|Implemented in this survey?|
In August 2005 Estonian Health Insurance Fund initiated primary health care consultation phone service. The aim of the service is to offer 24/7/365 access to primary health care phone consultation for the public. The Primary Care Hotline improves access to primary health care by enabling primary care consultation during out-of-office hours and for inhabitants in rural areas. The Primary Care Hotline should also decrease the burden of ambulance calls and emergency rooms visits at hospitals.
The main purpose of the primary health care hotline - "General Practitioners Advice 1220" (GPA) - is to offer easy and continuous access to high quality primary health care for public. The main
objective is to create 24/7/365 phone-access to primary health care consultations, which is critical during out-of-office hours and in rural areas to reduce the unnecessary workload of
ambulance services and emergency rooms at hospitals. The phone line is accessible with single 4-digit number (1220) in The purpose of the advisory phone is to provide the insured persons with a
feeling of security upon occurrence and solution of potential health problems, to ensure a wider availability of health services of general medical care in the conditions of limited resources, to
give guidance for giving first aid at home and also for treatment at home in the case of more simple health problems, distribute general information about the organisation of health care
The consultation can solve simple individual problems with professional advice, book the family doctors visit for next days or refer the person to ambulance care or emergency room at hospital. First 5 minutes of the call are free-of-charge for the patient if using fixed line operator and at base operator price if called from a mobile phone or from abroad.
The measurable success indicator is increasing number of effectively finished consultations - improved responsiveness of primary health care system. Indirect outcome is increasing patient satisfaction with primary health care. At a health care system level also financial gains are expected though more effective use of ambulance services and specialised hospital care.
There are no special incentives, it is a "monopolistic service" paid from health insurance fund general budget to one provider chosen through public tendering process.
|Medienpräsenz||sehr gering||sehr hoch|
The policy is rather innovative because the new service is developed on universal manner of all Estonian citizens. The leadership was held by the Estonian Health Insurance Fund, but the service is available for all people in Estonia as small country have implemented the system that is reachable for all citizens and this system is rather transferable to any country in the world.
The general purpose of the general practitioners advisory phone arises from the mission of the Health Insurance Fund, which is to provide the insured persons with a feeling of security upon occurrence and solution of potential health problems. The implementation of the general practitioners advisory phone helps to achieve one of the main strategic goals specified in the development plan of the Health Insurance Fund for 2005-2007 - to ensure the availability of health services in the conditions of limited resources. The implementation of primary health care phone consultation service is also in accordance with the health policy statements of the Ministry of Social Affairs and Estonian Health Insurance fund that there should be an easy and timely access to health care services for all Estonian citizens.
Strategic goals of the Ministry of Social Affairs among others state ?better health care services accessibility and quality?
|Implemented in this survey?|
Since the autumn of 2002, Estonian Health Insurance Fund (EHIF) and Estonian Society of Family Doctors (ESFD) have analysed the possibilities for improving access to general medical care. One
possibility identified was to provide the population with the advising service of a general practitioner in the case of different problems. EHIF analyzed the experience of other European countries (
The driving forces behind this idea were EHIF and ESFD who developed general service description and algorithms of consultations. The main purposes of the primary health care phone consultations are
to improve the accessibility and quality of primary health care services.
The primary health care phone consultation services have been developed before mainly locally in Great Britain areas. But Estonia is small enough to cover the whole state with whole service at the same time and give the universal access for all Estonian citizens and Estonians travelling around the world.
The approach of the idea is described as:
renewed: First descriptions of primary health care phone consultations were found in Great Britain from 1990-ies.
EHIF as the initiator of the policy is very satisfied with the results so far. The policy is also responding to the expectations of citizens. In the autumn of 2003, a representative survey of the
population was carried out to find out the expected needs for the service. The possibility to consult a family physician twenty-four hours a day was considered important by 69% (years 15-74) of
people and medical phone advising would be used by 89% of people if possible.
Family doctors themselves are verysupportive to the idea. However, there was created some tension due to fact that the initial developers of the idea among family doctors were not satisfied as they lost the public tender. Consequently some articles in the public press were published criticizing the outcome and the winning organisation. Yet, as the services has proven itself later on, the critique is not significant any more.
Estonain Alarm Centre and emergency ambulance services expect this service will reduce their workload and thus have been very supportive to the idea from the beginning.
The representatives of the Health Insurance Fund, the Ministry of Social Affairs, the Estonian General Practitioners Association, the Alarm Centre and other main related authorities participated in this work.
|Ministry of Social Affairs||sehr unterstützend||stark dagegen|
|Family doctors||sehr unterstützend||stark dagegen|
|Emergency ambulance services||sehr unterstützend||stark dagegen|
|Hospitals||sehr unterstützend||stark dagegen|
|Health Insurance Fund||sehr unterstützend||stark dagegen|
|Patients/citizens||sehr unterstützend||stark dagegen|
Every service reimbursed by EHIF must be listed in the Government Regulation "List of Health Care Services". "National General Practitioners Advisory Phone Service" was introduced into this list on October 15, 200. This gives EHIF the entitlement to assume the obligation to pay consideration to one health care service provider on the conditions agreed on the treatment financing contract.
|Ministry of Social Affairs||sehr groß||kein|
|Family doctors||sehr groß||kein|
|Emergency ambulance services||sehr groß||kein|
|Health Insurance Fund||sehr groß||kein|
Almost three years of preparatory work was required in order to put the idea of the service in practice. In 2002 after discussing the possibilities of improving primary care services in A
principal decision to launch the phone service was adopted on 13th of January, 2004. The planned date for launching the phone was initially 1st of August, 2004 or 1st of September, 2004. However,
preparation of the basic documents, necessary legal arrangements and the tendering process to find the service provider postponed the actual opening of the service until August 2005. The winner of
the public tender has right to operate the service for 3 years after which the contract can be extended. During this period EHIF pays 80% of the price set by the Government Regulation.
There were no true opponents to the development of the advisory phone as everybody felt that there is a need for such a service. The only exception may be initial critique after the decision about the actual provider of the service by an individual group of family doctors who were closely engaged in the development of the service, but did not win later on the public tender. Information on the general attitude by all family doctors towards the service has not been studied yet.
The service provider makes performance studies on the basis of the quality criteria determined by the Health Insurance Fund. The service provider receives feedback by the following studies: study of the confidence in and satisfaction with the advisory phone among co-operation partners; study of the co-operation effectiveness of the advisory phone among the co-operation partners; the servicing level in answering the advisory phone; satisfaction of employees; preciseness of the advice and messages communicated; servicing quality and effectiveness of work; free feedback, proposals and complaint of the population; free feedback and proposals of co-operation partners. All those studies with the statistics derived from the servicing programme form a basis for further developing the satisfaction of callers with the service and for achieving reliability.
Today there are mostly results of structure and process evaluation available as the service has been operation less than a year.
10 doctors and 14 nurses were involved in service provisin during first 3 months. Call volume was in August 2005 - 11,952 calls; in September - 8661 calls, in October - 10304 calls. In October, a wider informing campaign was launched. Based on international experience EHIF is expecting up to 25 000 calls monthly.
The average age of the caller to the General Practitioners' Line was 45 years in the year 2005. There were 39,909 (77 %) calls in Estonian, 11,921 (23 %) calls in Russian. The percentage of female and male callers was divided as follows: 35 % of the callers were men and 65 % women.
Majority, i.e. 95% of the calls received asked for medical consultation and 5% for information about the health care organisation.
The list of advisory phone users is wide (children call in the case of health problems of grand parents and general practitioners from rural areas call to consult with colleagues). Many calls are from older people and mothers of small children.
Awareness of the service and satisfaction with the service is assessed each year by a survey of the population. Also the satisfaction of general practitioners and other health institutions, as well as the complaints of the population and partners are analysed.
The service is expected to be sucessful due to its high responsivness to patients' expectations - 89% of those surveyed in 2003 stated they would use this type of service if necessary. The main
expected outcome is that more people can recieve the help and consultation in very short time period and all day around.
The service is also effectively targeting inequalities in health service utilisation - it is free-of-charge (first 5 minutes), both insured and uninsured have equal access, the service is available in Estonian as well in Russian (the mother tongue of 28% of the population), patients in rural areas have access to primary care advice outside the office hours.
The initiative needs properevaluation of estimated financial impact for the system. On average currently each phone contact will cost 45 EEK (2.86 EUR) for EHIF, whereas the average cost of FD visit (without analyses or tests) is 100 EEK (6.39 EUR)
However, it remains to be seen if the use of FD Advice Line will have impact on the call-volume of the emergency ambulance services and the amount of hospital emergency rooms visits. Also the workload of family doctors may not be reduced as the problems when advice from one's personal family doctor is needed, may differ from the problems with general characteristics.
The service probably needs promotion among the population, which is most effectively done by family doctors themselves.
The initiative is primarily targeting the responsiveness of health system to the patients' needs, which is an important element of health system quality. Also it is the first service paid by EHIF that is equally available to uninsured persons (6% of the population). Additionally it improves equity for rural inhabitants. The phone consultations should in theory be a cost-effective measure as simple problems could be solved remotely and doctors can concentrate to more serious problems. Also it is expected that unnecessary calls to emergency ambulance service and visits to hospital ambulance service will diminish with the help of FD Advice Line service. Third indirect financial impact would be the reduction of costs to patients for they do not have to travel and spend time to solve problems that FD Advice Line is suitable for. Current data do not allow to estimate the actual cost-effectiveness of the service, but the potential is probably high.
Agris Koppel, Sirje Vaask, Ain Aaviksoo