Tallinn, 4 February 2015 - The National Audit Office is of the opinion that the Estonian Nursing Care Network Development Plan 2004-2015 has largely failed to achieve its objectives. The system of independent nursing care and welfare has not been tied into a whole, the number of beds and service volume in inpatient nursing care does not correspond to plans in any region and the trilateral financing principles – where the Estonian Health Insurance Fund, local authorities and the patient all make agreed contributions – have not been implemented. A quarter of patients who received inpatient nursing care in 2013 should actually have received a different kind of care.

The independent nursing care and welfare system has not been tied into a whole. The provision of nursing care is financed by the Estonian Health Insurance Fund and organised by the Ministry of Social Affairs, while welfare services are overseen by local authorities. The audit revealed that no uniform criteria have been established to find the most suitable service for a person in the nursing care and welfare system. Doctors merely determine the health service and do not weigh up the alternatives. The National Audit Office is of the opinion that the Ministry of Social Affairs has not been able to join the two systems into a whole or to develop uniform assessment criteria in the 11 years the development plan has been in effect.

A quarter of those who were provided the most expensive service, i.e. inpatient nursing care, should ideally have been provided with another service. The reason for this is the absence of uniform and clear criteria as well as weak cohesion between the health system and the welfare system. The experts assessed that 37% of those who received the incorrect service needed the service of a welfare institution and ca half would have coped at home if nursing care or welfare serviced had been offered to them at home. 18% did not need any services at all and would have coped on their own at home.

The number of inpatient nursing care beds does not comply with plans. According to the develop plan, which is still considered adequate, ten beds per 1000 people aged 65 and older are prescribed for the provision of inpatient nursing care in a county. On average, the objective of the development plan had been achieved to the extent of 84% by the end of 2013, but large regional differences were a problem: Jõgeva, Pärnu, Viljandi and Valga counties have considerably more beds than they need, while the number of beds in Järva and Saare counties is only 57% of the objective.

The Health Insurance Fund has not guaranteed that the accessibility of nursing care in different regions is as equal as possible. In addition to the significantly unequal distribution of beds, there are also major differences in the provision of the service. Whether or not a person is provided with services depends on where they live. The contract between service providers and the Health Insurance Fund covers 46% of estimated need for people in Lääne-Viru County, but 83% and 88%, respectively, in Lääne and Põlva counties. Inequality in access to services is also increased by the different terms and conditions of the contracts entered into between the Health Insurance Fund and the service providers. The result is that the service is provided for the shortest time to people in Valga County (23 days per patient per year) and for the longest time in Põlva County (40 days per patient per year). The difference in the provision of the outpatient service is also significant. The Health Insurance Fund has explained that the situation has developed as such historically. The Health Insurance Fund has been drawing attention to this problem since 2014, and regional differences have decreased somewhat.

The principles of financing the nursing care service have not been implemented. The development plan prescribes the trilateral financing of inpatient nursing care, according to which the local authority, the Health Insurance Fund and the patient pay 49%, 35% and 16%, respectively. At present, the Health Insurance Fund pays 85% and the patient pays 15% of the cost of nursing care. Local authorities do not participate significantly in financing the service. Sharing the costs was not the only goal of the trilateral financing of nursing care - it should also increase the interest and responsibility of all three parties to ensure that the patient receives the service that is the most suitable and financially the most reasonable. The National Audit Office is of the opinion that the Ministry of Social Affairs has not taken any steps during the implementation of the development plan to integrate the financing of the sector. The fact that local authorities primarily finance welfare services and health insurance money is spent on nursing care is another reason why combining the two systems has failed.

This is why the National Audit Office recommended combining the organisation and financing of the health system and the welfare system to guarantee a service that is best for the people and cheapest for society. Uniform criteria for determining the services a person really needs should be developed at the same time.

Auditor General Alar Karis said the following when commenting on the audit: “Estonia is struggling with a shortage of labour, but we have ca 13,000 people who cannot work because they are caring for a family member. The number of people who have to decide what to do with a family member who needs care is increasing every year. Where can we send them? Because the family needs feeding and it is impossible to simply stay at home. Sending a person who needs care to a nursing home is not the only answer, as providing them with independent nursing care either at home or in a hospital is also an option that would burden their family members too much or force them off the labour market. However, nursing care must be placed in the same system as other care. It is not up to people to know who provides what services, whether they fall within the competency of the local authority or are financed from the health insurance budget. People must be able to go to one place for help and have the service that meets their needs offered to them. This would guarantee better treatment of and correct services for patients and save them time, but also help the state save money in the long run.”

Background:

Independent nursing care is a health service whose goals are maintaining and, if possible, improving a person’s state of health and their current functional condition; long-term treatment of stable patients and supporting them via nursing activities; preparing people for referral to general nursing homes or home nursing care; and nursing care for those who are dying.

The nurse performs the necessary procedures, e.g. dresses wounds, removes sutures, performs tests and takes blood pressure, doses and administers medicines, gives infusions, look after bladder catheters and performs bedsore and position therapy. The nurse should also give advice to the patient and their family members.

The Health Insurance Fund finances this to the extent of 100% when the service is provided in the person’s home during a visit (so-called home nursing), and to the extent of 85% if it is done in a hospital (inpatient nursing care). This is not a treatment service, i.e. only nursing services, and to some extent care services, are provided.

The total number of people who received independent nursing care in 2013 was 18,537; 12,313 of them received inpatient nursing care and 9073 received outpatient nursing care (with some receiving both outpatient and inpatient nursing care).

24 million euros was spent on independent nursing care in 2014.

Toomas Mattson
Head of Communication Service, National Audit Office
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• Posted: 2/4/2015 12:00 AM
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