Family Doctor Hotline - follow up

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

Abstract

In August 2005 the Estonian Health Insurance Fund initiated a 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 of rural areas. The Primary Care Hotline should also decrease the burden of ambulance calls and emergency rooms visits at hospitals.

Neue Entwicklungen

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 to the public. The general practitioners advisory phone is becoming an integral part of the general health care system and is available for everybody - irrespective of the presence of insurance or the particular residence status.

The main objective is to provide 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 a single 4-digit number (1220). 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 simpler health problems. Furthermore, it is supposed to distribute general information about the organisation of the health care system.

The consultation can solve simple individual problems with professional advise, book a family doctor visit for the next days or refer the person to ambulance care or to an emergency room at the hospital. The first 5 minutes of the call are free-of-charge for the patient if using a fixed line operator and at base operator price if called from a mobile phone or from abroad.

The measurable success indicator is an increasing number of effectively finished consultations - it indicates an improved responsiveness of the primary health care system. The indirect outcome is increasing patient satisfaction with primary health care. Moreover, at a health care system level financial gains are expected by a more effective use of ambulance services and specialised hospital care.

Main objectives

• better access to primary health care
• quality improvenment of primary health care services
• better responsiveness of the primary health care system to the public need

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

The policy is rather innovative because the new service is developed in a universal manner for all Estonian citizens. The Estonian Health Insurance Fund had the leadership, but the service is made available for all people. Estonia is a small country and the implemented system is reachable for all citizens irrespective of the place of residence. Moreover, the system developed in Estonia is transferable to any (small) country in the world.

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: Description of actors and their positions

• Leistungserbringer: Description of actors and their positions

• Kostenträger: Description of actors and their positions

• Patienten, Verbraucher: Description of actors and their positions

Stakeholder positions

Origins of health policy idea

Since the autumn of 2002, the Estonian Health Insurance Fund (EHIF) and the 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 the 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. Moreover, the survey among the general population revealed that there exists a high demand for such a service. 

Primary health care phone consultation services have been developed earlier mainly locally in Great Britain areas. But Estonia is small enough to cover the whole state with the consultation service and to provide universal access for all Estonian residents and Estonians travelling around the world.

Approach of idea

The approach of the idea is described as: renewed: First descriptions of primary health care phone consultations were found in Great Britain from the 1990-ies.

Stakeholder positions

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 89% of people stated they would use medical phone advising if possible.

Family doctors themselves are very supportive of the idea. However, there was some tension due to fact that the initial developers of the idea among family doctors lost the public tender and where dissatified with this. Consequently some articles in the public press were published criticizing the outcome and the winning organisation.

Yet, as the service itself has proven later on, the critique is not significant any more. The Estonian Alarm Centre and emergency ambulance services expect that this service will reduce their workload and thus have been very supportive of 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.

Actors and positions

Regierung
Ministry of Social Affairs	sehr unterstützend		stark dagegen
Leistungserbringer
Family doctors	sehr unterstützend		stark dagegen
Emergency ambulance services	sehr unterstützend		stark dagegen
Hospitals	sehr unterstützend		stark dagegen
Kostenträger
Health Insurance Fund	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patients/citizens	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

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 to this list on October 15, 2005. This gives EHIF the entitlement to assume the obligation to pay consideration to one health care service provider on the conditions agreed on in the treatment-financing contract.

Actors and influence

Regierung
Ministry of Social Affairs	sehr groß		kein
Leistungserbringer
Family doctors	sehr groß		kein
Emergency ambulance services	sehr groß		kein
Hospitals	sehr groß		kein
Kostenträger
Health Insurance Fund	sehr groß		kein
Patienten, Verbraucher
Patients/citizens	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

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 the 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 everbody felt that there is a need for such service. The only exception is perhaps the initial critique, after the decision about the actual provider of the service had been made, 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 is currently being studied.

Monitoring and evaluation

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;
• satification of employees;
• preciseness of the advice and messages communicated;
• servicing quality and effectiveness of work;
• free feedback, proposals and complaints 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 development of the service in order to achieve satification of callers and ensure the reliability. The quality assurance system implemented in the first half of 2007 is aimed at the continuous monitoring of the servicing level and quality of the practitioners advisory phone services based on the data collected from the phone interchange system. The quality assessment includes also the contents and preciseness of the messages, advice and also the work efficiency is based on the recorded communication.

Results of evaluation

The general practitioners advisory phone service has been on operation for two years. The main results of the structure and process evaluations are presented below.

Currently there are 13 doctors and 12 nurses involved with the advisory phone service. In 2006 approximately 400 calls were serviced in a day. This number has increased to 438 calls in a day by the first half of 2007, averaging to 13 230 calls per month. Based on the international experience EHIF is expecting up to 25 000 calls monthly, so this target has not been reached yet.

The average age of the caller to the General Practitioners' Line was 45 years in the year 2005 and 43 years for the year 2006 and the first half of 2007 (the decrease in the average age may indicate that the share of minors with health issues may have increased). There were 76 % calls in Estonian and 24 % calls in Russian. The percentage of female and male callers was divided as follows: 35 % of the callers were men and 65 % women and this has remained stable for the whole period of operation. A majority, i.e. 99% of the calls asked for medical consultation and only 1% of the callers for information about the health care system. 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.

The awareness of the general public about the practitioners advisory phone service was investigated by the EHIF in 2006 as a part of a more general survey "Public opinion on health and health care". According to the survey the share of people that have used this service has increased from 7% (in 2005) to 10% in 2006. Moreover 74% of the questioned were aware of the service and the phone line number. However, only 59% of the non-Estonian speaking minority were aware of the service.

Expected outcome

The service is expected to be successful due to its high responsiveness 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 receive help and consultation in a 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), and patients in rural areas have access to primary care advice outside the office hours.

The initiative needs a proper evaluation of the estimated financial impact for the system. Currently each phone contact will cost on average 45 EEK (2.86 EUR) for EHIF, whereas the average cost of a 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 an 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.

Impact of this policy

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

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 the 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 on more serious problems. Also it is expected that unnecessary calls to emergency ambulance service and visits to the hospital ambulance service will diminish with the help of the FD Advice Line service. The third indirect financial impact would be the reduction of costs for patients since they do not have to travel and spend time to solve problems that FD Advice Line is suitable for. Current data do not allow the estimation of the actual cost-effectiveness of the service, but the potential is probably high.

References

Sources of Information

Estonian Health Insurance Fund annual report Ministry of Social Affairs (http://www.sm.ee/est/pages/goproweb0057 ) OÜ Arstlik Perenõuandla self-monitoring reports to EHIF

Reform formerly reported in

Family Doctor Hotline Process Stages: Umsetzung

Author/s and/or contributors to this survey

Agris Koppel, Ain Aaviksoo, Gerli Paat

Empfohlene Zitierweise für diesen Online-Artikel:

Agris Koppel, Ain Aaviksoo, Gerli Paat. "Family Doctor Hotline - follow up". Health Policy Monitor, 12/10/2007. Available at http://www.hpm.org/survey/ee/a10/5