|Implemented in this survey?|
The MoH of Slovenia decided to restructure duty and on-call services in health care. There would be a reduction in the salary bonuses for those who perform these services. In some cases the physical presence of doctors would be replaced by stand-by arrangements. One of the controversies of the present system are the differences in payments for comparable posts in comparable specialties, where in some cases these were 30 to 40 per cent higher than in others. The original reform attempt failed.
The purposes of this attempted reform were the following:
1. Reduction in the number of posts with continuous presence of medical doctors (24/7/365)
2. Institution of more stand-by posts, especially for non-critical medical specialties
3. Reforming salary bonuses and supplements for duty and on-call services by standardising these posts
4. Introduction of the possibility to organize duty services during daytime hours (6.00-22.00) shifts as well.
The idea behind the proposed changes was to provide room for optimization of on-call and duty services. This would mean that some of these posts in the smallest departments would be abolished. In addition, some of these services would be abolished entirely in some of the smallest hospitals.
Objectives/characteristics of the new policy:
Financial incentives actually are disincentives as the key policy objective was to reduce the total workforce costs for these services by 11 million Euros.
Non-financial incentives included a reduced workload for doctors performing these services in bigger centers, attracting additional doctors to perform them, and limiting the workload of senior medical doctors.
Medical doctors, Hospitals, Primary care providers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
This policy's approach is traditional as it approaches a complex issue through reductions in costs through reduced salary expenses (which, of course, are a major contributor to health care expenditure). It raised huge controversies, leading to a strike of physicians that only could be diverted through a significantly reduced concept of the new arrangements. This process gave the policy a very high public visibility that later obscured some of its intended positive effects.
The present Government (elected for the term 2008-2012) has committed itself to a comprehensive health care reform as the present system is the result of a specifically placed reform process of the period 1990-1992. This earlier reform was prepared in a long process, but implemented in a rather hasty manner, due to different circumstances .
The promise that the on-call and duty posts would be revised and reformed was given by the organised medical profession (The Medical Chamber and the Medical Trade Union) after the end of the medical doctors' strike in 1996 (agreement between the two parties and the Government, later amended and revised in 1999). However, this part of the agreement never got implemented and the issue remained largely unresolved.
The main issues were the following:
Consequently, there were increasing differences in salaries bonuses across different medical specialties, and even among providers, which created imbalances. In a setting of continuing shortage of medical doctors, it was hard to find doctors who are available for delivering these services at all.
the declared goals and objectives of the health care reform and the changed salary system for civil servants (including all employees in the publicly owned health care in Slovenia)
|Implemented in this survey?|
The idea derives from the estimates from the early 1990s that on-call and night services in Slovenia are too expensive under the changed circumstances. The services have already become more expensive because doctors are paid for these services not in terms of the generic tasks they are expected to provide but based on their basic salary. This means that an on-call trauma surgeon who is also a professor and a consultant will be much more expensive on on-call duty than a recently qualified specialist, although they will, when emergency cases occur, basically perform very similar tasks and duties.
In addition, costs of these services soared because of the combined effect of increasing physicians´ salaries and bonuses on additional working hours. This has led to an unsustainability of these services, both financially and organisationallly in some environments, especially in middle-sized and smaller hospitals. This situation got even more complicated through the shortage of medical doctors, which made a smooth planning process almost impossible.
Therefore, it was necessary to address the issue of on-call services from the viewpoint of their rationality, as well as from the viewpoint of ensuring equal access to all medical services for all citizens of Slovenia.
The approach was top-down, as the Ministry of Health (MoH) decided to go for a reform of on-call services, which are a point of frequent discussion and pressure. On the one hand there are those medical professionals, who see these services as a source of additional income, on the other hand there is an increasingly bigger group of doctors who would prefer more spare time for their private lives rather than additional income generated by additional workload from on-call services. In any case, there was fierce opposition of the medical profession to the execution of any changes, especially to those changes that would significantly influence the income generated by these services.
|Medical doctors||very supportive||strongly opposed|
|Hospitals||very supportive||strongly opposed|
|Primary care||very supportive||strongly opposed|
|Medical doctors||very strong||none|
|Primary care||very strong||none|
The policy could not achieve its objectives as it was blocked by the organised medical profession at its very beginning, and had to be significantly modified in order to divert a widespread strike by medical doctors. This became imminent when doctors started withdrawing consent forms, which are required when doctors work more than 48 hours a week. Without a written consent nobody can constrain a medical doctor to performing services in excess of 48 weekly working hours. Around 70% of the doctors in hospitals withdrew these forms, which had only two possible effects - either a complete halt to on-call and duty services, which is impossible given the risks, or a reduction in all those services which depend on the real availability of medical doctors (including their on-call services!). This led to long negotiations in which the Government decided not to change the present system at once, but committed itself to prepare and implement changes over the next two years.
Therefore, the government postponed the implementation of a new structure and distribution of on-call and duty posts which it had meant to reduce significantly. Currently, there is also process going on which is meant to stratify hospitals and their departments into several categories. After this process is completed, not all departments will keep 24-hour services but some will continue only as day hospital with some diagnostic and out-patient services. It was agreed that this process runs in co-ordination with the different medical colleges which are responsible to determine the specific standards and requirements for the different medical specialties. This will then also be revised by the MoH and the two chambers, the Medical and the Nursing Chamber.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The proposed policy would have had a rather marginal impact on the quality of health care services as it would generally not influence the standard delivery of care.