TALLINN, 20 September 2004 - When auditing the performance of Estonian emergency service, the State Audit Office (SAO) found that the current system does not grant optimal access to emergency medical care – on the one hand, ambulance service is overloaded with thoughtless calls, on the other hand, people do not have adequate access to medical care outside the working hours of general practitioners, except by alerting an emergency unit.

The analysis of the SAO shows that 27 % or about a quarter of all calls do not require an emergency response, in other words they are not conditioned by a life-threatening condition, injury or poisoning.

Indeed, an ambulance has been called even to verify pregnancy. Referral for emergency service has been justified by unwillingness to disturb a family physician. The situation where ambulances are burdened with such calls for service may result in emergency service being late for the patients who are most in need of immediate medical attention – acutely ill patients may suffer because of irresponsible callers.

Another issue with regard to overloading ambulance service – the relevance of which the SAO could not even estimate - is uninsured individuals in proportion to all patients: there are no data currently collected on this matter.

Emergency service instead of family physician

Non-serious calls for an ambulance which in fact do not require immediate medical response account for approximately 70 % of the work of emergency service, and serious calls for about 30 %. Compared with the Nordic countries, Estonian emergency service is heavily burdened: there are almost twice as many calls a year per 1000 inhabitants.

It is a common practice in Estonia that people call an ambulance at night or weekends with a minor problem that does not, in fact, require immediate intervention. However, unjustified reliance on emergency service is to a great extent caused by inadequate access to alternative medical care. The family physician telephone consultation system is not yet in operation, information about the functions and opportunities of hospital emergency departments is insufficient, transportation is not provided to patients needing it.

In Estonia family physicians see patients during business hours for 40 hours per week (20 office hours plus home visits). Reception must follow normal opening hours - between 8 and 18 hrs every workday. The office of the family physician must be open on workdays for at least 8 hours a day. Hence, provision of general medical care is confined to working time and during the other hours of the day a person must call an ambulance or refer to an emergency department (trauma centre).

Another reason for relying on emergency service is the negative experience of some people from communication with a family physician or a trauma centre. According to the 2003 survey by EMOR, 11 % of respondents indicated that the reason for not contacting the family physician was unfriendliness displayed by the physician or the nurse. In the past three years 15 % of people have changed their family physician, about one fifth have done so out of dissatisfaction with service. There are few emergency calls in the regions with a competent family physician because people have got used to and trust their doctor.

Forcing transportation of patients on emergency service

In line with the currently effective national regulation, emergency department is entitled to charge 50 kroons as fee-for-service when a patient goes to the department on his/her own. However, there is no charge for the ambulance service and the patient does not have to pay 50 kroons even if transported to hospital. Under the circumstances, it is cheaper for a patient to call an ambulance even in the case of a non-serious injury or condition than to arrive at the trauma centre by own car.

The analysis proves that family physicians, too, take advantage of the possibility of “palming” the transportation of patients off on emergency service. According to the interviews conducted by the SAO, there have been occasions when a family physician has recommended or even instructed what is to be said in order for an ambulance to arrive. Detailed written instructions on how to alert an emergency unit have been found by crew members next to patients’ telephones.

Further, performance of emergency dispatch centres is not always efficient. There are no unified guidelines on handling emergency calls, and therefore the dispatch centres work under different rules and prioritize calls for service differently. The lack of guidelines allows dispatching an ambulance too readily, for there is no ground for declining a call. Similarly, emergency dispatch centres are not able to meet the prescribed standards for responding a call and there have been occasions where in the event of an urgent call the actual response time exceeded the standard by times.

The arrival time of an ambulance in severe emergencies varies greatly. In the case of an urgent call in an urban area, an ambulance arrives within 15 minutes, as a rule, but not within 7 minutes as is established by the standard of the Estonian Association of Emergency Medical Care. Emergency response is more problematic in rural areas where it may take as long as 30 minutes for an ambulance to arrive even in the case of serious calls.

Proposals by the SAO

In order to reduce the workload on emergency medical staff, the SAO recommends developing a model for the provision of primary emergency care which would take into account the cumulative effect of all components of the system on patients’ access to health care. The model should regulate the division of work between ambulances, family physicians, emergency departments and providers of transport services and improve delivery of primary emergency medical care to patients.

The SAO also finds that the job description of a family physician should spell out the cases when the physician is obliged to pay a home visit and under what circumstances he/she may refuse a home visit. This would help patients better recognize the occasions when a family physician must pay a home visit and there is no need for alerting an ambulance.

The introduction of the family physician consultation line must be completed as fast as possible, so that people could get medical advice also outside normal working hours of general practitioners. The SAO is disappointed at the delay in the set-up of a 24-hour advice line. The report on the project preparation was finalized in November 2003, but progress of the project has been hindered by the search for an appropriate provider. According to the Estonian Health Insurance Fund, telephone consultation service will be unlikely before 2005.

The advice line of family physicians will help cut the proportion of non-serious calls among emergency calls, creating an alternative source of primary care. In case the advice line is not conducive to the same, provision of night watch of general practitioners in bigger towns should be deliberated.

In the opinion of the SAO, the practice of using ambulances for transportation of patients should be terminated, unless there is an emergency. This will help reduce the workload on emergency medical staff and ensure that ambulance crews are better prepared for performing the duties imposed on them. Furthermore, this will enable to save the resources necessary for the main functions of emergency service.

The procedure for reimbursing the cost of transport should be elaborated, by clearly defining the possibilities for a patient to receive a transportation service to and from medical facilities in order to prevent the exploitation of ambulances as a means of transport. Transportation fees will reduce the number of occasions when an ambulance has been alerted only for arriving at hospital free of charge.

There are 26 emergency service providers in Estonia, with 90 ambulance crews. The operation of emergency medical service is funded from the state budget, with the allocations amounting to about 170 million kroons in 2003. The allocations from the 2005 budget, almost 183 million, are still below what is required: according to the cost model for emergency service prepared by the Ministry of Social Affairs, the emergency budget should be approximately 215 million, given the current number and size of crews. Hence, in the opinion of the SAO possibilities should be sought for improvements to the system in order to maintain high quality service.

The SAO also found that administration in the field of emergency medical service is inadequate in places. There are no sufficient national statistics collected, neither are there analyses performed to provide an overview of the performance of emergency service. Shortage of elementary statistical data and analyses attests to the lack of system in management. For more than a year, the relevant entities have failed to adopt a final decision on the contest for emergency service providers.

Several issues pertaining to emergency medical service are unregulated (medical coverage at a mass gathering event, provision of advanced life support services). Furthermore, the instrument drawn up on emergency aid logistics has not been followed.

Sven Soiver
Press Representative of State Audit Office
Telephone: (372) 640 0787
GSM: (372) 53 414464
E-mail: [email protected]

• Posted: 9/20/2004 12:00 AM
• Last Update: 10/1/2015 9:32 AM
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