National Audit Office in its annual report: The shortage of health care professionals is increasing even further, but important decisions have not been made

10/31/2022 | 4:01 PM

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TALLINN, 1 November, 2022 – Today, Auditor General Janar Holm presented the annual report of the National Audit Office to the speaker of the parliament, Jüri Ratas, which this time focuses on trends in Estonian health care. The shortage of workers has become one of the biggest obstacles to the provision of health services, which, judging by the developments so far, will increase even further. However, the decisions necessary for functioning in the new circumstances and reorganisations which would concern family medical care, the organisation of the hospital network, and the financing of health care are still waiting to be made.

“Despite the fact that the shortage of health care professionals has been talked about for a long time, the problem has worsened – there is a shortage of family physicians in Estonia, waiting lists for specialised medical care are long, and problems at other treatment levels are piling up in nursing care and emergency medicine,” said the Auditor General Janar Holm when handing over the report. “This will lead to a situation where a patient gets a doctor’s appointment and treatment is started later than it should be, which in turn causes more damage to health, further burdens the understaffed health care system, and increases health care costs.”

The Auditor General pointed out that, foremost due to personnel problems, it is likely that in the near future, Estonian residents will have to be prepared for the fact that health services will not be available uniformly and of uniform quality throughout the country. There is no quick solution to the shortage of staff because training lasts for years, and the results of increasing the training mandate for health care professionals can only be seen in the distant future. It is not enough to only increase the training mandate for health care professionals as not all student places are occupied even now. Good students must be found for vacant student places in the field of health care in a situation where labour shortages set the tone in many areas and competition is for the same people.

“Estonian health care lacks not so much analyses or strategies, but the will, courage and ability to implement what has been agreed upon,” said the Auditor General Janar Holm. “The main thing is to clearly recognise that we have to cope with a smaller number of doctors and nurses than necessary, while there will be no fewer diseases and problems.”

The National Audit Office concludes in its annual report that there is a particularly high shortage of nurses, psychiatrists, emergency medicine doctors and family physicians. The new generation of health care professionals has been in a downward trend for some periods. The recent increase in the training mandate for health care professionals has been important, but its results are years away. For example, in order to cover the minimum need for new employees in emergency medicine in the next ten years, there should be 30–40 residency places per year. However, there are only 10–12 applicants.

While Estonia is among the averages in the OECD countries in terms of the ratio of doctors to population, Estonia is further behind when it comes to nurses. While the average number of nurses per 1,000 people in the OECD countries is 9.4 and in the Nordic countries 13.7, the figure in Estonia is 6.48. Enrolment in nursing education is increasing, but its impact will only be seen in years to come.

Compared to other countries, Estonia has a lower proportion of nurses who have arrived from elsewhere. In OECD countries, an average of 6.1% of nurses have received their education elsewhere. In Estonia, 0.2% of nurses have received their education elsewhere.

The National Audit Office is pointing out that the difficulties in providing family medical care have worsened over time. Nearly half of all family physicians are 60 years old or older, i.e. they are already at retirement age or can retire in the near future if they wish. As of December 2020, there were 737 practice lists of a family physician in Estonia, of which 48 did not have a permanent family physician. By June 2022, the number of practice lists without a family physician (i.e. with a substitute physician) had increased by another six. In 13 practice lists, the temporary substitution has lasted for five years or longer.

The National Audit Office looked at 311 competitions organised to find doctors for practice lists of a family physician, which took place from 2015 to the first half of 2022. In the first half of this year, three quarters of the competitions have failed. During the entire period, competitions have been successful in less than half of the cases (42%).

The emergency medicine department continues to be the place to address bottlenecks at other levels of health care, but it is expensive and a burden on the system. 57% of those who turn to the emergency medicine department have minor health problems. The main reason is the deficient availability of family medical care.

A significant shortage of staff, which may soon worsen significantly, also prevails in the area of mental health. More than half of psychiatrists are of retirement age or will reach retirement age in the near future. According to the National Institute for Health Development, 222 psychiatrists worked in Estonia in 2021, including 18 child and adolescent psychiatrists. Thus, there were approximately 15 psychiatrists per 100,000 people in Estonia, which is clearly fewer than in the Nordic countries. In comparison, in 2019, according to the OECD, the number of psychiatrists per 100,000 people was 26 in Norway, 24 in Finland, 23 in Sweden, 23 in Lithuania, and 16 in Latvia.

According to the development plan for the specialty of psychiatry drawn up by the Estonian Psychiatric Association, the required number of psychiatrists would be 30–40 more than currently, and an additional 130–160 clinical psychologists are needed at the first contact care level. There is also a shortage of school psychologists and mental health nurses.

The National Audit Office finds that contribution to prevention should be higher. Unfortunately, children’s health problems go unnoticed because a large number of children do not go for medical examinations. While 88–96% of children of up to 2 years of age underwent regular medical examinations, the number was only 6% among 3–6-year-olds. However, 43% of children between the ages of 3 and 6 remained completely out of sight of a health care professional for years, because they never underwent a medical examination.

Refusal to vaccinate children is increasing and this can lead to the return of dangerous diseases. As a result of previous successful vaccination, quite a few dangerous diseases have almost disappeared from Estonia. Unfortunately, refusal to vaccinate (for example, against diphtheria, polio, pertussis) has increased. Depending on the vaccine, in 2014 there were 1.9–3.5% of people who refused vaccination, but in 2021 the number had increased to 3.8–7.8%.

Patients with increasingly complex conditions come to inpatient nursing care. The reason for this trend is the deficient availability of specialised and family medical care. In addition, in nursing care, the problem for people is the high co-payment, which is why they cannot always afford the service at the desired time or in the necessary volume. It is positive that the availability of home nursing has increased. However, its further expansion is limited by the shortage of nurses.

Better prevention would help to reduce more serious consequences in cancer treatment as well. Unfortunately, for example, participation in screening tests in cancer treatment is low, and the start of cancer treatment is delayed. Poor participation in health screening is one of the reasons why malignant tumours are detected too late. Participation rate in screening is considerably below the 70% agreed in the Cancer Control Plan, reaching 59% for breast cancer, 51% for cervical cancer and 48% for colorectal cancer in 2021.

According to the Cancer Control Plan, the duration of the patient’s pathway from cancer suspicion to first treatment should be a maximum of 63 days. In reality, only breast cancer patients started cancer treatment on time (within 52 days, on average). It took about 100 days for cervical and lung cancer patients and 122 days for colorectal cancer patients.

The development of various e-solutions and remote services, the creation of health centres, the specification of the conditions of dental care benefits, and the review of treatment pathways have helped to alleviate the concern regarding the uneven availability of health services. Such changes help to solve problems in the short term, but as long as fundamental decisions at the level of the system are not made, the impact of individual development projects is limited and temporary solutions can become permanent.

Priit Simson
Head of Communications of the National Audit Office of Estonia
+372 5615 0280

+372 640 0102
[email protected]
[email protected]

  • Posted: 10/31/2022 4:01 PM
  • Last Update: 11/1/2022 10:35 AM
  • Last Review: 11/1/2022 10:35 AM

Enrolment in nursing education is increasing, but its impact will only be seen in years to come.

Kristjan Teedema/Postimees

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