TALLINN, 22 January 2025 – As the EMS is too often used in situations where people’s lives and health are not in immediate danger, there is a risk that in critical situations people may be left without life-saving assistance because crews are busy elsewhere, the National Audit Office finds in the audit report published today. Some of the time, ambulance crews deal with issues that are actually the responsibility of GPs or social workers, and EMS is often used to transport non-urgent patients between hospitals. The National Audit Office finds that the Ministry of Social Affairs should take more decisive control over the field of EMS, as currently the tasks and responsibility are fragmented.

The significant difference between the severity assessments of calls by the Emergency Response Centre and ambulance crews also indicate that the EMS is often not used for its intended purpose.

The National Audit Office finds that the Health Board and the Emergency Response Centre should systematically analyse how ambulance calls are handled, which is unfortunately not done at present. The analysis carried out by the National Audit Office indicated that, in the opinion of ambulance crews, the Emergency Response Centre overestimated the severity of urgent and life-threatening (priorities C and D) calls in 56% of all cases. This means that the problem was not so time-critical. At the same time, the Emergency Response Centre underestimated the severity of non-urgent (priorities A and D) calls in 18% of all cases. This means that help should have reached people faster.

Over- or underestimating the severity of events is natural to a certain extent and helps mitigate the risk of leaving a person in serious need of assistance without help, as the call-taker in the Emergency Response Centre never has the full information to assess an event, as people are not always able to adequately describe the situation. However, when crews are busy dealing with concerns that are not part of the primary tasks of the EMS, people in life-threatening situations may be left without rapid assistance. Overestimating the severity of events is a drain on resources and underestimating is dangerous for patients.

According to the Health Board, in order to more accurately determine the severity of ambulance calls, it would be necessary to have health professionals working in the Emergency Response Centre who could support the call-takers in taking ambulance calls. At the moment, there are only one or two of them on duty to cover all Estonia.

The National Audit Office finds that too often, hospitals use ambulances like taxis to transport non-urgent patients. In two-third of cases where patients were transported between hospitals, the priority was A or B, i.e. low, but ambulances should mainly be used to transport urgent patients, i.e. in the case of high priority events. The hospital’s own transport should be used for patients in a stable condition. If an ambulance brigade is far from its service region, there is a risk that the ambulance will arrive too late for persons who need urgent assistance.

The Ministry of Social Affairs should improve cooperation between the health and social care systems in a way that supports the targeted use of the EMS. People who need social services or the help of a GP often call an ambulance, which is a significantly more expensive service, rather than go to their GP or social worker. Elderly people who live alone and need help, people who do not follow their treatment regimens, people with mental health problems, and drunk people stand out. GPs and social workers often do not find out about these people’s need for help, because there is a lack of data exchange between the ambulance service and local authorities, GPs and hospitals.

The necessary legislative changes should be prepared and IT developments should be planned in order to increase the integration of the health and social systems.

The Health Board has only partially performed its tasks of planning, organising and supervising the EMS and has been passive rather than focusing on the prevention and solving of problems. Supervision has only been carried out in recent years, responding to the need for legislative changes has been slow and only occurs on the initiative of EMS providers. The Board does not use the information resulting from supervision to update the EMS sector.

The Health Insurance Fund has not organised a public competition to select the best service providers in the service regions for ten years, although the National Audit Office believes that there have been sufficient reasons to organise a competition, given the changes in the operating environment. Also, the Health Insurance Fund does not have a sufficiently detailed view of the level of EMS performance and gaps in capacity, as EMS providers are not able to submit all quality data automatically and the information available is not used to improve the service. The Health Insurance Fund needs to make sure that all important aspects of providing the EMS are measured and analysed.

The National Audit Office finds that fragmented responsibility is a major cause of the problems in the field of EMS. This is also reflected in the fact that the Ministry of Social Affairs and the Ministry of the Interior have not agreed on the level of medical knowledge that emergency call-takers should have. Cooperation between the subordinated institutions of ministries and the EMS providers in solving bottlenecks in the organisation of call handling has also not been successful so far. If the emergency call-take’s assessment of an event is inaccurate, it may not be possible to provide the necessary assistance to the patient in time. The Ministry of Social Affairs and the Health Board should take the lead in changing the rules on ambulance call handling. It would make sense for the Ministry of the Interior to supervise whether and how the Emergency Response Centre complies with the requirements for ambulance call handling and dispatch. This had not been done at the time of the audit.

The Ministry of Social Affairs needs to take the lead in the field of EMS, complete the preparation of the EMS development directions and ensure that the Health Board and the Health Insurance Fund perform the obligations assigned to them by law. Due to poor management and the failure to deal with bottlenecks, the field has developed without guidance. For a long time, the Ministry of Social Affairs has not had a clear view on what kind of ambulance service the Estonian state wants and is able to maintain. The field has been without development directions for years, and many of the field’s problems have long remained unsolved. As one of the EMS parties interviewed during the audit said: “Health care is not managed in Estonia. Health care manages itself. It could be said that there are three members on the management board of the company Estonian Health Care – the Ministry of Social Affairs, the Health Board and the Health Insurance Fund. No decisions are made when all board members are treated equally and there is no chairperson. Each board member can pass unpleasant topics on to another member, and no one takes responsibility.”

Background:

An ambulance is dispatched by the Emergency Response Centre, which is under the Ministry of the Interior, but the Health Board, which sets the rules for handling ambulance calls, is under the Ministry of Social Affairs. The Health Insurance Fund also has a hand in organising the EMS.

In Estonia, there are 10 ambulance service providers and 10 service regions. At least 102 ambulance crews consisting of three members are on call 24 hours a day. Of these, 82 crews consist of nurses and 14 of doctors, and 6 are resuscitation crews. There is also one two-member crew of nurses (in Iisaku), one two-member support crew of doctors (in the centre of Tallinn) and four first aid crews on small islands. In situations where the need for EMS is greater than normal (e.g. when it is slippery, during major events and holidays), EMS providers assemble additional crews for short periods in agreement with the Health Board. When crews are not responding to calls, they are based in EMS centres (61 in total).

Ambulance calls are divided into four categories according to their severity, from A to D, where A stands for the lowest priority and D for the life-threatening condition of the person who needs help. In 2023, the people living in Estonia made 260,000 ambulance calls. According to the Emergency Response Centre, 7% of them were priority A, 23% were priority B, 57% were priority C and 12% were priority D. Approximately €79 million was spent on financing the EMS in 2023.

Priit Simson
Communication Manager, National Audit Office
+372 640 0777
+372 5615 0280
[email protected]
[email protected]
http://www.riigikontroll.ee/

• Posted: 1/22/2025 11:00 AM
• Last Update: 1/25/2025 3:26 PM
• Last Review: 1/25/2025 3:26 PM