By: Dr France Cukjati
Healthcare has already firmly entered the forefront of the current government’s political concerns. At the same time, we listen to warnings and apologies that we do not have any accurate information about the actual situation yet, and neither does the public health service network. Just as long-term care has been pushed into an unknown future, even though almost everything was already ready for its launch in January of this year, so too is the health care reform retreating into an unknown future. Of course, it will be necessary to do new studies, new analyses, and write new proposals, far into the future, because “We will do it completely differently”, they said.
The 1992 Health Activity Act stipulated in Article 4 that healthcare as a public service is performed within the framework of the public health service network, and in Article 94 that until the criteria for the public health service network are adopted, it is not allowed to invest in new spatial capacity. But to this day, 30 years later, we have not yet adopted the criteria or the network of the public health service, and a lot has been invested in new buildings, if I only mention the oncology institute and the paediatric clinic in Ljubljana.
When I was appointed State Secretary for Primary Health Care at the Ministry of Health in the short Bajuk’s government in 2000, I immediately set about making a snapshot of the state of the personnel network of primary health care, because without a clear picture of the current situation it is difficult to plan the solution to problems that have a very long beard. First, I convinced the minister, and then I harassed the staff working in basic health care, but I got the answer from all of them in many variations that “it is not possible”. So, I took it on myself. I first looked for the data in health centres and the Institute for Health Insurance, edited them, and then returned them to the health centres and doctors, active members of the Medical Association in the field, for verification and addition.
I supervised the following personnel: paediatrician, school doctor, general practitioner, occupational medicine, dentist for children, for adults, orthodontist, gynaecologist, internist, pulmonologist, psychiatrist, patronage, physiotherapy, health education and care. The rest of the medical staff (nurses) is already included in the standard outpatient unit. The data of each individual included: surname and first name, year of birth, workplace, employment (regular, contract, concessionary), and volume of work (100% or less).
I compared the data on the situation with the standards, and as a standard I considered the Slovenian average of healthcare providers per corrected number of insured persons, since we did not yet have real norms that are independent of actual staffing needs. And yet, painful anomalies were immediately apparent, which even then required adequate planning of long-term measures. For example, ZD Mozirje and ZD Jesenice reached less than 85% of the standard, while ZD Brežice barely reached 72% of the standard when it came to the occupancy of paediatricians, school, and general practitioners. We had even bigger deviations in dentistry, as quite a few areas of medical centres did not even reach 50% of the standard, Jesenice, for example, only 29%. Differences in the number of primary care gynaecologists were also unacceptable. For example, according to the standard, the entire regional unit Koper had 9 gynaecologists, but they actually had only 5. The regional unit Kranj had 12 gynaecologists according to the standard, but they only had 8. Therefore, for example, Ljubljana, which according to the standard belonged to 23 gynaecologists, had as many as 30.
Despite the boycott of the ministerial staff during the short Bajuk’s government, in four months we were able to obtain a detailed and indisputable state of the personnel capacities of the basic health service. The snapshot of the situation was then handed over to the new minister in digital and written form on 174 pages of spreadsheets. But even then, the new left-wing government made it known that “We will do it completely differently” and the recording of the personnel network of primary health care probably went to the cut and was “deleted”.
Since in 2000 I also had data on the birth years or ages of all the mentioned health professionals, I was able to make a projection of human resources for the future. Since the average age of general practitioners was already very high at that time, I rightly warned that in eight years the shortage of providers of basic healthcare will begin to worsen significantly. This staffing crisis has in fact become even more severe than we expected, because the specialisation of family medicine also took off and stricter norms were adopted. However, adequate state concern for the improvement of working conditions, which would reduce the outflow of personnel abroad, did not come into being.
Working conditions also include the attitude of the state towards the providers or holders of the public health service. When the system of personally selected doctors was introduced in 1993, there was a constructive cooperation between ZZZS and the Medical Association of Slovenia. Even then, European experience convinced us that the system of a personally selected doctor generally enables greater patient trust in the doctor and greater commitment of the doctor to the patient. It soon became apparent that some doctors were willing and able to treat only about 1,000 and others 2,000 or more of those insured. But the salary system did not follow this innovation. The salary regulator pays both doctors the same. And it is normal that over time even a good doctor who does not look at the patient through money glasses asks himself, “in honour of who am I working so hard” if others who work half as much have the same salary. Anyone with even a hint of common sense knows that often only the possibility of giving a higher salary opens up the possibility for the employer to transfer staff to more difficult and less comfortable jobs.
The days of socialist healthcare are gone
Imagine if all the inns were state-owned, and the innkeeper was paid according to the salary adjustment and not according to performance. Do you think he would gladly welcome you and serve you kindly even when he did not feel like it!? If doctors were paid according to the number of defined insured persons (or head tax quotients), believe me, there would be no undefined insured persons in Slovenia. The current situation is the tax we pay to the ruling socialist mentality. And even the pathological differences in the coverage of individual areas in Slovenia would eventually disappear if providers of ambulatory primary health care were given the option of granting a concession. Even in remote rural areas, many concessionaires would be happy to move, as there would be an unoccupied “market” waiting for them. Medical faculties, however, should produce at least a few percent more doctors than we need according to the norms.
Gone are the days of socialist planned healthcare, when the authorities thought that they could play chess with the providers of healthcare as with the farmers on a chessboard. And even like a bad chess player who arrogantly repeats, “We will do it completely differently!” If anything, it is most dangerous to solve long-term problems of public health if those in power are convinced that they are “all-knowing” and “all-powerful”.