Family doctor system in serious need of rehabilitation

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TALLINN, 27 April 2011 - In its recently completed audit, the National Audit Office found that the family doctor system in Estonia is unable to perform all of its functions in the health system because doctors do not always provide the agreed services, frequently referring patients to specialists without reason. The availability of family doctors has worsened, patients are having to wait longer to see them, and the system is failing to guarantee access to doctors in all regions. If the family doctor system does not work the way it is intended to, this leads to additional expenditure for the health insurance budget.

With input from medical experts, the National Audit Office audited the family doctor system, assessing whether they are fulfilling their roles in the health care system as gatekeepers and treatment coordinators, and concluded that they are not.

The family doctor system can only be considered to be operating effectively if patients are approaching the emergency medicine departments of hospitals in true emergency cases. However, the study conducted by the National Audit Office in four such departments revealed that 39% of patients with minor health problems (colds, insect bites, aches and pains etc.) sought medical assistance from the departments without good reason and should instead have approached their family doctors. This figure represented 14% of all patients seeking help from emergency medicine departments. Although people tend to come to such departments during the working hours of family doctors, the issue of doctors on call needs to be resolved so that consultations are also available in the evenings.

The audit also examined whether family doctors are providing the services they should be and whether they themselves are monitoring patients suffering, for example, from high blood pressure. The results showed that more than half of all patients who should be being monitored by their family doctors are being referred to cardiologists for no good reason. Also, not all family doctors provide the services they should be providing pursuant to legislation, but instead refer patients to specialists who provide the same services.

The National Audit Office calculated the cost of unnecessary referrals to cardiologists and visits to emergency medicine departments. It emerged that in regard to certain diagnoses in these two areas alone the costs amounted to almost one and a half million euros. There is little reason to assume that the results would be significantly different were the work of family doctors in the treatment of other illnesses to be analysed.

In order to reduce the number of cases of family doctors referring patients to specialists without reason, the National Audit Office advised the Minister of Social Affairs to implement an e-referral and e-consultation system which would allow family doctors to consult specialists without necessarily sending patients to see them. The National Audit Office also recommended that a competence evaluation system be established so as to ensure higher and more consistent quality in the work of family doctors.

As part of its audit, the National Audit Office felt it necessary to look into the possible reasons for family doctors not fulfilling the roles society expects of them. Studies have shown that the availability of family doctors has worsened: people are having to wait longer and longer to get appointments with their doctors. The number of patients having to wait at least 3 or 4 days to see their family doctor has grown steadily. The audit also showed that there are villages in 78 local government areas where people are unable to reach a family doctor in one day using public transport.

Moreover, the family doctor service, like the health care system in Estonia as a whole, is suffering from an ever-worsening lack of personnel. Even if every doctor who had successfully completed family doctor studies started working as a family doctor in the country today, there would still be 60 fewer family doctors in 20 years, since 72% of currently working doctors will have attained retirement age by then. The overall population is decreasing, but considering the growth in the volume of work that family doctors and nurses are having to cope with, Estonia will continue to lack the required number of such specialists. As a result, the National Audit Office has recommended that the required number of resident family doctors be ensured and that measures be taken to bring people with the necessary qualifications back into the sector who are not currently working as family doctors or nurses.

Although the shortage of family doctors is a national problem, it is particularly keenly felt in regional areas. The audit revealed that the family doctor system does not motivate doctors to work in rural areas: their income is lower; they work in single-doctor practices, making it difficult to find someone to replace them if they wish to take holidays or go on training courses; their working weeks are longer; and they have to spend more time on other work. It may be assumed that local governments support the family doctors working in their areas, but the audit revealed that such support remains modest at best.

In order to simplify the work of family doctors in rural areas, the National Audit Office proposed that measures be established to make the opening of surgeries in rural areas easier (with loans being issued on favourable terms or state benefits being provided). To the same end, the National Audit Office recommended that an analysis be carried out of the options of combining the patient lists of family doctors in rural areas, creating the option of paying additional remuneration to family doctors who go to work in certain regions and implementing a national locum system for doctors on holiday and undergoing training as quickly as possible.

The majority of the problems identified by the National Audit Office are highlighted in the ‘First Contact Care Development Plan 2009-2015’. The measures set out in the plan are largely the same as the recommendations made by the National Audit Office, and the ministry has begun implementing quite a few of them. However, some drafts concerning the system have not been approved due to political considerations. The National Audit Office believes that the main problem lies in the fact that progress in the implementation of the plan has been much slower than intended. As a result, several of the goals set for 2015 cannot realistically be achieved, and many of the interim goals set for 2010 have not been attained.

Tarmo Olgo, chief auditor with the Performance Audit Department, said in commenting on the results of the audit: “The family doctor system in Estonia isn’t in the best of health at the moment and needs a systematic and comprehensive course of treatment, or at least to be kept in check before its problems get the better of the system as a whole. If the right decisions aren’t made at the right time, we’ll soon find ourselves in a situation where it’ll be the family doctor system we’re wheeling into the emergency medicine department.”

Background information
A regulation of the Minister of Social Affairs allows for a total of 837 family doctor patient lists in Estonia. In 2010 there were 803 such lists in the country. Almost 70 million euros in health insurance funds is spent on family doctor care every year, comprising 9.2% of all such funding.

Family doctors are appointed to patient lists by county governors. The activities of such doctors are funded on the basis of agreements entered into with the Estonian Health Insurance Fund, the general terms and conditions of which are agreed by the fund with the Estonian Association of Family Doctors. The funding system of family doctors comprises base funding, primary funding, a research fund, distance pay and performance pay.

Family doctor services form part of first contact care. Family doctors are people’s first point of contact with the health care system, referring them to specialists and coordinating their treatment processes within the system thereafter where necessary. The functions of family doctors also include monitoring healthy children and people suffering from chronic diseases and promoting good health and the prevention of diseases at the individual level. Family doctors act as the ‘gatekeepers’ of the health care system, charged with the task of assisting patients on matters within their area of competence and referring them to specialists if their health problems demand it.

Toomas Mattson
Head of Communication Service
National Audit Office
Telephone: +372 640 0777
Mobile: +372 51 34 900
E-mail: toomas.mattson@riigikontroll.ee
 

  • Posted: 4/27/2011 11:00 AM
  • Last Update: 11/10/2015 5:48 PM
  • Last Review: 11/10/2015 5:48 PM

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