Hospitals and territory, the nefarious practice of zero-cost reforms

How much confusion there is at the moment in the affairs of the public health service! As if the chronic delays in collective bargaining and the ever-worsening working conditions were not enough, the political decision-makers do one thing and think of a hundred. I am referring to the DDL that the Council of Ministers approved on 12 January and which aims to revise the organisational model of the SSN by also intervening on the organisation of territorial and hospital care. There is talk of level III hospitals and elective hospitals without emergency rooms and other interventions, especially on the territorial side. In the draft law, however, there is a rule (Article 3) that imposes a surreal financial neutrality of the implementing decrees, unless new parliamentary appropriations are made.

It is the same old story: a reform of this magnitude can hardly be achieved without a stable increase in the so-called National Health Fund, but also without truly effective investments in personnel. It is an ambitious project, which tries to bring order to a system marked by organisational fragmentation, inequalities between the north and south of the country, and chronic structural deficiencies. Apart from the process of differentiated Autonomy, which, at least for health care, seems to have the same aims, some perplexities arise from the asymmetry of the interventions and the long-standing dispute between the State and the Regions. In fact, while the government approved the delegated DDL, in the same days the revision of Liguria's healthcare system formally came into force with Regional Law no. 18 of 12.12.2025, which 'reformed' the regional healthcare system. There are two main changes: the creation of the Agency for the Protection of Health Liguria (ATS), which unifies Liguria's five ASLs into a single centralised structure to rationalise governance and spending, transforming the old ASLs into district areas. The second is the creation of the metropolitan hospital agency (AOM) that will manage San Martino, Villa Scassi, Galliera (albeit with the well-known institutional anomalies) and the future Erzelli hospital, once it is built.

To make sure nothing is missing and to continue the trend of favouring universities, paragraph 938 of the Budget Law perpetuates the 20-year amnesty of Italian polyclinics that do not have formal authorisation. It is better to pass over in silence the situation of direct healthcare, which is provided on a daily basis by some 50,000 professionals who are not formally so, either because they have been on the special exhaustive lists of professional orders for seven years, or because they are foreigners awaiting recognition of their qualifications; and in the latter case, thanks to paragraph 939 of the Budget Law, it will last until the end of 2029, hoping that everything will go well for the patients.

Other legislative initiatives should not be forgotten: A.S. 1241, the so-called 'Health Benefits', approved by the Senate and under discussion in the House since 15 July 2025. Then we have the next one, A.C. 2700, the 'Health Professions', whose examination started on 10 December in the House.

All the interventions are extemporaneous, lacking systemicity, and often cyclical rather than structural in nature. But the constant feature is that they are unfunded, following the nefarious practice of zero-cost reforms, harshly stigmatised years ago by Sabino Cassese. If we then add the hundreds of paragraphs of the budget laws, the frequent decree-laws and the unfailing, punctual annual Milleproroghe, the scenario of health legislation becomes complete in its confused approximation.