The Emergency System

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

In Polish health care, the Emergency system is still one of the most important issues demanding essential systemic solutions. The main purposes of the new Law on a National Emergency System are: creation of an integrated emergency system, establishment of a new medical curriculum (rescuers education) and creation of specialized emergency teams.The expected outcomes focus on increasing the effectiveness of the system (in an institutional, organisational and financial sense).

Purpose of health policy or idea

The major aim of the new Emergency System is to improve first aid procedures and facilities, mainly by reducing the time lag between an accident and hospital admission to 8 minutes within the cities and to 15 minutes outside the cities for 75% of emergency calls, and by developing close cooperation between emergency services, fire brigades and the police.

In 2001, the the policy idea of creating a national emergency system was for the first time transformed into a piece of legislation (Law on a National Emergency System, 25 July 2001). From the very beginning, the main purpose of this legislation concentrated on the question of systemic integration. After the failure of the first Law there were no significant changes in the emergency system - looking at the problem from the patients point of view. The idea of the new legislation on the emergency issue was one of the fundamental ideas of political discussions. The old solutions in this area were inadequate to the changes of the health care system as a whole and to patients' needs and expectations. Moreover they were improper in the context of administrative reform ( the process of decentralisation of competences, changes in the ownership of health care units).

Main points

Main objectives

The main objectives of the policy idea is:

• To increase the number of medical dispatch centres and improve their distribution
• To increase the number of emergency ambulances
• To locate and equip hospital emergency units
• To set standards for receiving emergency calls and to ensure the accessibility of ambulances under the supervision and coordination of a physician.

The instrument (the Law) is divided into following chapters:

1. introducing provisions
2. medical rescuers and others rescuers
3. planning and organisation of the system
4. units included into system
5. the procedure of medical rescue activities
6. system units financing 
7. changes in the legislation in force
8. the intertemporal adjustment and final provisions.

The Law on Emergency system divides the created system of emergency into three pillars:

• Centres for Rescue Information (CPR) - receiving the alarm calls and coordinating of the activities
• Medical Rescue Teams (pre- hospital emergency)
• Hospitals Emergency Units (SOR) - undertaking emergency actions in the hospital area.

Type of incentives

The Law introduces provisions on emergency services financing that divide   responsibilities in this sphere between MoH, voivodships and NHF. On the level on voivodships there are no possibilities for financial decisions undertaking (no professional personnel, knowledge, skills and technical base). Voivods transmit the competencies on contracts agreement to the directors of particular, regional NHF units. 

• in article 46: the tasks of the medical rescue teams (excluding the air rescue teams) are financed from the state budget and the voivods are responsible for the money distribution 
• the costs of the medical rescue activities include costs of the medical dispatcher functioning. 
• plans on medical rescue teams financing are delivered to the MoH by the voivods before the 31st of March, in the year previous to the budget year.
• on the basis of voivods plans MoH before the 20th of May, in the year previous to the budget year, delivers to the Minister of Finances the proposition of financing resources (with the division into particular voivodships - adequately to the algorithm provided in the Law). 
• the Ministry of Finances delivers to the NHF the information on the financing level (on recourses including into the project of the budget Law)
• MoH by the executive regulation defines the rules of the algorithm setting (determinant indicators: the number of population, the density of population, maximum limit for the accident reaching time and the number of events that cause the state of the sudden health threat on the area of particular voivodships). 
• in the article 47: the heath care services provided by the hospital rescue unit and by the organisational units of specialised hospitals (in the sphere of the health care services indispensable for the medical emergency) are financed on the rules and procedures defined in the Law from 27th of August 2004 on health care services financed by the National Health Fund. 
• In the article 48: the air rescue teams activity is financed from the state budget ( MoH competences)
• Article 50 sets the opportunity for co- financing of investments aimed on creation and modernisation of medical rescue teams, hospital emergency units and medical dispatchers work place ( MoH, other Ministers, voivods and local authorities). Apart from above, co- financing can be provided on the basis of long term programs established by the government.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Medienpräsenz	sehr gering		sehr hoch

The change introduced by the new Law was absolutely necessary. All engaged in the problem groups were standing for the new solutions seeking process. They also agreed in the sphere of fundamental priorities. Disagreement concerns particular issues: financing, structure, organisation and control. In the discussion however the issue of the reforming (or even establishing) the hospitals net in Poland that would be adequate to the population structure, to the health care needs assessment and to the local specifics have not been recalled. This question is strictly connected to the problem of proper decisions on hospital rescue units creation. The threat maybe caused by not rational nature of decisions but by particular political interests

Political and economic background

The change in government in case of the necessity of the emergency system creation played an essential role. The previous legislation from 2001 (adopted by the central - right government) has never been implemented due to the new Ministry of Health (left wing- 2003 elected) decisions: all the financial resources foreseen for the implementation of described Law were directed aiming in the institutional and organisational systemic reform (creation of centralised NHF). For the current government the issue of the emergency system creation became one of the priorities that resulted in a form of legislation. The Law takes into account standards accepted in EU and confirms the possibility to perform the medical rescuer profession for persons qualified (certified in EU or EFTA or in the other country under the condition of acceptance by Poland).

Change of government

see above point 4

Complies with

EU regulations

Article 26 of the Universal Service Directive ( Directive 2002/22/ EC of the European Parliament and of the Council of 7th of March 2002 on universal service and user?s rights relating to electronic communications networks and services, OJ of EU No L 108

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The idea was generated by previous Ministry of Health (political background described in point 4). The main purpose of the health policy idea, apart from mentioned before, was also the need to comply with EU standards and procedures. To achieve this idea the financial resources and re- organization process of the system are necessary and such changes may be introduced in the form of the Law. The next important question is a proper and compatible with the EU standards education process (medical rescuers). The main actors are: MoH, Minister of Finances, NHF, and indicated groups affected (see point 3.1).

Initiators of idea/main actors

• Regierung: The present Minister of Health (opposite to the previous Ministers) declared the emergency system construction as a priority. His success may be seen through the new Law adoption. The government as a whole was also essentially involved in the process of legislation due to it support for the idea. The introduced solutions could be interpreted as an attempt to more centralised methods of financing the system (budget financing replacing the NHF financing) and institutional (transmission of formal competencies to voivods).

• Leistungserbringer

Approach of idea

The approach of the idea is described as:
renewed: Comment: The approach in the described Law is renewed, it follows earlier discussions and replaces the old Law that has never been implemented (see also point 4).

Stakeholder positions

The main groups affected are described above. Special importance should be granted to the hospitals that include emergency units. These are the health care system units that have to deal with the patients in very bad health condition (high level of responsibility, a need to undertake action fast, often in a situation of life threatening conditions). The hospitals may be put into a difficult position in case of unsuitable access to the health care services (e.g. specialists). Patients may tend to use emergency "path" rather than to wait in long queue.  

Actors and positions

Regierung
Minister of Health	sehr unterstützend		stark dagegen
Leistungserbringer
Hospitals (with emergency units)	sehr unterstützend		stark dagegen
Medical rescuers	sehr unterstützend		stark dagegen

Influences in policy making and legislation

As it was mentioned above the first Law on Emergency System in Poland was enacted in 2001, but it did not come into force. The discussion on the processes of establishing the renewed Medical Emergency System started in 2005, before the last parliamentary election. The new Law on the Medical Emergency System was based on the original proposal from 2001- but only in the sphere of main objectives. There were also several following changes caused, for example, by the implementation of the health care reform in the year 2001 (replacement of Sickness Funds by centralized NHF).

• creation of the medical rescue profession, establishing of formal standards of their education and setting the range of activities performed by medical rescue in the situation of qualified first aid.
• the main public institutions defined in the medical Emergency System belong to the governmental administration only (Ministry of Health , voivods). In the first version of the Law also the administration organs on the level of local authorities (powiat district ) were included.
• The main units included in the system are not only hospital emergency units and medical rescue team but also air medical rescue teams.
• The financing methods of the system were described in the 3.1 point. The main change in the aspect of financing the system is connected to the creation of the new payer institution in the Polish health care system.

The main actor involved in the legislation process was: MoH, who declared the emergency system construction as a priority of his health policy. The described Law has been agreed between the all parliamentary political parties.

Legislative outcome

major changes

Actors and influence

Regierung
Minister of Health	sehr groß		kein
Leistungserbringer
Hospitals (with emergency units)	sehr groß		kein
Medical rescuers	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The main stakeholders involved in the Law implementation process are medical rescue teams and emergency hospital units. Those groups are responsible for the direct contact with the patient and for the first aid actions. The another groups of actors were already mentioned. The most important means necessary to successful implementation are the financial and organisational tools. Quite important is also creation of standardised professional medical rescue education process.  The actively participating and directly affected by the process implementation groups are also the police and the fire brigades. It is hard to say haw successful the implementation of the process will be on this stage of it (too short time to evaluate) The main obstacles could be financial or organisational. The budget financing protects the system on one hand, but on the other, under the condition of financial problems the lack of recourses may substantially influence the emergency system functioning. The provisions on system financing are criticised due to the lack of the solution on the specific financing necessity, concerning the permanent readiness of the hospital's emergency units. The mixed financing methods introduced for this units activity (for the readiness and for the health care services provision - both from the central budget) together with the adequate and rational evaluation of the units performance could be the guarantee of the proper functioning and the tool of motivation for the permanent increase of the quality. The main opponent to this policy was the Main Chamber of Physicians that criticised the new Law for being to theoretical and not consulted with the professionals. The medical professionals recall as a weak side of the law the solution concerning the variety of hospitals units. In fact they underline the lack of provisions that would concern different clinical units due to the possibilities of sudden specialised interventions. Such possibilities in practice could be connected to almost all clinical disciplines, starting from the intensive care units. They stress the necessity of cooperation between such clinical units (partly adapted to the sudden interventions) and the rescue teams. The cooperation is understood as the immediate health care services provision.

Monitoring and evaluation

The Law, in the chapter 3 "Planning and organisation of the system", foresees mechanisms for the regularly reviewing the implementation process, the impact and the overall appropriateness. It divides the control and monitoring tasks into two levels: national and local. The organs responsible for the process are MoH and viovodes. The process of monitoring and control on the level of voivodships includes three main spheres: 

• The cooperation with the system units - police and fire brigades (checking the standards defined in article 17th in the Law,)
• The health care units on the voivodship level (adequately to the roles and procedures defined in the Law on health care units provisions) 
• The education units - the rescue courses (checking the standards defined in the article 13th) The evaluation and monitoring tasks are realised also by the physicians coordinators of medical rescue who are employed by the Voivodship Centre for Crisis's Management.

 The measuring indicators have been determined independently to the introduced Law (they were applied for quite a long period of time): they concern the question of reducing time lag between an accident and hospital admission to 8 minutes within the cities and to 15 minutes outside the cities, for 75% of emergency calls. For the evaluation of the change results and measurement using the above indicators the significant period of time and adequate data are necessary. 

Dimensions of evaluation

Struktur, Prozess, Ergebnis

Results of evaluation

Results not known due to the "fresh" nature of the Law.

Expected outcome

 In the expert opinions the policy should achieve the main objectives of the change, but there are also defined above obstacles (especially concerning financial and educational issues) that could disturb the process of gaols achievement. The unexpected and undesirable effects are attributed (mainly by the medical professionals) to the excessive development and establishment of the administrative structure (new centres and posts occupied by persons not qualified in the medical rescue sphere). This can result as higher than expected costs and as the lower quality.  

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

• The impact on quality of health care services is obviously very important: the perspective of the time lag between an accident and hospital admission to 8 minutes within cities and to 15 minutes outside cities shortening, for 75% of emergency calls, should significantly influence the services quality.
• For the level of equity the change will not bring substantial change, but due to the medical dispatchers functioning improvement (rules of information, data collection and of decision making) the equity may also be improved.
• The impact on cost-efficiency relation is potentially large: better diagnostic methods, better qualified rescuers, better effectiveness of rescue team's actions should influence the relation cost- efficiency, looking from the perspective of the whole health care system functioning.

References

Sources of Information

• The Law from 8th of September 2006 on National Emergency System, O.J. no 191, clause 1410.
• The Law from 25th of July 2001 on National Emergency System, O.J. no 113, clause 1207 with amendments.
• Directive 2002/22/ EC of the European parliament and of the Council of 7th of March 2002 on universal service and user's rights relating to electronic communications networks and services, OJ of EU No L 108 of 24/04/2002.

Author/s and/or contributors to this survey

Iwona Kowalska, Anna Mokrzycka

Empfohlene Zitierweise für diesen Online-Artikel:

Iwona Kowalska, Anna Mokrzycka. "The Emergency System". Health Policy Monitor, November 2006. Available at http://www.hpm.org/survey/pl/a8/3