A. Hospital income from then is based on DRGs; the L.H.A. (and hospitals) leadership is now entrusted to managers and not politicians. We describe now how these changes were experienced by our hospital (A.O. Senese), placed in Southern Tuscany, Italy. We elaborated hospitalisation data regarding residents in the province of Siena (252,000 inhabitants) and activity data regarding its main hospital (A.O. Senese, 1200 beds, 47,000 admissions/year). Using the Gandy's Nomogram, we show the variation of patients mobility from 1988 to 1999. Our survey demonstrates that the Italian hospital system answers well enough to the legislative regulations: following the Law 833/1978 our hospital diminished its ability to attract patients from other areas; at the same time migrations of hospitals patients from Siena increased. Following the Law 502/1992, the power of attraction of our hospital is increased. Nevertheless the flow of escape continued to increase. It appears that to discourage the attraction power means to promote the loss of perceived quality and that it is difficult to correct such effects.