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Family Doctor Hotline - follow-up II

Country: 
Estonia
Partner Institute: 
PRAXIS Center for Policy Studies, Tallinn
Survey no: 
(14) 2009
Author(s): 
Gerli Paat, Ain Aaviksoo
Health Policy Issues: 
System Organisation/ Integration, Access, Responsiveness
Reform formerly reported in: 
Family Doctor Hotline - follow up
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Abstract

In August 2005 the Estonian Health Insurance Fund initiated a primary health care consultation phone service. The aim is to offer 24/7/365 access to primary care phone consultation for the public. The Primary Care Hotline improves access by enabling primary care consultation during out-of-office hours and for inhabitants of rural areas and should also decrease the burden of ambulance calls and emergency room visits. New evaluation results show the service to be successful.

Recent developments

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 healthcare 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 healthcare 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 4-digit number (1220). The purpose of the advisory phone is to

  • provide patients 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 healthcare system.

The hotline has been operating for four years now. In the meantime, there have been a number of developments. For instance, there have been improvements of the algorithms for general medical counseling and provision of information on the organization of health care according to the changing need for such services (for example due to the H1N1 influenza (swine flu)). Moreover, an implementation and management plan for improving access to the phone consultation has been worked out together with quality standards for the service. For instance, a mandatory self-assessment sheet has been introduced which helps to select  the most complicated calls to counsel and serves also as a basis for quality evaluation of the service. In addition, the database connections are developed with healthcare providers, emergency centres and other related systems.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent rather system-neutral system-neutral
current current   previous previous

The family doctor hotline has successfully started its operations and the popularity of the service is increasing. It is also noteworthy that the service is used particularly by very low- income families and the unemployed. Hence the phone counseling service may contribute to reduce inequality of access to health services. It is important to further raise public awareness of the service, particularly among less informed population groups (incl. the non-Estonian speaking population).

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Initiators of idea/main actors

  • Government
  • Providers
  • Payers
  • Patients, Consumers

Stakeholder positions

The Estonian Health Insurance Fund (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% of people  (years 15-74) 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 dissatisfied with this. Consequently some articles in the public press were published criticizing the outcome and the winning organisation.

Emergency medical staff are currently not satisfied with the work of phone counselling and doubt its cost-effectiveness. There are complaints that they have to respond to more frequent emergency calls motivated by phone counselling that appear to have no immediate health concern (e.g. small fevers or abdominal pain).

Actors and positions

Description of actors and their positions
Government
Ministry of Social Affairsvery supportivesupportive strongly opposed
Providers
Family doctorsvery supportivesupportive strongly opposed
Emergency ambulance servicesvery supportivesupportive strongly opposed
Hospitalsvery supportiveneutral strongly opposed
Payers
Health Insurance Fundvery supportivevery supportive strongly opposed
Patients, Consumers
Patients/citizensvery supportivevery supportive strongly opposed
current current   previous 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 healthcare service provider on the conditions agreed on in the treatment-financing contract.

Actors and influence

Description of actors and their influence

Government
Ministry of Social Affairsvery strongvery strong none
Providers
Family doctorsvery strongvery strong none
Emergency ambulance servicesvery strongneutral none
Hospitalsvery strongneutral none
Payers
Health Insurance Fundvery strongvery strong none
Patients, Consumers
Patients/citizensvery strongweak none
current current   previous previous
Patients/citizensHealth Insurance FundEmergency ambulance servicesMinistry of Social Affairs, Family doctorsHospitals

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

 The family doctor hotline 1220 is a national phone counseling service that can be reached 24h/day in both Estonian and Russian languages. The counseling service offers an advice for simpler health problems, guidelines for the immediate assistance and information about the organization of health care. The calls are anonymous and do not depend on whether callers have health insurance. The use of hotline services has gained popularity over the years. During the period 2006-2008, the number of calls has increased by 25,6% (see figure 1). 

Figure 1. Use of family doctor hotline in 2005-2008

Monitoring and evaluation

EHIF has carried out a survey of client satisfaction. It was found that more than 75% of those who have called the hotline counseling service are satisfied with the experience; 15% of the clients expressed their dissatisfaction with the service. The main reasons for dissatisfaction were communication problems (including the language barrier) and not receiving the expected help. The hotline dialing number was familiar to 20% of the persons between 15 and 74 years of age and an additional 20% of the people questioned would be able to find the number if necessary.

The vast majority of incoming calls to the counseling hotline in 2008 were health issues related. Only 1,8% of the calls requested information about the organization of health care. Most calls were received outside of normal working hours and on weekends. For most of the incoming calls a solution was found during the call, 17% of the calls received a suggestion to seek professional help (1% were asked to call an  ambulance, 8% to turn to the hospital emergency desk and 8% to see a family doctor).

The following table lists the hotline service availability and quality related factors, which have been analyzed once every month for the last three years.

TABLE 1. Phone counselling service availability and quality factors in 2006-2008 (% of maximum possible level)
  2006 2007 2008
General phone counseling service level 85 92 93

Accurateness of offered information

88 91 96
Quality and efficiency of services 91 91 97
Blocked calls 4 1,3 0
Lost calls 7,8 7,2 5

 

Expected outcome

The main expected result of the phone counseling service would be that the majority of the population would acknowledge the service and start actively using it if feasible. It is expected to decrease the number of medical emergency calls and the workload of family doctors. However, although the number of hotline users has increased, the statistics show no positive effect on emergency calls and workload of family doctors yet.  Rather, there are complaints from the emergency care institutions that their workload has increased, which is however not supported by data (only 1% of callers are referred to contact emergency medical care).

Each month the phone counseling service is allocated 23 000 EUR to continue the provision of the service. So far there are no estimations about the cost-effectiveness of the service and its overall impact on the healthcare system. Hence it is also necessary to estimate the possible impact on the workload of family physicians, the volume of emergency medicine service visits and the number of outpatient visits to the emergency medicine departments in hospitals.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low high very high
current current   previous previous

The Family Doctor Hotline improves access and quality of care. Since it is mostly used by vulnerable population groups, it reduces inequities. So far there are no estimates about the cost-effectiveness of the service. If it is successful in reducing visits to emergency rooms and ambulance calls, cost efficiency can expected to be high.

References

Sources of Information

  • Estonian Health Insurance Fund annual report Ministry of Social Affairs 2008. http://www.haigekassa.ee/uploads/userfiles/Majandusaasta%20aruanne%202008_ENG.pdf
  • OÜ Arstlik Perenõuandla self-monitoring reports to EHIF
  • Koppel A, Kahur K, Habicht T, Saar P, Habicht J, Ginnenken E. Estonia Health system review. Health Systems in Transition 2008.
  • Family doctors hotline 1220. www.haigekassa.ee/raviasutusele/1220

 

 

Reform formerly reported in

Family Doctor Hotline - follow up
Process Stages: Implementation

Author/s and/or contributors to this survey

Gerli Paat, Ain Aaviksoo

Suggested citation for this online article

Paat, Gerli, and Ain Aaviksoo. "Family Doctor Hotline - follow-up II". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/ee/a14/3