Working Time of Health Professionals II

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

On the 1st of January 2008 the amendment of the Law on Health Care Services Providers from the 22nd of May 2007 was implemented. The amendment concerns certain aspects of working time conditions according to EU Directive 2003/88/EC. The new regulation shortens the working time of health professionals to up to 48 hours per week. The Ministry of Health is not prepared to implement the amendment and has made an appeal to the physicians, aiming at postponing the realization process of the law.

Neue Entwicklungen

The Ministry of Health is not adequately prepared to implement the amendment on the Law of Health Care Services Providers from the 22nd of May 2007, which regulates the weekly working time of health care professionals. Obviously, the MoH is involved in many other issues concerning health care system reform (elaboration of new systemic laws, change of status of health care units etc.) but it is also a question of a lack of finances - there is no money for doctors' extra hours and the MoH cannot support hospitals managers this way. Moreover, the MoH did not propose any specific solution for such a situation and managers have been left alone with this problem alone. MoH appealed to all doctors working in hospitals for patience and asked them to work on the old rules for some unspecified period of time.

In many hospitals the schedules of duty were elaborated for a few days or weeks only. The management of the hospitals was not able to ensure the full staffing of the duty. The amendment of the legislation cannot be implemented without the indication of financial resources. In a situation of financial shortages in the system, the MoH asked the professionals for support. In her statement, the Minister of Health appealed to the medical professionals for a compromise between their demands and the real possibilities of the system. The next step of the MoH was the idea to organize a  "White Summit". This forum focused on the fundamental problems of health care in Poland and brought together professionals, researchers, politicians, and representatives of trade unions of doctors.

The provisions of the new legislation harmonized Polish law with a EU directive but the real situation forced hospital managers to introduce differentiated solutions, adequate to the possibilities of the particular hospital. As a result there are many different ways of problem solution (overtime work, additional agreements with doctors, approval of exceeding 48 hours work time by a doctor, 12 hours working time system,  the daily stated number of hours division and 12 hour duties after work time, mostly temporary schedules), but in all cases hospital managers have to find extra finances to pay for the extra work. The next effect of the legislation is a growing number of the doctors resigning from work. All together the legislation creates big trouble for the hospital managers - it is the manager who has to ensure the proper functioning of the hospital in such difficult circumstances. The MoH is mostly engaged in the process of consultations, discussions and propositions for health system changes, mainly preparing legislative proposals (the new Law on health care units (see HPM report "Status of health care units - project of law"), the Law on additional insurances, the Law on patient rights and a package of MoH executive regulations).

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

Judgment of the policy - see the previous report. The implementation brought much more controversies than it was expected. The MoH did not use her competences in this matter and it could even be judged as her willingness not to do this and to stay aside on a safe position. Decisions on the problem have been decentralized and left to the managers without any financial support.

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

• Regierung: The MoH is aware of the necessity to implement the legislation but she tries to postpone the process and to convince doctors to wait for the extra finances and a significant change of the situation.

• Leistungserbringer: The group of providers differs in opinions, interests and the level of influence. The conflict is mostly engaging doctors and hospital managers as they are at the opposite sides of the problem.

• Kostenträger: NHF as a ?guard? of the health insurance finances is strongly opposed to the implementation of the Law. It may change its position in case of an increase of the insurance fee level.

• Patienten, Verbraucher: Patients are the group at highest risk: they are afraid of being neglected in hospitals and these fears are stoked by media reports showing drastic cases.

• Andere: Local authorities are in a difficult position. As the founding body of hospitals at the local level they have to take responsibility for financial debts arising from the situation.

Stakeholder positions

The position of the MoH has changed slightly: the Minister lost very strong influence due to the growth of the position of hospital managers in the conflict with doctors. Hospital managers become the main stakeholder: it is up to them to decide on solutions, they have to negotiate with the staff under the pressure of financial shortages and pressure by trade unions, and they cannot count on additional financial transfers from the NHF. Managers are responsible for the realization of health services contracts but they are facing a growing number of doctors resigning from work and thus the problem of insufficient human resources. Managers have also taken responsibility in front of the local authorities (the last ones acting as owners of hospitals). Local authorities are mostly opposed to implementation of the legislation in such a way that it would increase hospital debts.

At the stage of implementation the EU is not so much engaged, the same situation concerns European Court of Justice.

The NHF entered the political scene: it would expect an increase of the insurance fee to generate additional financial resources for salary increases. The position of the NHF is very strong due to its role in the decision making process in health care services contracting.

Providers and trade unions can benefit from the new legislation. It is a very important legal instrument that opens the door to labor courts in cases violation of doctors' rights.

The "White Summit" was an idea of the MoH and it is to function as a forum for the creation of alliances, not only for the issue of working time conditions. The role of the Prime Minister should be noticed in this respect. He strongly supports all the actions, initiatives and propositions initiated by the MoH or the parliamentary health commission.

Actors and positions

Regierung
MoH	sehr unterstützend		stark dagegen
MoF	sehr unterstützend		stark dagegen
Leistungserbringer
Hospitals managers	sehr unterstützend		stark dagegen
Physicians	sehr unterstützend		stark dagegen
Nurses	sehr unterstützend		stark dagegen
Trade Unions of doctors	sehr unterstützend		stark dagegen
Kostenträger
NHF	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients	sehr unterstützend		stark dagegen
Andere
Local authorities (poviat, voivodship)	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

The law has been issued and the process of legislation has been finished at this stage. As it was described above hospital managers developed many different solutions for the implementation of the law, depending on the financial resources. It makes the situation complicated and ambiguous, the results of the managers' actions cannot be clearly defined at the moment.

The next step is the unification of the implementation process and it needs at least one executive regulation of the MoH in the near future.

Legislative outcome

Hold

Actors and influence

Regierung
MoH	sehr groß		kein
MoF	sehr groß		kein
Leistungserbringer
Hospitals managers	sehr groß		kein
Physicians	sehr groß		kein
Nurses	sehr groß		kein
Trade Unions of doctors	sehr groß		kein
Kostenträger
NHF	sehr groß		kein
Patienten, Verbraucher
Patients	sehr groß		kein
Andere
Local authorities (poviat, voivodship)	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

In the implementation process, as it was stated before, the most difficult situation concerns the responsibility of the managers. At the present stage they can be seen as the losers because all the processes have become only their burden. Patients are also involved at this stage of implementation: they are indirectly affected because they cannot be sure of obtaining access to health care services. The most drastic result  reported by the media is the abandonment of patients by doctors.

The implementation process so far can be judged as extremely provisional and temporary. The above indicated executive regulation of the MoH will play a key role in the process of harmonization of working time solutions in the public health care sector. The differentiation of solutions leads to conflict escalation.

Some changes in the future depend on the new law on health care units - the project of this law has been elaborated recently - bringing fundamental changes concerning the ownership of the health care units and new solutions on the role of the local authorities and their legal status as the founding body for hospitals.

Monitoring and evaluation

The implementation policy has not foreseen any mechanism of evaluation and monitoring. The best indicator for assessment of the instrument would be the level of provider satisfaction (ie. a decreasing number of notices of resignation from work, increasing financial resources available for the disposal of managers). The first few months of the implementation process of the law proved that there is a need to find the best solution, and different examples from different practices of hospitals should be analysed and assessed, aiming at the identification of best practice.

Expected outcome

The expected outcome of the new law has been achieved (adoption of EU regulations concerning working time conditions). Regarding the implementation process, however, very important outcomes can be observed. As it was described in the previous report, the impact on the system could be predicted: limitation of access to health care services, shortage of human resources, lack of financial resources, impact on quality of health care services, additional costs of the system (see the previous report). All the predicted problems appeared just at the beginning of the implementation process of the law. As it was underlined the situation cannot be improved and the objectives cannot be achieved without a reform of the whole system based on the elaboration of the benefit basket, the introduction of additional health insurance, and it needs difficult decisions concerning changes of the salary level, new sources of finances and a new legal instrument concerning the transformation of health care units.

Impact of this policy

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

Looking at the quality of health care services based on the psycho-physical state of medical doctors the quality should have improved - but without the adequate number of medical staff in health care units the situation looks quite the opposite. Moreover, the quality can fall further taking into account the problem of doctors' absence from work. Nurses who are replacing doctors cannot fulfill all the doctors' duties and patients may be abandoned and neglected.

It was expected that access for patients after the implementation of the law should be more equal as a result of the end of protests and strikes. Surprisingly, the situation is still very difficult and access cannot be observed as more equal. However a decrease in the tension among professionals can be observed. At the time of strikes and protests doctors omitted their duties - now hospitals simply cannot admit as many patients as they did before due to the doctors' resignation from work. Regarding the additional costs for the solution of the problem, the situation has not changed and the government still has to search for money.

References

Sources of Information

• Sikora D. "Krótszy czas pracy lekarzy wymusi zmiany w szpitalach" (The shortened working time of doctors forces changes in hospitals). Gazeta Prawna, nr 3, from 04 - 06. 01.2008. www.zgzza.pl/index2.php?option=com_content&task=view&id=517&pop=1    
• The Law on Health Care Services Providers from 30th August 1991 with amendments. O.J. No 91, clause 408. 
• Amendment from 22nd May 2007 of the Law on Health Care Services Providers from 30th of August 1991.
• European Council. Council Directive No 93/104/EC of 23 November 1993 concerning certain aspects of the organisation of working time with amendments.
• European Union. EU Directive, concerning certain aspects of the organisation of working time (Directive 2003/88/EU). 2003.

Reform formerly reported in

Working Time of Health Professionals Process Stages: Veränderung/Richtungswechsel

Author/s and/or contributors to this survey

Kowalska, Iwona and Anna Mokrzycka

Authors work as Lecturers in:

Health Policy and Management Department
Institute of Public Health
Medical College, Jagiellonian University

Empfohlene Zitierweise für diesen Online-Artikel:

Kowalska, Iwona and Anna Mokrzycka. "Working Time of Health Professionals II". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/pl/a11/4