From the doctors' criminal shield to the staff engagement rules to the nurses' exclusivity: the Milleproroghe in watermark

On 11 December, the 'Milleproroghe' decree 2026 was approved by the Council of Ministers, as is now a consolidated end-of-year tradition. Among the many regulations extended in the sixteen articles of the decree-law, Article 4 deals with matters falling within the competence of the Ministry of Health with no less than eleven paragraphs. Considering also last year's extension for the activities of foreign health workers in derogation, three seem to be the most complex issues whose final solution is once again postponed: the so-called 'criminal shield', the rules of engagement in derogation for foreign health workers, and the activities that can be exercised by health workers in the sector in derogation of the exclusivity constraint.

The key word is evidently 'derogation' and all three aspects date back at least five years, but, as we can see, they fail to leave the conjunctural and provisional regime and finally be regulated in a structural and decisive manner. The events at San Raffaele have highlighted with great clamour in the media how urgent it is to put an end to the provisional status of foreign personnel, but it is quite clear that the solution is far from being found and the responsibility, in the words of Minister Schillaci, lies with the State-Regions Conference where the text of the Understanding has been lying since April 2024. The affair of the foreign health workers is similar to that of the 'token' doctors and, in general, to the now unacceptable decision to outsource health care.

As things stand, it was inevitable that the umpteenth extension would be reached because the issues are extremely complex and there is no shortage of opponents either; but a reflection is necessary regarding the future scenarios of the three issues mentioned. Perhaps only the criminal shield could find a solution in the short term - so to speak - because the issue is hinged on the delegated bill A.C. 2700, approved by the Government on 4 September, presented on 13 November and assigned to the XII Social Affairs Commission of the Chamber of Deputies, which began its examination on 10 December.

With regard to foreign healthcare workers and OSSs, Article 2, paragraph 8-bis of Law 187/2024, converting the so-called Flows Decree, extended to 31 December 2027 the possibility for healthcare agencies and private or accredited healthcare facilities to recruit healthcare professionals or OSSs authorised by a regional provision. A positive solution for professional practice as an exception by tens of thousands of foreign workers seems more distant, since if in all these years a square has not been found on the titles, it could mean that it will never be found; but one does not credibly have the courage to put thousands of workers out on the street. It is just a case of remembering that exercising a profession without having the qualifications constitutes an offence under Article 348 of the Criminal Code, and the government's reiteration of the 'derogation' could end up in front of the Constitutional Court for the possible violation of Article 32 itself, given that in this far west the Republic certainly does not 'protect health as a fundamental right of the individual'.

But there are also profiles of violation of Article 3 because these tens of thousands of individuals compared to all Italian professionals 'in order', are not registered in their respective registers and do not pay the annual fee, are not subject to the Ecm obligation, and do not have insurance coverage. This is why the Fnopi Federation has proposed the creation of special lists. On the other hand, the solution would be similar to that of the special exhaustive lists that have already existed for years for all healthcare professionals who do not meet the qualifications, pursuant to paragraph 537 of Law 145/2018. Of course, conjunctural needs and the absolute necessity to guarantee continuity of care are pre-eminent; but if we also add trainees, we could arrive at an army of more than 50,000 health professionals practising in derogation of the general rules.