Family doctors’ choice: which law to break

Photo: Tairo Lutter

Every day, around 30 people call the Estonian Health Board to report that Tallinn family doctors cannot accept them into their practice lists even though the latter are not full. Family physicians claim that working extensive practice lists endangers quality and availability of medical assistance.

One of the people who turned to the health authority was an elderly person who needed a new family doctor after moving to the capital from Haapsalu. They needed a walking frame and wanted to find a practice close to home. Their nearest practice refused to take them on as a patient.

The board contacted the doctor and asked them to register the elderly person as a patient. The doctor refused and said they would rather pay a fine than accept any more patients. It took the person months to find a family physician in Tallinn despite needing medical assistance during that time.

Patients are also retracting applications themselves. “I wish to withdraw my application. At first, I thought it was a technical problem. When I phoned the practice, I realized they were doing everything in their power not to accept me. Even if the practice is obligated to see me, our communication would not be constructive,” a patient told the board.

Quality or quantity

Director of the Health Board Merike Jürilo said that situations where family doctors refuse to work a full practice list are no longer isolated. Jürilo explained that the board takes people’s complaints seriously as patients have the right to change doctors and the latter are obligated to register patients in their service area.

Head of the Estonian Family Medicine Association Le Vallikivi said that family physicians’ hands are tied. “We have a choice between breaking the law that does not allow us to refuse new patients or the law according to which people need to be seen on the same day in case of acute illness or within five working days for a chronic condition,” she said.

The doctor said the problem is largely with the changing role of family medicine. Vallikivi said that while practice lists were the same size back when family doctors started in the early 2000s, there was only half the work. “The workload of family doctors has increased over the years: society is ageing and there are more patients with chronic illnesses; we must also find time for prevention,” she said.

Family doctors do not want to let quality slip because of increased workload. That is why some family doctors do not hide the fact they are knowingly breaking the law.

The health board brought control actions against three family medicine practices that had refused patients in late June. The board can also register people in the place of family doctors which it has done on 18 occasions this year. Family doctors who refuse to take on patients despite control action must pay a fine of up to €640.

One family doctor at the other end of the board’s control action is Laura Prett from the Linnamõisa Family Medicine Center. The center’s 2000-place practice list has room for 267 patients. “I am breaking the law by refusing,” Prett admitted. “At the same time, I feel that considering my modest experience, the current size of the practice list is optimal in order to maintain quality,” she said.

Prett is pointing to the health service organization act that obligates family doctors to ensure availability and continuity of medical services. “I sent a reply to the Health Board where I emphasized that I wish to offer high-quality medical assistance as I am required to do by law, instead of just offering the service in the maximum volume,” she said.

“I want to be there for my patients when they need me. The queue is too long as it is,” Prett explained.

To ensure availability, the Linnamõisa center has replied to people looking to register as patients as follows: “The practice lists of our doctors are of optimal size for offering high-quality medical assistance at present and new patients are not registered.”

Finding a family doctor to be made easier

Such letters make the health board frown. Merike Jürilo said that the websites of several of Tallinn’s family medicine centers suggest practice lists are full in a situation where they actually have free places. Patients are told registration of new patients begins next month at others.

Chief specialist of healthcare system development at the Ministry of Social Affairs Liis Sildnik described the situation in the capital as controversial. Tallinn has family doctors whose practice lists have more than 2,000 patients (29 lists) as well as those who have fewer than 1,200 patients (10 lists) but do not want to see any more.

That is why the family medicine association and the social ministry decided in October to target practices where there is vacancy. The association and the health board will map Tallinn and Harju County practices that want to lock the size of their lists and those open to new patients. The option of freezing a list would not be available to those with fewer than 1,600 patients.

The data will be used to publish a list of available practices with their contact information and service language on the websites of the health board, the health insurance fund and the family medicine association. The ministry is considering a good will agreement according to which practices that have hit 1,600 patients will not be forcibly enlarged.

Tallinn’s situation is different than that of the rest of Estonia also in terms of service areas. The capital has 276 family doctors with their own practice list. The service area of 171 of them is based on streets and 106 on city districts, while 17 lists cover the entire city. While family doctor competitions are citywide since 2013, existing service areas can only be changed with consent from practices active there. Doctors are not keen on abandoning the street- and district-based system created with the family medicine reform at the start of the century.

Head of the board’s healthcare services department Pille Saar said it is a way to keep size of practices down and one of the reasons the workload of family doctors differs so much in the capital.

Family physician Le Vallikivi said that having a small service area is the only way to keep doctors from having to work themselves to death and safe from officials’ violence – control actions. She added that family doctors are willing to give up the old system as soon as a sensible limit to the size of practice lists is introduced.

The association feels the limit could be 1,500-1,700 patients instead of the current 2,000. Vallikivi pointed out that 180 family doctors out of 181 questioned said a doctor should be able to choose the size of their practice. 38 said they only accept family members of existing patients, two doctors said they are not taking any new patients, while 24 were willing to register new people.

Impossible to change the limit

Healthcare systems development specialist Liis Sildnik said that while smaller lists are not out of the question in theory, it is currently impossible. “Lowering the limit to 1,600 patients would no longer ensure coverage of first contact medical care in Estonia,” she said.

Laura Prett said that should her practice grow to 2,000 patients, she would have two options. “I would either keep working at the expense of my health and family until I burn out or give up the practice,” she said. Neither would be a good solution for Prett. “I like my work and my patients. It seems that most of them are satisfied with our center and their family doctor. It would not be a solution for the health board as they are having trouble finding doctors as it is. It would benefit no one,” Prett said.

Estonia has 30 family practices in the hands of temporary replacements. The number of family doctors who have reached retirement age keeps growing while that of young doctors keeps falling every year.