The court case of Dr. Igor Gorjatšov, charged with causing a patient's death out of negligence, is a painful reminder of why medics prefer not to talk about their mistakes publicly. A new patient insurance system that will cost around 2 million euros to launch should change the situation in the coming years.
«Every doctor makes treatment mistakes; however, they could be learned from,» said Secretary General of the Estonian Medical Association Katrin Rehemaa. «Doctors will try to hide mistakes if they fear punishment. It is unfortunate but also understandable. Complications and mistakes are reviewed inside institutions, in close circles; however, no one wants to make them public as it would constitute putting you own neck on the line. Should criminal punishments become commonplace, some riskier procedures could even be waived, which would mean the patient would not have access to all possible treatment options.»
Rehemaa said that the current system is not patient-friendly either as the procedure of applying for compensation is complicated and time-consuming. «If a person wants financial compensation for a treatment mistake, they have to prove the fault of the doctor or the hospital in court. It is extremely difficult and insensible,» she said.
Head of the Estonian Patient Advocacy Association Pille Ilves agreed: «In a situation where mistakes by medics are criminalized, it will be very difficult to achieve openness and honesty from the other side. A doctor's mistake should not be criminalized, unlike murder and intentional causing of bodily injury. Most treatment mistakes are not intentional.»
Ilves believes, however, that every patient complaint should be valued in terms of improving the quality of treatment, and that mistakes need to be established and their causes eradicated.
Neither Rehemaa nor Ilves believe doctors are the only ones to blame for treatment mistakes in most cases. Everything depends on conditions the hospital can provide, including the range of specialists the attending physician can consult.
Rehemaa believes that it would be best to learn from mistakes if hospitals reported errors and unwanted treatment results. The example is Finland with its non-fault patient insurance system. Estonia has been working on a similar system since the entry into force of the European Union's patient rights directive; however, progress has taken years.
«In Finland, mistakes in treatment are sincerely admitted and recorded. There are no punishments. If we know what caused the mistake, others have a lot to learn from that,» said chairman of the board of the Estonian Health Foundation, family physician Eero Merilind.
«When the new system enters into force, patients no longer have to go to court to demand compensation; instead they can turn to a special committee; compensation will be paid out by the insurance fund,» Rehemaa explained. This would make it possible to offer compensation for damages quickly and without the injured party having to go to great lengths to collect it.
The Estonian Medical Association believes that to motivate health care institutions to report mistakes, the patient insurance system could be tied to the initiative of hospitals – while the latter would be insured against damages claims, insurance would be voided in cases where the mistake first comes to light after the patient turns to the committee. Hospitals would have to pay for damages in full in those cases.
Merilind believes compensation should come from a national fund that could either be an independent public law entity or be attached to an existing state institution, for example the health insurance fund. «It would also be possible to insure hospitals with the help of insurance companies. Estonia should also follow Finland's example in maintaining a list of treatment mistakes and their cost,» Merilind suggested.
Rehemaa finds that the new fund should not be attached to the health insurance fund. «First of all it should not be financed from the health insurance budget, which is meager as it is, and secondly there exists the possibility of a conflict of interests in a situation where the same institution finances treatment and evaluates the quality of work of hospitals and clinics, and at the same time pays out compensation,» Rehemaa said.
Member of the board of the Estonian Insurance Association Andres Piirsalu agrees and believes the main thing is to make sure victims of treatment mistakes get their compensation quickly.
Piirsalu said that things would go much more smoothly if all doctors would be members of the insurance system. He believes the new insurance could work like the Estonian Traffic Insurance Fund that makes sure all victims get compensation. Hospitals would make payments into the system for insurance against compensation claims.
The public law fund idea is also to the liking of hospitals' association chairman Urmas Sule, who said that additional financing should be found for the fund as recent sums are insufficient. Sule said that constant efforts to cut in-patient care volumes that cause hospitals to send patients home and therefore increase the likelihood of treatment mistakes are bad enough.
«The system's operation should be carefully thought out before it is launched. We believe it would be sensible to have it operate as a separate agency, similarly to the unemployment insurance fund,» Sule added. He believes that in order to attach the fund to the health insurance fund, sickness benefits should be taken out of the latter's budget to free up funds.
Voluntary insurance currently covers a little more than 70 percent of Estonian doctors. Most are members of the Estonian Medical Association where insurance against severe mistakes in treatment is included in the 9-euro membership fee.
Piirsalu said that if insurance currently deals with a few dozen compensation claims annually, the social ministry forecasts that number could grow to 500 cases in the new system. Treatment mistakes are confirmed in one case in three in Finland. In a situation where compensation would be paid on par with Finland and in the same relative proportion to cost of living, the new system would cost a little over 2 million euros.
Head of the health care network at the Ministry of Social Affairs Heli Paluste said that the system's launch is scheduled for 2018 when insurance will become mandatory for all institutions licensed to offer medical services, including dental and private practices. She said that it is important both doctors and patients would be satisfied with the new system. The necessary funds will be found from the state budget.
Other European countries that have non-fault liability patient insurance systems include Latvia, Denmark, Norway, Sweden, Belgium, and the United Kingdom. Patients first have to prove medics' guilt in other countries.