The long goodbye to the tokenists who are burning funds to hire nearly 10,000 doctors and nurses.

Barring any surprises, such as a last-minute extension, this will be the last summer for the token workers: doctors (and nurses too) paid a fortune—even up to €1,200—to cover a single eight-hour shift in areas where there are the greatest shortages, such as emergency rooms. Staff "rented" from cooperatives averages nearly 20% of the workforce, but in some hospitals, it even exceeds half of all healthcare workers.

For local health authorities, this is a long, difficult, and costly farewell: long because Minister Orazio Schillaci's crusade against payroll workers began in May 2023 with the bill decree, but then, due to subsequent guidelines and decrees, only the deadline arrived at the end of July, effectively blocking the signing of new contracts that will now expire in the coming months. It's difficult because emergency rooms, in the height of summer, risk not having the staff to guarantee services, although freelance contracts can now be signed directly with doctors (without the filter of cooperatives) at rates of around €85-100 gross per hour. But above all, it's costly because the bill presented by the payroll workers has been extremely high: according to the latest data from ANAC, local health authorities and hospitals spent €2.141 billion between 2019 and 2024 to fill the gaps in their wards with payroll workers, a whopping €457 million in 2024 alone. These resources would be sufficient annually to hire 3,000 permanent doctors—which roughly corresponds to the shortage in emergency rooms—and 6,000 nurses (Italy is short 60,000) based on the costs of the contracts in force in 2024 (€85,000 for doctors and €35,000 for nurses).

The use of payroll workers is a huge waste and a shortcut, adopted because it's increasingly difficult to find healthcare workers willing to work in Italy's public hospitals. The reasons? "Many calls for applications are being rejected, especially those for emergency rooms, because working in the National Health Service is no longer attractive. Then there's the spending cap on hiring, which gives the regions more leeway by resorting to contracting out services, such as payroll workers," warns Stefano Simonetti, a healthcare expert at Il Sole 24 Ore. He suggests: "If completely abolishing the cap isn't feasible, one solution could be a partial and targeted reduction, limited to essential hiring of doctors and nurses in emergency departments and other restricted operational units, in agreement with the regions."

For over 20 years, the healthcare system has been grappling with spending caps, from pharmaceuticals to hiring. In his waiting list decree a year ago, Schillaci outlined a path to overcoming this issue, which has been holding back new doctors and nurses for years. However, as is often the case, the final implementation steps are still missing: from calculating regional staffing needs, which will no longer require the approval of the Ministry of the Economy and Finance (MEF)—as recently approved by the Constitutional Court—to defining staffing standards to be calculated using an algorithm already developed by Agenas. Now, the budget (see article alongside) could provide an initial boost by addressing the most urgent needs, given that the situation in Italy regarding healthcare personnel appears truly uneven. According to the latest data from the State General Accounting Office's recently published Annual Report, the NHS's workforce increased slightly (+2.8%) in 2023, reaching 701,170 doctors, nurses, healthcare workers, and administrative staff. But there are striking regional differences: while the national average is 131.57 NHS employees per 10,000 inhabitants, some regions have between 140 and nearly 180 local health authority (ASL) and hospital employees per 10,000 inhabitants, such as Valle d'Aosta, Friuli, Liguria, Emilia Romagna, and Tuscany. Other regions—especially those that have been under special administration for years or are still undergoing recovery plans—have just over half that figure, such as Lazio, Campania, Sicily, Molise, and Calabria.