JUDGMENT NO. 177

YEAR 2025

ITALIAN REPUBLIC

IN THE NAME OF THE ITALIAN PEOPLE

THE CONSTITUTIONAL COURT

composed of:

President: Giovanni AMOROSO;

Judges: Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Filippo PATRONI GRIFFI, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI, Massimo LUCIANI, Maria Alessandra SANDULLI, Roberto Nicola CASSINELLI, Francesco Saverio MARINI,

has pronounced the following

JUDGMENT

in the constitutional legitimacy trial concerning Article 1, paragraph 1, of the Law of the Sardinia Region of January 31, 2025, no. 2 (Amendments to Article 1 of Regional Law no. 5 of 2023 on Primary Care), initiated by the President of the Council of Ministers with an appeal served on April 1, 2025, filed in the Registry on April 2, 2025, registered under no. 16 of the Appeals Registry 2025, and published in the Official Gazette of the Republic no. 16, special first series, of 2025.

Having seen the statement of constitution of the Autonomous Region of Sardinia;

Having heard Judge Rapporteur Maria Alessandra Sandulli in the public hearing of October 22, 2025;

Having heard State Attorney Enrico De Giovanni for the President of the Council of Ministers and Attorney Sonia Sau for the Autonomous Region of Sardinia;

Deliberated in the Chamber of Council on October 22, 2025.

Facts of the Case

1.– With an appeal served on April 1, 2025, and filed on the subsequent April 2, registered under no. 16 of the Appeals Registry 2025, the President of the Council of Ministers, represented and defended by the State Attorney General, initiated a question of constitutional legitimacy regarding Article 1, paragraph 1, of the Law of the Sardinia Region of January 31, 2025, no. 2 (Amendments to Article 1 of Regional Law no. 5 of 2023 on Primary Care), which amends the second period of paragraph 2-ter of Article 1 of the Law of the Sardinia Region of May 5, 2023, no. 5 (Urgent Provisions on Primary Care). The latter provision was introduced by Article 1, paragraph 1, of the Law of the Sardinia Region of August 20, 2024, no. 12 (Amendments to Regional Law no. 5 of 2023 on Primary Care), which was, in turn, challenged by the State with the appeal registered under no. 39 of the Appeals Registry 2024 and decided by this Court with Judgment no. 84 of 2025.

The State Attorney General preliminarily notes that the aforementioned second period of Article 1, paragraph 2-ter, provides for the possibility of recalling to service retired physicians who have joined corporate projects for primary and continuity care, without excluding General Practitioners (GPs), for whom, instead, Article 21, paragraph 1, letter j), of the National Collective Agreement for the Regulation of Relations with General Practitioners of April 4, 2024 (hereinafter: NCCA) expressly precludes return to service once retired.

Article 1, paragraph 1, of Regional Law no. 2 of 2025 (the subject of the present trial), by replacing the words "until December 31, 2024” with the phrase "until the completion of the new procedures for the assignment of primary and continuity care posts and in any case no later than June 30, 2025” in the second period of Article 1, paragraph 2-ter of Regional Law no. 5 of 2023, as amended by Article 1, paragraph 1, of Regional Law no. 12 of 2024, extends the effects of the provision without affecting the substantive content of the aforementioned Article 1, paragraph 2-ter.

Therefore, Article 1, paragraph 2-ter itself, in the version resulting from the amendment challenged in the present trial, stipulates that: "[Local Health Authorities (ASL), in order to guarantee uniform essential levels of assistance in the territory and with the priority aim of identifying organizational measures capable of ensuring basic healthcare for citizens in disadvantaged areas of the Region, are authorized to provide all physicians engaged in corporate projects for primary and continuity care with the prescription pads referred to in Article 50 of Legislative Decree no. 269 of September 30, 2003, converted with amendments by Law no. 326 of November 24, 2003 (Conversion into law, with amendments, of Decree-Law no. 269 of September 30, 2003, containing urgent provisions to promote development and correct public accounts). The provision is also applicable to retired physicians who have joined corporate projects for primary and continuity care, even with professional consultancy contracts, where the complete coverage of primary care is not guaranteed, to ensure the same functions, solely for the activities and limited to the patients of the territorial areas relating to the aforementioned projects, until the completion of the new procedures for the assignment of primary and continuity care posts and in any case no later than June 30, 2025.]”

The challenged Article 1, paragraph 1, of Regional Law no. 2 of 2025, thus, allegedly presents the same grounds for constitutional illegitimacy as those contested in Article 1, paragraph 1, of Regional Law no. 12 of 2024, challenged with the aforementioned appeal registered under no. 39 of the Appeals Registry 2024.

In particular, it allegedly exceeds the statutory powers of the Autonomous Region of Sardinia under Articles 3, 4, and 5 of Constitutional Law no. 3 of February 26, 1948 (Special Statute for Sardinia), and, by conflicting with the relevant national legislation, as well as with Article 21, paragraph 1, letter j), of the NCCA, it allegedly violates the exclusive legislative competence of the State in matters of civil law, pursuant to Article 117, second paragraph, letter l), of the Constitution.

The appellant emphasizes that Article 1, paragraph 1, of Regional Law no. 2 of 2025 does not introduce corrective measures but merely extends the temporal scope of application of the second period of Article 1, paragraph 2-ter, of Regional Law no. 5 of 2023, which thus remains unchanged in its substantive content.

The retired GP could therefore continue to participate in the care project activated by the local health authority (ASL), use the prescription pad, and de facto resume functions analogous—in nature and instruments used—to those held prior to retirement; thereby conflicting with the aforementioned Article 21, paragraph 1, letter j), of the NCCA.

The President of the Council of Ministers further adds that the exemption under Article 2-bis, paragraph 5, of Decree-Law no. 18 of March 17, 2020 (Measures to strengthen the National Health Service and provide economic support to families, workers, and businesses related to the COVID-19 epidemiological emergency), converted, with amendments, into Law no. 27 of April 24, 2020, which allows Regions and Autonomous Provinces of Trento and Bolzano to recall retired healthcare personnel to service to cope with the impact of the COVID-19 epidemiological emergency and ensure essential levels of assistance (ELA), cannot be extended to GPs.

Only National Health Service (NHS) employees are, in fact, permitted to return from retirement with self-employed contracts, as expressly provided for by national legislation, whereas this possibility is precluded to GPs by the NCCA.

Indeed, the relationship of GPs is a contractual relationship, characterized by professional autonomy and, in this case—as clarified by the Court of Cassation (citing the United Civil Sections, Order of October 21, 2005, no. 20344, and the Labour Section, Judgment of April 8, 2008, no. 9142)—"a private relationship of self-employed professional work with the public administration.”

It is further observed that state legislators delegated the regulation of the employment relationship of contracted primary care medical personnel as early as Law no. 833 of December 23, 1978 (Establishment of the National Health Service), and that this system was reaffirmed and specified by Article 8, paragraph 1, of Legislative Decree no. 502 of December 30, 1992 (Reorganization of health discipline, pursuant to Article 1 of Law no. 421 of October 23, 1992), which reserves the regulation of the relationship between the NHS and GPs and freelance pediatricians to specific three-year agreements consistent with national collective agreements. It is also recalled that Article 2-nonies of Decree-Law no. 81 of March 29, 2004 (Urgent interventions to address public health threats), converted, with amendments, into Law no. 138 of May 26, 2004, confirmed "the regulatory structure of the contract for contracted health personnel,” ensured through the conclusion of agreements following a collective bargaining procedure, defined at the Permanent Conference for Relations between the State, Regions, and Autonomous Provinces of Trento and Bolzano.

In the opinion of the President of the Council of Ministers, therefore, the relevant regulation in this case can only be represented by the provisions of the NCCA, and, as this Court recalled in Judgment no. 186 of 2016, the national collective bargaining in the sector is certainly part of the matter of civil law; this is to ensure the necessary uniformity of regulation throughout the national territory, as well as the compliance of the employment relationship not only with the prescriptions of state legislation but also with what is established by sector collective agreements.

Finally, the state defense notes that it would not be possible to overcome the alleged grounds of constitutional illegitimacy by resorting to a constitutionally oriented interpretation of the challenged Article 1, paragraph 1, as they do not derive from the absence of a textual reference to Article 21, paragraph 1, letter j), of the NCCA, but rather from the conflict that allegedly exists between the latter "and what is provided by Article 1 of the regional law under review, which, by extending the effectiveness of the provision, continues to violate the prohibitions set by sector collective bargaining.”

For these reasons, the appellant believes that Article 1, paragraph 1, of Regional Law no. 2 of 2025 violates the exclusive legislative competence of the State in matters of civil law under Article 117, second paragraph, letter l), of the Constitution, due to the encroachment upon the scope reserved for collective bargaining.

2.– With a document filed on May 7, 2025, the Autonomous Region of Sardinia constituted itself in the proceedings, requesting that the question of constitutional legitimacy be declared unfounded.

The respondent preliminarily states that basic assistance and continuity of care are areas of district assistance which, pursuant to Articles 4 and 5 of the Prime Ministerial Decree of January 12, 2017 (Definition and updating of Essential Levels of Assistance, pursuant to Article 1, paragraph 7, of Legislative Decree no. 502 of December 30, 1992), fall under the ELA, defined in Article 1 of Legislative Decree no. 502 of 1992 as the services that must be mandatorily provided with costs entirely or partially borne by the NHS, as instruments for implementing the fundamental right to health protection under Article 32 of the Constitution.

The Region therefore observes that the failure to provide basic assistance and continuity of care to all citizens would constitute a violation of Article 32 of the Constitution, and that it is required, bearing the related expense, to finance the aforementioned ELA and adopt the organizational measures necessary to ensure their effective implementation: an objective for the achievement of which the availability of an adequate number of qualified physicians is essential.

Still preliminarily, the Region recalls that it had already highlighted, in the preceding trial before this Court, concluded with Judgment no. 26 of 2024, the difficulties encountered in ensuring—both due to its territorial configuration and structural shortages, and due to the low attractiveness of the job positions—primary care and continuity of care.

This situation has further worsened, due to, on the one hand, the access to early retirement introduced by Decree-Law no. 4 of January 28, 2019 (Urgent provisions on citizen income and pensions), converted, with amendments, into Law no. 26 of March 28, 2019, and, on the other hand, the negative impact on the attractiveness of the medical profession caused by the COVID-19 epidemiological emergency.

Given this context, the respondent highlights that, starting from 2023, it undertook a series of actions aimed at addressing these critical issues. Initially, it temporarily increased, on a voluntary basis, the maximum number of GPs working in disadvantaged areas, and subsequently, given the low adherence to the measure, it allocated resources to the ASLs to finance corporate projects aimed at strengthening primary care and continuity of care, prioritizing the aforementioned GPs. The ASLs consequently initiated projects for extraordinary community care clinics (ASCOT), which, by supplementing primary care in underserved areas pending the assignment of vacant posts as provided for by the NCCA, are aimed at ensuring users without a GP the ordinary services falling under the competence of these professionals, such as prescriptions, consultations, renewal of treatment plans, activation of home assistance, and sickness certificates.

The Region, moreover, recalls that it has nevertheless proceeded annually with the procedures for the assignment of vacant posts, without positive results: so much so that in 2024, 527 out of 1427 posts were uncovered and "over half a million people” did not have "a GP in their area, particularly those not residing near large urban areas.”

In light of these critical issues—the respondent’s defense notes—the Region could not refrain from providing continuity, with the provision challenged in the present trial, to a regional measure aimed at guaranteeing the due healthcare, pending the outcome of the procedure for the assignment of vacant posts and, in any case, pending State interventions to remedy the consequences of the multi-year absence of planning that led to the current scenario.

The regional defense further recalls that the critical issues in primary care, which the challenged regional provision seeks to address, are also attested by the March 4, 2025 report by the GIMBE Foundation on the National Health Service.

Having concluded the extensive factual reconstruction of the critical issues identified in the provision of primary and continuity care, which the challenged regional legislative provision sought to remedy, the respondent deems that the alleged encroachment on the exclusive legislative competence of the State in matters of civil law, which the State claims the regional legislator has incurred by intervening on aspects of the relationship between the Regional Health Service (SSR) and primary and continuity care physicians, is unfounded.

The appellant’s premise for alleging the encroachment on its exclusive legislative competence is, first and foremost, erroneous. It is noted, in particular, that the challenged provision does not allow retired GPs to participate in the procedures for the assignment of choice-based primary care posts (so-called family doctors) and hourly activities (medical guards) governed by the NCCA, and thus to (re)establish the related contractual relationship with the SSR. This implies that the "incompatibilities provided for by the NCCA for participation in the aforementioned procedures (Article 19, paragraph 2) and for inclusion in the primary care roll subject to the NCCA (Article 21, paragraph 1, letter j)" are irrelevant in the present case.

In the Region's view, contracted GPs, to whom the NCCA refers, are not—contrary to the appellant’s assertion—all physicians who have professional consultancy relationships with the SSR, but exclusively those referred to in Articles 19 et seq. of the same agreement.

This clarified, according to the respondent, the appeal is, in any case, unfounded.

First, the Region reiterates that the failure to provide ELA would result in a violation of Article 32 of the Constitution and that—as this Court also affirmed in Judgment no. 62 of 2020—the quality and indefectibility of the health service also contribute to the full realization of this fundamental right.

On this basis, the respondent highlights that the task of organizing the aforementioned service regionally and ensuring the provision of related services in compliance with constitutionally conforming standards falls to the Regions—as also clarified by the cited Judgment no. 62 of 2020.

Therefore, in the presence of situations that would not allow the full implementation of Article 32 of the Constitution, especially where the State does not provide any measure to address these critical issues, the Regions have "the duty to adopt organizational measures suitable for protecting the right to health of those who do not have access to ELA.”

The challenged amendment to the second period of Article 1, paragraph 2-ter, of Regional Law no. 5 of 2023 responds precisely to this need, as it adopts extraordinary measures to safeguard a constitutionally guaranteed right, exercising a prevailing organizational purpose, in order to implement Article 32 of the Constitution, which excludes the illegitimacy alleged by the appellant.

In light of this, the Region adds (again referring to this Court’s Judgment no. 26 of 2024) that the regulation of the contractual relationship for primary care physicians must necessarily address the effects it has on the right of citizens to health protection.

Regarding Article 2-bis, paragraph 5, of D.L. no. 18 of 2020, as converted, which the State Attorney General cited to support the alleged constitutional illegitimacy of the challenged provision, the respondent requests this Court to refer to itself the question aimed at ascertaining its constitutional illegitimacy, insofar as it does not include retired GPs among those called upon to contribute to guaranteeing ELA, since, as the services provided by these physicians cannot be performed by others, it effectively excludes the related district services from the ELA.

In this regard, the regional defense notes that a provision which, for the stated purpose of guaranteeing ELA, allows for the exceptional recourse to physicians of all categories and even veterinarians, provided they are linked to the SSR by an employment contract, but not to the category of physicians who would exclusively provide the services pertaining to specific and lacking areas of ELA, would be, on the one hand, unreasonable, illogical, and contradictory, and, on the other, contrary to Articles 3 and 32 of the Constitution, as, despite having the general purpose of guaranteeing these ELA, it "unjustifiably excludes from its scope a portion of the holders of these rights, namely citizens who do not have access to primary care.”

Based on the considerations set forth above, the Region requests that the question of constitutional legitimacy of Article 1, paragraph 1, of Regional Law no. 2 of 2025 be declared unfounded.

3.– The Autonomous Region of Sardinia, in view of the public hearing, filed a memorandum in which, insisting on the positions expressed in the statement of constitution, it also recalled that this Court, with Judgment no. 84 of 2025, declared the question of constitutional legitimacy of Article 1, paragraph 1, of Regional Law no. 12 of 2024 unfounded, noting, the respondent continues, the "clear organizational rationale aimed at ensuring the complete coverage of primary care, otherwise prejudiced by the absence of doctors of this type of care in the most disadvantaged areas.”

Considerations in Law

1.– With the appeal cited in the heading (reg. app. no. 16 of 2025), the President of the Council of Ministers challenges Article 1, paragraph 1, of Regional Law no. 2 of 2025, which replaces, in the second period of paragraph 2-ter of Article 1 of Regional Law no. 5 of 2023, the words "until December 31, 2024” with the phrase "until the completion of the new procedures for the assignment of primary and continuity care posts and in any case no later than June 30, 2025,” thus extending the effects of this regulatory provision.

Therefore, Article 1, paragraph 2-ter, in the version resulting from the amendment challenged in the present trial, stipulates that: "[Local Health Authorities (ASL), in order to guarantee uniform essential levels of assistance in the territory and with the priority aim of identifying organizational measures capable of ensuring basic healthcare for citizens in disadvantaged areas of the Region, are authorized to provide all physicians engaged in corporate projects for primary and continuity care with the prescription pads referred to in Article 50 of Legislative Decree no. 269 of September 30, 2003, converted with amendments by Law no. 326 of November 24, 2003 (Conversion into law, with amendments, of Decree-Law no. 269 of September 30, 2003, containing urgent provisions to promote development and correct public accounts). The provision is also applicable to retired physicians who have joined corporate projects for primary and continuity care, even with professional consultancy contracts, where the complete coverage of primary care is not guaranteed, to ensure the same functions, solely for the activities and limited to the patients of the territorial areas relating to the aforementioned projects, until the completion of the new procedures for the assignment of primary and continuity care posts and in any case no later than June 30, 2025.]”

In the opinion of the appellant, the provision that is the subject of this trial perpetuates the defects of constitutional illegitimacy already denounced with reference to Article 1, paragraph 1, of Regional Law no. 12 of 2024, which introduced the aforementioned paragraph 2-ter, challenged with the appeal registered under no. 39 of the Appeals Registry 2024, which was in the meantime rejected by this Court with Judgment no. 84 of 2025.

The Sardinian legislator has therefore allegedly exceeded the statutory competences under Articles 3, 4, and 5 of the special statute, and has invaded the exclusive legislative competence of the State in matters of civil law, which reserves the regulation of the employment relationship of primary care medical personnel to collective bargaining.

The challenged provision, in fact, allegedly conflicts with "the relevant national legislation as well as with Article 21, paragraph 1, letter j),” of the NCCA, according to which a physician who "benefits from a retirement benefit as provided for by current legislation” is incompatible with the performance of the activities provided for by the NCCA.

2.– As already recalled, the Sardinian regulation, in the version preceding that amended by the provision challenged today, was the subject of the constitutional legitimacy trial decided by this Court with Judgment no. 84 of 2025. On that occasion, too, the encroachment on the exclusive legislative competence of the State in matters of civil law was denounced (with arguments almost identical to the present ones).

It is therefore appropriate to recall some of the argumentative passages of the aforementioned ruling, which rejected the question raised on the premise that the challenged provision should be ascribed "to the legislative competence of the Autonomous Region of Sardinia in the matter of ‘health protection,’ with reference to the organizational aspects of primary care.”

First of all, this Court—also in light of the most recent findings on the matter (Judgments no. 124 and no. 112 of 2023)—recognized the challenged provision as having "an organizational rationale, in function of health protection,” aimed at "ensuring primary care for citizens residing in disadvantaged areas lacking a GP”; this results (then as now) from the wording of Article 1, paragraph 2-ter, of Regional Law no. 5 of 2023 itself, in which "the finalistic matrix that motivated the regional legislator is clearly indicated; in fact, it states that the ‘purpose’ is that of ‘guaranteeing uniform essential levels of assistance in the territory,’ with ‘the priority aim of identifying organizational measures capable of ensuring basic healthcare for citizens in disadvantaged areas of the Region.’”

On these bases, it was recognized that "[T]he regional regulation is configured […] ‘as an extraordinary organizational remedy aimed at ensuring the complete coverage of primary care’” and it was consequently held that there was no "alleged conflict between Article 21, paragraph 1, letter j), of the NCCA and the challenged regional norm, which is not even evasive of the discipline of general medicine, considered as a whole.”

The challenged regional regulation was interpreted as "a response to the impossibility of resorting to regularly contracted GPs to ensure the ‘essential’ services attributable to these areas of assistance, necessary to guarantee ‘the quality and indefectibility of the service, whenever an individual residing in the regional territory is in need concerning health’ (Judgment no. 62 of 2020).”

It was therefore reaffirmed that "the adoption of measures aimed at responding to situations of ascertained critical need in the enjoyment of essential levels of primary care, in order to ensure the effective enjoyment of the right to health, falls within the ‘organizational responsibility of the territorial entity’ (Judgment no. 124 of 2023).”

While the centrality of "collective bargaining and the binding nature of the NCCA prescriptions” cannot be denied, it was ultimately affirmed that regions cannot be precluded "from adopting extraordinary organizational measures aimed at providing a prompt response to critical needs in the enjoyment of essential levels of primary care, moreover with a temporally limited scope, when they may have secondary or consequential effects on contracting.” To reason otherwise, in fact, would prevent "the Regions themselves from intervening with their own tools to prevent these contingent critical issues from leading to the sacrifice of the effectiveness of the fundamental right to health, depriving it of its inviolable core of minimum guarantees.”

3.– In light of the considerations set forth in the cited judgment, the question of constitutional legitimacy of Article 1, paragraph 1, of Regional Law no. 2 of 2025 must also be declared unfounded.

As the appellant itself notes, the prescriptive content of the second period of Article 1, paragraph 2-ter, of Regional Law no. 5 of 2023, as amended by the challenged Article 1, paragraph 1, of Regional Law no. 2 of 2025, which is the subject of the present trial, has remained unaltered, the regional legislator having solely extended the maximum term of effectiveness of the provision "until the completion of the new procedures for the assignment of primary and continuity care posts and in any case no later than June 30, 2025.”

The regulatory amendment, therefore, does not contradict the character of an extraordinary organizational measure that seeks to respond to the contingent situation of uncovered primary care and continuity of care in the Region.

Moreover, it is plausible that the identified shortages in this area, precisely because of their gravity, could not have been resolved in the short term and would have persisted—a circumstance that, in any case, the appellant has not specifically contested—when the challenged Article 1, paragraph 1, of Regional Law no. 2 of 2025 was introduced.

4.– For the foregoing reasons, the challenged provision (as well as the aforementioned Article 1, paragraph 2-ter, of Regional Law no. 5 of 2023 in its original version), due to its purpose and intrinsic content, must be attributed to the legislative competence of the Autonomous Region of Sardinia in the matter of "health protection,” with reference to the organizational aspects of primary care.

The censure relating to the violation of the exclusive legislative competence of the State in the matter of "civil law” is therefore unfounded.

for these reasons

THE CONSTITUTIONAL COURT

declares unfounded the question of constitutional legitimacy of Article 1, paragraph 1, of the Law of the Sardinia Region of January 31, 2025, no. 2 (Amendments to Article 1 of Regional Law no. 5 of 2023 on Primary Care), initiated, with reference to Article 117, second paragraph, letter l), of the Constitution, as well as Articles 3, 4, and 5 of Constitutional Law no. 3 of February 26, 1948 (Special Statute for Sardinia), by the President of the Council of Ministers, with the appeal cited in the heading.

Decided in Rome, at the seat of the Constitutional Court, Palazzo della Consulta, on October 22, 2025.

Signed:

Giovanni AMOROSO, President

Maria Alessandra SANDULLI, Rapporteur

Roberto MILANA, Registrar

Filed in the Registry on December 1, 2025