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The health and social services sector is a growing border area that seems to contain both the contradictions of the health service and those of social services. Operatively, economically, institutionally, culturally and procedurally, it is witnessing a transformation/evolution/involution of constitutionally guaranteed rights, and so of the meaning of citizenship. In our view, the difficult and complex relation between the health and social sectors, in terms of definition, institutional organisation and responsibility, organisational cultures, resources invested, profit-making and non-profit-making private interests operating, trade union relations and contract systems etc., is one of the keys for interpreting the evolution of welfare in Italy, and perhaps in the whole of Europe.

The welfare state is a polysemic idea and the various social sciences have given different definitions of it, each of them underlining this or that aspect, depending on the epistemological attitude of their field. In studies of the theory of the state and constitutional law, by «welfare state» we mean a liberal state that uses taxation to carry out policies that actively redistribute wealth so as to guarantee a minimum level of wellbeing to all citizens, whatever their capacity to produce income (Mortati, 1973): it is clearly a definition that corresponds to a historical-institutional perspective, which in the framework of the development of forms of the state underlines the transformation of the «neutral» liberal state, under the effect of mass parties and reforming political and union movements, into an «interventionist» state.

When we talk about health, social and welfare services it is useful to refer to health and wellbeing. They are two concepts that significantly overlap and mutually interfere with each other, and are difficult to separate out even in our own lives. Health influences wellbeing and vice versa, and we do not know where health ends and wellbeing begins. Legally, politically and administratively, in organising and providing services, the distinction and the separating out is a necessary phase. However, when they have been separated out, they need to be brought back together again. The first separation of the two is in the Constitution, where protecting the right to health is different, more precise and detailed, while the protection of social rights is weaker. This formulation is linked to a work logic, a logic that has been important in history, but is now reductive in terms of universalism.

Traditionally the creation of a welfare state has tended to centralise the powers and functions of central government in contemporary legal systems, as central government is regarded as offering better guarantees of stability and universal social services than more local bodies. This «centripetal» tendency of the policies connected with the creation of the welfare state has been noticed by constitutionalists since the 1980’s, particularly as regards federal systems, where egalitarian policies aimed at redistributing wealth have often set off processes centralising powers and functions in federal authorities, because of the need to guarantee uniform welfare standards nation-wide, in the interests of substantive equality.

Both common sense and methodological reasons should make it obvious that every time we leave a strict «experimental» context, data have extremely and explicitly ambivalent relations with the reality they describe, plan and evaluate: this is part of their role, which is never independent of context, and still less neutral or objective. The data are in the service of a hypothesis (in the best of cases: that means they correspond to an explorative work of research or comparison), or a theory (more frequently: they are a response to a plan that seeks to demonstrate, defend or confirm something that has already been decided). In systems that are more or less rapidly being redefined or evolving, and that are already «dependent» on «other» macro-variables, the potentiality/possibility of profound ambivalence in the data translates almost naturally into concrete and/or planned probability.

Returning to the thoughts in earlier essays on the difficulties for the functioning of the health and social services caused by an ongoing lack of information, this article considers the question of data policy in the welfare sector. This aspect is one of the enabling conditions for integration in both welfare policies and social policy in general, and is the basis for an effective and efficient functioning of the health and social system, understood as all those services and interventions that include care and social integration, treatment, prevention and protection.

In the face of a growing quantity of reports, information, surveys, statistics, descriptions and projections on so many aspects of the health and social system in our country, we are gradually becoming more and more aware of the limits of such contributions. As a simple example from the various national sources that are easy to access, one might cite all the institutional web sites and/or data banks such as the National Statistical Institute (Istat, see, for example, the Annuario statistico italiano 2006, recently published and available entire online); the Ministry of Health, the Italian Agency of Drug (Aifa); the Istituto Superiore di Sanità; the Istituto Nazionale per l’Assicurazione contro gli Infortuni sul Lavoro; and the Interuniversity Consortium (Cineca - Arno Report).

The care epidemiology in the title is not a contradiction in term: it is where science and methodology meet in an important research institute, and also how the heath and social workers of some local health authorities in the Veneto Region see their work in the daily practice of care. The best-known point of view on the need for information in the health and social services is that to be found in national/regional planning; various sources — such as surveys and Istat’s Multi-purpose Surveys — periodically provide an important picture of the population and demographic trends, the perceived state of health and the level of non-self-sufficiency, the structure of the modern family and recourse to services. The point of view here, by contrast, is the data produced by the health services themselves, particularly at district level, which is officially responsible for integration.

A response to the problems of the elderly who are no longer self-sufficient is today the point where we can most immediately assess our capacity to draw up innovative public policies and develop techniques and instruments for integrating the social services and the health service. The institutional, financial, organisational and professional innovations that now appear necessary for running both the health service and the social services need to offer practical solutions to the specific problem of the aging of the population, but also have a high symbolic value in relation to the role of the public sector in solving collective problems and empirically verifying the capacity of both these systems to radically renew themselves.

That health service costs tend to increase staggeringly is well known. The most recent forecast of PricewaterhouseCoopers Health Research Institute estimates a tripling of its impact on Gdp in the next fifteen years, reaching 21% in the USA and an average of 16% in other OECD countries. Italy’s relatively favourable position at 8.5% will tend to be eroded, if for no other reason than the worldwide tendency of health service consumption, supply systems and costs to converge.

This contribution is intended to answer two questions: 1) what do we mean by cost-performance, efficiency and efficacy; 2) why do we now talk about appropriateness. We can define these terms as follows: * cost-performance means conforming and responding to principles of economics in the sense of parsimony and saving; * efficiency is the situation of maximum productive capacity, at minimum possible costs, in a combination of production or supply of goods and/or services; * efficacy is the capacity to fully produce the desired effect and the obtaining of it. Nothing can be managed, still less managed well, that is, there can be no administration of the goods and/or interests for others, if the principles of cost-performance, efficiency and efficacy are not borne in mind and applied.

Integration in welfare policies, like the management of the processes of change in our welfare system are often dealt with and analysed from the perspective of the policy maker. In our country this is a response to a deficit in implementing and evaluating public policy and, still more, to the need for a more pragmatic approach to reform in the various areas of state intervention. This perspective becomes indispensable in the health sector, in particular, where the eternal debate on the public-private relation, on the costs of the national health service, or on the inadequacy of our services in relation to continually evolving health needs and demand, almost inevitably lead to large-scale questioning of the reforms carried out, starting from law 833/78, without there being any careful evaluation of the impact and the real effects of these interventions.

This article presents and discusses some characteristic features of welfare work in Italy, to try and understand better some of the challenges that the welfare system is facing today and, still more, will be facing in the near future. To deal with this subject synthetically, I propose to start from two central elements in the development of the Italian labour market in this field. The first, in the social field, is that of the unofficial «carers», that is, the private care work provided mainly by immigrant women to old people who are not self-sufficient and to the disabled. The second, in the health field, is that of the acceleration of the professionalisation process in the last ten years. These two phenomena will involve discussion of the labour market, regulation of the professions and professionalism.

Population ageing and technological development in industrialised countries have helped bring to the fore the subject of the efficient allocation of resources in welfare systems. In the health sector, economic evaluation is a tool designed to guide allocation decisions in relation to a crucial dimension of the problem: the opportunity cost. Since the 1960’s a strong increase in the number of studies has been noted particularly in the pharmacological sector, and in many countries the results of these studies have been used to issue specific guidelines.

I want first of all to concentrate on one important aim that has guided Rps in organising this Forum on welfare integration: placing the accent on the concept of «integration» rather than on that of «social-health», understood as a system of services, and this aim is particularly important for me. We can talk about welfare integration in various ways, meaning aspects that are also very different and potentially in conflict with each other. On the one hand, we hear talk of social-health integration as if it were the more or less official name for a sector, a synonym of the social-health sector, that accompanies the health and the care sectors.

I’d like to continue in the same direction as the other papers, analysing what we are trying to define as a welfare system. It’s a very particular system, incomplete, and which at the moment can at least be rebuilt theoretically. In fact, in considering social and health policies, we come up against the difficulty of having fragments rather than a real system: something that actually is more like a nebula, an archipelago or a system of archipelagos. Much has been written on whether social policies make up a system or not, and there are in-depth analyses and case histories; despite the lack of useful information, particularly as regards databases, for making decisions and evaluating results, there is an overall survey of these policies in the literature. The thoughts advanced in this debate too suggest that we actually know quite a lot about this «system».

My aim in these notes is to bring my own experience in the field to the debate: after battling for twenty years as a psychiatrist to dismantle the mental hospitals, and then ten more years to build alternatives to them, I have spent the last ten years managing local health units: three years in the province of Caserta and now in the Region of Friuli Venezia Giulia. I’d like to offer you some reflections from this viewpoint, on the basis of the kind of problems I meet every day in my work. In the regional law of Friuli Venezia Giulia, the non-self-sufficiency fund is known as a «Fund for possible autonomy». Just a matter of terminology? Perhaps.

I’ll try and explain what has been done in the last twelve years in Tuscany and Pisa. After reflecting on the question for several years, we were convinced of the importance of making the local administrations fully responsible for the problems of wellbeing and health. The starting-point was the integration between the social and health sectors. Some general considerations on these subjects, now generally known, which led the Municipalities to start this debate, may help us understand the various phases.

First of all I’d like to thank you for your invitation to contribute to this Forum. Various problems seem to have emerged, and I’d like to try and talk about them. Apart from some criticisms relating to questions of organisation, I particularly want to draw attention to a specific problem, that of the essential levels of care, with special reference to the question of non-self-sufficiency. I want to talk about it in cultural as well as political terms, though in this latter sense our policy on this should start to be implemented in the next few months. I start from one element for evaluating the present situation. It seems to me obvious that — and here I agree with the judgments given — the social sector is much less protected in the constitution than the health sector. Traditionally there has always been a strong difference in the level of services in our country.

As President of the Parliamentary Commission on Social Affairs I’d like to offer a few brief thoughts on the subjects introduced here and on which there has been a discussion, offering an institutional point of view on the path to follow. I refer in particular to the law on non-self-sufficiency, which is being discussed by the Commission I chair, and which comes from a failure in the previous Parliament. The Hon. Zanotti dealt with it in the last Parliament, and this time too, there is a risk of it finishing on the rocks of financial covering. This law is based on the setting up of the Fund for non-self-sufficiency, and it is clear that if this fund is not adequately financed with the necessary resources to guarantee an essential level of services, then the law cannot be approved.

I want first of all to dwell on some questions that were dealt with today by the Minister for Social Policy, Paolo Ferrero, which, quite honestly, I find difficult to share. First of all, the question of the Social Policy Fund. The resources to transfer to the Regions in 2007, compared with those transferred in 2006, have indeed increased — and we much appreciate this — but only to an extent equal to the cuts made by the previous government last year. That means that the Fund now stands at the same figure as in 2004. Substantially, there has been no additional investment since then down to the end of 2007. And this means that social policies and combating poverty are not seen as a priority by the new Centre-Left government. The Minister will agree with me that this is not at all good news.

I welcome the decision to devote a session of the seminar on health and welfare policies to issues related to a proper definition of informative system aimed to transferring knowledge among health workers, and from them to the general public, and vice versa. The debate is not new. On the contrary, it characterized the ’70’s and ’80’s in the period of health service reform and it was later taken up again during the discussions that led to the law (no. 328/2000) on welfare reform. Indeed, it is clear that this subject meets various needs. The first is that of identifying the needs to which we are to respond: this is an essential function if the services are not to fall into a merely self-referential logic rather than responding to the need to meet the general public’s requirements effectively.

I want first of all to consider a question: what made Cgil decide to take up the subject of integrated policies? We came to that point trying above all to understand what were the most critical features of the traditional welfare system compared with present innovations in this economic and social context. We set off in this direction because we were convinced that welfare is best defended if its critical features are rationally identified and new proposals put forward. Let us analyse some of its characteristics. First, we all know about the extraordinary changes in technology and production that have revolutionised the modern world, starting from the field of computers and communications. We also know about the potential of technology to provide greater autonomy, planning capacity for the workers themselves, and opportunities for a qualified job or a job that is deliberately chosen.