The Estonian healthcare system is comparably centralized. Due to the country’s low population density, the main hospitals are located in the cities. The same applies for specialists’ practices, which means that people who live outside the main urban areas often have to travel on top of spending weeks, often months, in queues waiting for an appointment.

This could be avoided by allowing local general practitioners (GPs) around the country to extend the range of the services they offer.

A general practitioner with the according specialized training can offer medical examinations and procedures like taking x-rays, performing ultrasound examinations, preliminary examinations of organs like the eyes, and more of the same sort.

But the Estonian law bans general practitioners from performing specialized procedures and examinations, limits them to specialists and hospitals often far away from the patients, and make the unnecessary duplication of procedures more likely.

An example is GP Madis Veskimägi, whose practice is in Tõstamaa in Pärnu County. Until recently, Veskimägi offered his patients ultrasound, x-ray, and eye examinations. Veskimägi is trained for all of the procedures he offered, and has regularly checked state-of-the-art equipment as well as premises that correspond to all of the legal requirements.

Because the law makes this set-up at least partially illegal, Veskimägi has been wrangling with the authorities for months. The dispute peaked when in early June this year, officials of the Environmental Board showed up and sealed his €60,000 radiological equipment.

Both the doctor as well as patients point out the enormous advantages of offering specialized services in GPs’ practices. It isn’t just about the distance the patients have to travel, but also about the fact that any GP before handing patients on to a hospital or specialist performs initial examinations - which the receiving end promptly repeats as soon as the patient makes it there.

Dr. Diana Ingerainen of Tallinn’s Järveotsa medical center describes how x-ray examinations are doubled at a recent example. A woman complaining about chest pains arrives at the center. Her chest is x-rayed to get an image of the woman’s lung. After it is decided to send the woman to the West Tallinn Central Hospital, the hospital will perform the same procedure -

Despite the fact that the Järveotsa medical center is a business partner, and the x-ray made in the center earlier already in the same system the hospital uses.

Radiological procedures are just one example. Veskimägi also says that two thirds of the practical work of an ophthalmologist can be done by an accordingly trained GP in a local practice, which means that patients can be offered eye examinations without having to take a long trip to Tallinn or another city upon themselves.

The matter of increasing cost is also visible when it comes to laboratory analyses. A blood screen done in a GP’s practice in the morning is promptly repeated in the afternoon if a patient is sent to hospital or to a specialist’s practice. Why? According to Veskimägi, there really is no other reason than the belief that the preceding analyses might not have been done with the same care.

Former lead inspector of the Health Board, Peeter Mardna, says that especially reducing the multiplication of costly procedures such as radiological examinations could lead to enormous savings. If his estimate that about a third of x-rays are done unnecessarily is anything to go by, and considering that the Health Insurance Fund spends some €44m a year on that special area of medicine, some €15m could be saved annually.

Mardna also points out that this problem can be solved easily. If the Health Insurance Fund spots an instance where the same procedure was performed on the same patient twice on the same day, the fund could simply refuse to compensate the second instance.

The argument of the authorities as well as doctors who oppose broadening the availability of specialist treatment is that despite existing training, the work of GPs offering such extended services would be very difficult to supervise, also with regard to the recent trend towards alternative methods.

The country’s association of general practitioners thinks that all those GPs qualified and trained to perform specialized procedures and examinations should be allowed to do so, but that supervision should be very strict.

Veskimägi points out that the question isn’t about doctors in remote locations working by themselves offering all kinds of treatment. For example, despite having the equipment in his practice, radiological examinations required him to work with a radiologist.

Naturally not every single practice can be expected to employ such a specialist. But modern technology and the Internet solve the problem, as there are unified medical databases and it is possible to cooperate across longer distances.

Member of the Riigikogu Mark Soosaar (SDE), who is a patient of Veskimägi’s, has initiated a law change that would make it possible for GPs to offer the kind of specialized procedures they have training for.

This, according to Soosaar, would save millions and shorten queues everywhere in the country. Patients everywhere could reach doctors with top-of-the-line equipment and specialist training within reasonable time, and these services would be available to local patients instead of forcing them to travel to the nearest hospital.

In the current situation, where the Health Insurance Fund’s deficit has recently been reported at three times the budgeted size, such savings could prove the way to go trying to make the system work as well as keep up the current level of services.