Family doctors, integration between territorial medicine and the healthcare system, community homes and hospitals, there was all this in the territorial healthcare reform decree which was withdrawn due to the impossibility of finding a convergence in the managementmajority up a topic such as that of the territorial healthcare reform, thorny as the deadline of 30 June approaches, crucial for the objectives of the Pnrr, which brings with it organizational and planning problems, of effective guarantee of the right to health, but also economic ones. Let’s try to understand what we are talking about, given that it is a crucial issue that concerns everyone, a time in which many citizens encounter difficulty in finding a doctor.
WHO ARE GENERAL PRACTICE DOCTORS
In Italy the general practitioner, the current technical name General Practitioner (GP), from a formal point of view is now not employed by the National Health System, but a freelancer who works under an agreement with the Local Health Authority (ASL): his employment relationship is regulated by the National Collective Agreement (ACN), by the Regional Supplementary Agreements and by the Company Implementation Agreements, defined at the level of the individual ASL. It is paid by the State based on the number of clients (70 euros gross per year per client if there are up to 500, around 35 euros gross if there are more, with the addition of fixed bonuses for some services). From time to time, the proposal to change the employment relationship by making general practitioners formally employees of the NHS like hospital doctors appears in the public debate. A theme also partially contained in the “set aside” decree and which immediately divided the majority.
HOW IT HAS WORKED SO FAR
Law 833 of 1978 which established the National Health Service (SSN) in Article 25 established that: «General medical and pediatric assistance is provided by staff employed or affiliated with the National Health Service operating in the local health units or in the citizen’s municipality of residence». It means there is no supstream, in outlining the framework of the System, a prescription regarding the professional status of the doctor basic: he could have been classified either as an employee or as a freelancer under an agreement.
The choice, in which we opted for free profession in agreement, took place with law 508/1992 which in article 8 establishes that: «The relationship between the National Health Service, general practitioners and paediatricians of free choice is governed by specific three-year agreements compliant with the national collective agreements stipulated, pursuant to art. 4, paragraph 9, of law 30 December 1991, n. 412 (b), with the most representative trade union organizations at national level”.
The agreements must take into account various principles, including the maximum number of patients and the possibility for patients to choose their own doctor and the rules for revoking it.
5,700 are missing
For some time now, citizen rights and the maintenance of the system, including the effectiveness of free choice and the maximum number of patients, have clashed with the lack of available general practitioners. According to data released by the Italian Society of General Practitioners and Primary Care Doctors (SIMG), which is an autonomous scientific society of a non-union nature, between 2013 and 2023 over 10 thousand general practitioners lost their way. According to an estimate by the Gimbe Foundation, drawn up on data from the inter-regional healthcare structure Sisac as of 1 January 2025, Italy has 36,812 general practitioners with an average of 1,383 patients each. According to estimates, 5,700 are missing at a national level, with marked regional differences. In Lombardy alone, 1,533 are missing and more and more people are struggling to find a general practitioner.
The shortage is due to various factors including, as the president of the Nino Cartabellotta Foundation explains, “inadequate programming”. It is estimated that between 2025 and 2028, 8,180 general practitioners have reached or will reach retirement age and that turnover will not be able to cover the gaps left because the “loss of attractiveness” of the profession will be discounted, in a demographic context that is becoming increasingly complex due to the aging of the population and the consequent incidence of chronic diseases.
All critical issues which, according to the analysis, can be addressed with emergency solutions: «The ACN signed in January 2026», we read, «confirmed the increase in the optimal ratio already defined in 2024, going from one doctor for every thousand residents to one for every 1,200». Things are not much better with paediatricians: according to a note from Gimbe from a few days ago, in Italy there is also a shortage of at least 497 paediatricians of free choice and almost 80% of the shortages are concentrated in three large Northern regions: Lombardy, Piedmont and Veneto.
HOW TO BECOME A GP
Currently, the training of general practitioners is not entrusted to university specialty schools as for specialist doctors but to a specific three-year training course, regulated by Legislative Decree no. 368/99, amended by Legislative Decree no. 277/2003, in compliance with European standards, which is open to qualified medical graduates, selected through a public competition announced every year by the Regions.
The Italian Society of General Medicine has long asked that general practitioners also be trained in a specialty school.
DEPENDENCE OR FREELANCE PROS AND CONS
For some time now, the debate on the role of general practitioners has been polarized on the topic of the relationship between independent freelancers and employees, a controversial topic which also brings with it the collateral issue of the sustainability of Enpam, the category social security body largely supported today by GPs as freelancers, who would pass to INPS if the relationship became dependent. The trade unions are also divided on the issue: Fp Cgil Mmg has been pushing for direct dependence for some time, while Fnomceo and Fimmg are against it. The main argument against the transition to dependence on the NHS would be the emptying of the doctor-patient relationship of trust in the face of depersonalization linked to the shift of different people linked to the number of employee hours and the risk of reducing doctor-patient proximity as the population ages. The arguments in favor would be better integration of the national health system between hospitals and the territory, wider hourly coverage through shifts (assuming that doctors can be found to cover them) and greater protection in the employee relationship for doctors (illness, maternity, holidays, etc.). But as we can see, the opinions of the trade associations also partly diverge.
COMMUNITY HOMES AND PNRR, BETWEEN DELAYS AND STAFF SHORTAGE
Above all there is the difficulty of filling the community houses with staff (those structures, foreseen by the Pnrr reform which should bring together general practitioners and specialists, as well as nurses and psychologists and guarantee assistance and tests in the area, guaranteeing continuous assistance from 8am to 8pm every day through shifts. But the Gimbe Observatory on the NHS which monitors the implementation of the Pnrr Health Mission in a note published on 31 March found that as of 31 December 2025 just 3.9% of community homes were “fully functional”, over half of which were in Lombardy, and only 27.4% of community hospitals had “activated at least one service while none were fully functional”..
Even hoping that things have improved in five months, the risk is underlined that even where all services are declared active, community homes remain empty boxes due to a lack of medical and nursing staff. All this while the final reporting of the Pnrr health mission is scheduled for June 30th. The Minister of Health Orazio Schillaci said in these hours that he is convinced that the community houses will be ready to go on that day. But there are many issues to be resolved.
WHAT IS BEST FOR THE CITIZEN
Behind the proposal of a dependency relationship for general practitioners there is probably the belief or hope of being able to divert them more towards community homes, being able to arrange and establish the distribution of their working hours from above. But it is not easy to establish what the number of hours currently worked by the current doctors classified as freelance professionals are, moreover they too, like the entire healthcare sector, are increasingly burdened with an infinite number of bureaucratic tasks, even if it is true that the new agreement already provides for new hires to provide hours of availability for community homes.
In theory, there could be an advantage for the citizen if the sum of hours worked per week for each freelance GP was on average lower than the 38 hours established by an employment relationship, but there might not be, or it would translate into a disadvantage, if we discovered that, as the trade unions claim, the average number of hours worked per week by the freelance GP in agreement was greater than those 38 hours, or if in any case his load was already saturated, as is likely especially in places where the doctor-patient ratio reaches or exceeds the ceiling of 1:1,500, a situation which in Lombardy reaches 71% of cases.
A comparison of numbers in hand, however, is not simple because the characteristics of the two systems are not homogeneous. A Cergas-Bocconi study entitled: Changes in the service models of general practice by Giulia Broccolo, Francesca Guerra, Francesco Longo, Angelica Zazzera, presented in December 2024, attempted to make an approximate calculation of the current workload.in which it is estimated that general practitioners respond to an average of 45 contacts a day with patients, which rises to over 70 if we also include those who pass through the secretariats, and that especially in the North a significant part of these contacts already take place remotely, via email, WhatsApp, telephone.
A BLANKET TOO SHORT
The feeling that one gets from all the data is that, however the professional relationship is regulated, it is in any case a matter of drawing a short blanket, that what is pulled here is taken away from there and therefore on one side or the other something remains uncovered.
Objectively, it is difficult for those who are already at the maximum number of patients, rounded upwards, or beyond to be able to give hours to community homes without taking them away from the patients they already have. And in the meantime, community homes, where they exist, may also be far from the capillarity of the territory where perhaps a general practitioner already covers three/four practices in various small municipalities: and then the risk is that the proximity of the assistance that is promised to improve is lost and that an elderly person who has health problems and difficulty in moving around before arriving at the community home many kilometers away could go to the emergency room which the idea of community homes aims to alleviate.
THE PROBLEM OF THE FUTURE
Then there remains the problem of the future: making general medicine attractive for young doctors, competitive compared to private medicine, abroad and specialty schools, in a context in which we are already witnessing, in the most demanding and stressful specialties, an escape from the public contract for the private sector or for “token” services, with all the complexities that this already generates for service and assistance today. This is demonstrated by the fact that finding candidates for general medicine is increasingly difficult. «According to FIMMG data, in 2025 the participants in the national competition were higher than the available places: 2,810 candidates for 2,228 grants, with a differential of 582 candidates (+26.1%). However, the failure to present candidates in relation to the available places is very evident in some Regions: Autonomous Province of Bolzano and Valle d’Aosta (-60%), Marche (-49%), Autonomous Province of Trento (-38%), Piedmont (-29%)”.
