Staff shortages

Coin-operated doctors and nurses: in Piedmont and Lombardy record 'parallel channel'

The use of cooperatives has been limited but the phenomenon remains crucial to ensure the functioning of essential services such as emergency rooms

by Claudio Testuzza

12 December 2025

3' min read

Translated by AI

Versione italiana

3' min read

Translated by AI

Versione italiana

The 'token' doctors continue to be the most conspicuous symptom of a general organisational and decision-making deficiency of the National Health Service (NHS) in the hospital sector. The law allows health professionals, even those with foreign titles, to operate in Italy without the rigorous ordinary path of verification, qualification, and registration with the Orders. In practice, a parallel system is being created that lacks the essential guarantees for safe care.

Junk doctors introduced into the pandemic

The shortcut to this dangerous reality is represented by Article 13 of the 'Cura Italia' decree, conceived to cope with the most acute phase of the pandemic, then extended by Article 15 of DL 34/2023 and finally extended until 2027 by Law 187/2024. A regulatory structure that, despite being created to respond to an emergency, continues to operate as if the emergency had never ended.

A further critical issue concerns the total lack of transparency on numbers. There is no public and up-to-date data showing how many doctors, nurses and operators are now serving through the waiver, with which titles, in which departments, and with which verifications completed.

Insufficient reality data

Although the analysis of the phenomenon had already been noted in the past, for the economic aspects, by the Anac, the National Authority against Corruption, in its report to Parliament, now appears incomplete. With specific reference to the year 2024, the analysis of the data on token doctors had shown that the value of contracts and QAs/Conventions, compared to 2023, had increased by 20%, from 35.2 to 42.3 million euro. Even more pronounced was the growth concerning 'token nurses' (+49%), as the value of contracts and QA/Conventions rose from EUR 3.9 million to EUR 5.8 million.

The best contractors from which to procure 'coin-operated doctors and nurses' were generally chosen by means of a negotiated procedure without prior publication of a call for tenders, confirming what was already observed in the four-year period 2019-2022.

Direct Procurement

The contracting stations made use of direct awarding while the use of the open procedure was only marginal.

In particular, in 2024, it was observed that the trend in public service contracts for personnel and QA/Conventions was downward (-49.2%), the observed value falling from EUR 523.7 million to EUR 265.9 million.

The territorial analysis of the demand of the SSN revealed that. in the year 2024, the phenomenon affected the geographical area of Central-Northern Italy the most.

Specifically, we find: Piedmont, which expressed a quarter of the total market demand (115.2 million euro), Lombardy, with 105 million euro, corresponding to 22.95% of the total annual demand, followed, at a distance, by Tuscany with 56.7 million euro, corresponding to 12.40% of the total market demand.

Existing contracts last until expiry

As of 31 July, the contracts of doctors coming from cooperatives should be non-applicable, as had been foreseen in the decree of 17 June 2024.

But existing contracts will continue until they expire. While an alternative of autonomous 'itinerant' doctors is being created, whereby doctors organise themselves autonomously, directly managing job offers from ASLs, to cover shifts, especially in emergency rooms. Unions such as the Simeu (Italian Society of Emergency-Urgency Medicine) have raised the alarm, predicting worsening shortages, especially in peak periods, if no alternative solutions are found.

There may be exceptions in exceptional cases, but the difficulty lies in filling staffing gaps with stable and qualified personnel, given the preference for the higher fees offered by the 'token' system. In short, while the use of cooperatives has been limited, the phenomenon of 'token' doctors (now more often autonomous) persists and remains crucial to guarantee the functioning of essential services such as emergency rooms, highlighting a crisis in the public health workforce.

Doctors' Associations and Trade Unions spoke

The Fnomceo, the Federation of Doctors' Associations, has challenged in all venues, including the courts, the recruitment of these professionals without adequate guarantees of professional competence checks . The court has already ruled twice on the issue, upholding, with the Lombardy Regional Administrative Court's ruling of 15 September, the Fnomceo appeal on the merits and partially annulling the Lombardy region's decision on the matter, where it eliminated, in practice, the substantive verification of the skills of professionals, particularly those with qualifications obtained abroad.