By: prim. Janez Remškar, dr. med.
Do Slovenes really believe that the issues faced by patients, who regularly contribute the required amount to the Health Insurance Institute of Slovenia (ZZZS), are the responsibility of the doctors? In the agreement between FIDES and the Government, signed on January 1st, 2023, it is stated in point 1, and I quote:
“The government states that doctors are not responsible for the unsustainable conditions in the public healthcare system.” End of quote. So, who is responsible for the chaos in our healthcare system?
A significant portion of the population is unclear about why doctors are currently on strike. Depoliticised media argue that the strike is unjustified, claiming that doctors are well-paid. In doing so, they cite and manipulate figures that are not salaries but rather compensation for regular work and additional hours due to on-call duties, readiness, extra work in clinics, etc. It is important to note that many allowances and good compensation for work outside regular working hours are legally established and a result of objectively low salaries for regular work. This is an anomaly for which the left-wing politics is responsible, still operating on the principle of equal stomachs. In my personal opinion, regular work is highly undervalued compared to on-call duties. Additionally, some of the allowances for working conditions are outdated, a situation that has long been resolved in other parts of the world (such as radiation exposure at certain workplaces, as defined here).
Specialist doctors’ salaries have, since the late 90s when the ratio between the average salary in Slovenia and the salary of a specialist doctor was set at 1:3 after a strike, now fallen to a ratio of 1:2. All of this is connected to collective agreements in the public sector, the so-called pillars, and individual adjustments over time. Currently, there is an anomaly considering the number of years of study and work it takes for a doctor to become a specialist and what their basic salary is now compared to other public sector employees. The government has signed two agreements with FIDES. The first one on October 17th, 2022, stating that by April 1st, 2023, it will formulate a separate salary healthcare pillar within the public sector salary system and submit it to parliamentary procedures by June 1st, 2023. In the second agreement signed on January 10th, 2023, Article 2 states that doctors are not responsible for the unsustainable conditions in the public healthcare system.
I cannot fathom what the government was thinking and how it plans to meet FIDES’ demands given the current legislation. Currently, doctors’ payments depend on seniority and hours spent working, not on the scope and success of their work, much like in the rest of the public sector. Our legislation lacks proper management and accountability for healthcare institution leaders, and there is no accountability for members of healthcare institution boards. We have the Health Insurance Institute of Slovenia (ZZZS) with an assembly that even includes suppliers. ZZZS sets the prices of healthcare services, and we have prices that are paid to providers and those that are not. Is this normal? With the lingering ideology of the past, changes seem impossible. However, contemplating this issue was not FIDES’ responsibility.
I am convinced that the current government, when signing the agreement, about which the Prime Minister was undoubtedly informed, was thinking, “we will somehow get them across the water thirsty”. If nothing else, through discrediting and thus turning public opinion against the doctors. This is happening now, and it is the path to the collapse of public healthcare. Throughout the EU, reforms have been tackled through discussions and measures, which cannot be resolved in a matter of months.
In addition, it should be noted that among doctors, there are individuals who find themselves in disarray and probably engage in fraudulent activities. If this happens in the public sector, the responsibility lies with department heads and directors. However, to date, except at the Orthopaedic Clinic in the University Medical Centre Ljubljana, there is no known data indicating that excessive hours have been incorrectly billed or attendance falsified. Also, as far as I know, the Ministry of Health has not conducted administrative oversight in this regard. Why not?
It is also unethical for someone to strike while simultaneously working for a concessionaire, private entity, or another public institution. This is not good legitimacy for FIDES or the Medical Chamber if the doctor happens not to be a FIDES member.
Nevertheless, it is worth noting that the vast majority of doctors, from the young to the oldest, do good work. Even during the strike, they provide patients with all the necessary and essential care. Government statements, like those suggesting that waiting times will increase, are simply evasive, as waiting times continually extend even without strikes. If there are issues with administrative matters, such as extending driving permits for disabled individuals, it is merely a sign of our bureaucratic state. Perhaps the government could consider issuing a decree for the temporary extension of the validity of these permits?
Regarding the reporting on the work of doctors in so-called “depoliticised media” and some private media, nothing has been said so far about what makes the work of doctors difficult and consequently causes problems for patients. Everything is deliberately focused solely on the dissatisfaction of doctors with their salaries. Considering the basic salaries, this dissatisfaction is justified, especially since the media constantly misleads the public with payment data while omitting the number of hours worked. If doctors persist in their demand and revoke consent to work beyond 48 hours, a severe shortage of doctors will become apparent. It will be interesting to see what the media will write at that time. They will probably stop discussing hours and instead write that doctors are mean, unethical because they refuse to work as much as needed for duties in emergency units, clinics, on-call shifts, and readiness.
For a long time during the doctors’ strike, there was no discussion about the signed agreements with the government, in which, as I have previously stated, the government committed to specific actions by June 1st, 2023. Now they have admitted that they failed to fulfil these commitments. In response, they started talking about the unethical nature of the strike. The Prime Minister even stated that they did not fulfil their commitments due to floods and immense damage, citing financial constraints. When were these floods, and until when had the government committed to submitting a proposal to parliament? Excuse me, but this seems to be another instance of misinformation!
Now, let’s talk about ethics. In the Code of Medical Deontology, Article 9 states: “Physicians have the right and duty to strive for appropriate recognition of their work through their professional and other organisations.”
The Commission for Medical Ethics of the Republic of Slovenia stated that it acknowledges the right of all professions to strike. Each strike has its cause, representing a confrontation between two unaligned partners, each assuming responsibility for its consequences. It is expected that signed and concluded agreements will be respected. Any subsequent breach by either party causes a new wave of dissatisfaction and deepens mutual mistrust in the long term. The commission also noted that, from the standpoint of ethical values, the strike of doctors and dentists, when adhering to all strike rules, is for patients useless, harmful, unjust, and contrary to their will and needs. All initiatives by doctors and healthcare staff to reduce or eliminate waiting times, the right to access a personal doctor, payment to the ZZZS fund, and equal access to healthcare services, even for residents in remote areas, are ethically acceptable. Representatives of doctors have already presented all these initiatives, along with proposals on how to regulate the prices of medical materials and technology to reduce or prevent corruption, to the government or the Ministry of Health, unfortunately without any results.
Moreover, it is questionable that a person who, before the elections, referred to political opponents as fascists and claimed that they would prevent the victory of dark forces in the presidential elections, is speaking about ethics.
I conclude with a quote from the book of David Zupančič, MD, an infectious disease specialist, on page 80 of his book Life in the Gray Zone, where he described the situation during the COVID-19 pandemic in Slovenia: “At the beginning of the pandemic, I never imagined that the human factor would contribute such a huge share to the problem. It was by no means just a health crisis. The escalation of intolerance, fervent opposition to expertise, and the literally unstoppable spread of misinformation. Public attacks on healthcare personnel and epidemiologists increased in proportion to the number of COVID cases. As if the pandemic of viral pneumonia had triggered a simultaneous epidemic of anger and hatred. Perhaps we can understand this at least to some extent. A person who is convincingly pushed into a corner can eventually lose their humanity. The result was a sad division at a time when we should have been most united.” This is Dr. Zupančič’s perspective.
I would like to add that this was not a reflex due to being pushed into a corner but rather a deliberate act, solely for the political calculations of the then opposition and media favourable to them, to gain the support of people who felt cornered! And we can discuss the ethics of Marcel Štefančič and those who are f***ing more of, and those who followed them!