Audit Office: Healthcare worker shortage worsening, key decisions unsettled

A sign on the door of a family doctor's office at Räpina Health Center apologizing for the absence of one nurse affecting operations. July 27, 2022.
A sign on the door of a family doctor's office at Räpina Health Center apologizing for the absence of one nurse affecting operations. July 27, 2022. Source: Aili Vahtla/ERR

The shortage of healthcare workers in Estonia has become one of the biggest obstacles to the provision of healthcare, and is set to get worse. Nonetheless, key decisions such as the organization of the country's hospital network and the financing of healthcare are still waiting to be made, the National Audit Office said in its latest annual report, which this year focused on trends in Estonian healthcare.

"Despite the fact that the shortage of healthcare professionals has been talked about for a long time, the problem has worsened," Auditor General Janar Holm said when presenting the annual report to President of the Riigikogu Jüri Ratas (Center) on Tuesday, according to a press release.

"There is a shortage of family doctors in Estonia, waiting lists for specialized medical care are long, and problems at other treatment levels are piling up in nursing care and emergency medicine," he highlighted. "This will lead to a situation where a patient gets a doctor's appointment and treatment is started later than it should be, which in turn causes more damage to health, further burdens the understaffed healthcare system and increases healthcare costs."

The auditor general pointed out that, first and foremost due to personnel issues, it's likely that, in the near future, Estonian residents will have to be prepared for the fact that healthcare services will not be available uniformly and of uniform quality throughout the country.

Map by municipality of presence or lack thereof of a primary health center, family doctor's office and/or after-hours availability. Source: National Audit Office

There is no quick solution to the shortage of staff as training lasts for years, and the results of increasing the training mandate for healthcare professionals won't be seen until the distant future.

Nurses, family doctors in particularly high demand

According to the auditor general, it isn't enough to just increase the training mandate for healthcare professionals, as even now, not all student spots in healthcare are filled. Good students must be found for these vacant spots in a situation where labor shortages set the tone in many areas and competition is for the same people.

"Estonia healthcare lacks not so much analyses or strategies, but rather the will, courage and ability to implement what has been agreed upon," Holm said. "The main thing is to clearly recognize that we have to cope with a smaller number of doctors and nurses than necessary, while there will be no fewer diseases and problems."

The National Audit Office concludes in its annual report that there is a particularly high shortage of nurses, psychiatrists, emergency medicine doctors as well as family doctors. The new generation of healthcare professionals has been in a downward trend for some time.

The recent increase in the training mandate for healthcare professionals has been important, but its results won't be seen for years. For example, 30-40 residency spots a year would be needed in order to cover the minimum need for new employees in emergency medicine in the next ten years; currently, however, there are only 10-12 applicants a year.

While Estonia falls among the averages in OECD countries in terms of the doctor-to-population ratio, it falls further behind in terms of nurses. While the average number of nurses per 1,000 people  is 9.4 in OECD countries and 13.7 in Nordic countries, Estonia averages 6.48 per 1,000 people.

Enrollment in nursing education is increasing, however the impact of this increased enrollment won't be seen for years.

Compared with other countries, Estonia has a lower proportion of nurses who have arrived from elsewhere. In OECD countries, an average of 6.1 percent of nurses have received their education elsewhere; in Estonia, meanwhile, just 0.2 percent of nurses have been educated outside of Estonia.

In its annual report, the National Audit Office points out that the difficulties in providing family medical care have worsened over time. Nearly half of all family physicians are 60 or older, i.e. already at or approaching retirement age. The number of practice lists without a permanent family doctor has increased as well.

As of December 2020, there were 737 family doctor practice lists in Estonia, 48 of which did not have a permanent family doctor, i.e. were being served by a substitute doctor. By June 2022, however, the number of practice lists without a permanent family doctor had increased by another six. In 13 cases, practice lists had been served by a substitute doctor, which is supposed to be a temporary solution, for five years or more already.

The National Audit Office examined 311 competitions organized to find doctors for family doctor practice lists held between 2015 and the first half of 2022. In the first half of this year, three quarters of competitions failed. Throughout the seven and a half year period, just 42 percent, or less than half, of all competitions have been successful in finding a new family doctor.

Hall outside of a family doctor's office on the second floor at Räpina Health Center. July 27, 2022. Source: Aili Vahtla/ERR

Emergency care, mental healthcare

Emergency rooms across Estonia continue to be the place where bottlenecks at other levels of healthcare end up addressed, but this is expensive and a burden on the system.

According to the annual report, 57 percent of patients who seek care at hospital emergency rooms have minor health problems. The primary cause behind this is the deficient availability of family medical care.

Likewise experiencing a major staff shortage, which is moreover at risk of soon worsening significantly, is the mental healthcare sector.

More than half of psychiatrists are of retirement age or will reach retirement age in the near future. According to the National Institute for Health Development (TAI), 222 psychiatrists worked in Estonia in 2021, including 18 child and adolescent psychiatrists. Thus, there were approximately 15 psychiatrists per 100,000 people in Estonia, significantly fewer than in the Nordic countries, for example. In comparison, according to 2019 OECD figures, Norway had 26 psychiatrists, Finland 24, Sweden 23, Lithuania 23 and Latvia 16 psychiatrists per 100,000 people.

According to the development plan for the specialty of psychiatry drawn up by the Estonian Psychiatric Association (EPS), 30-40 more psychiatrists and an additional 130-160 clinical psychologists are needed than currently work at the first contact care level. Estonia is also facing an ongoing shortage of school psychologists and mental health nurses as well.

Increased focus on preventive care needed

The National Audit Office finds that contributions to preventive care should be higher. The report noted that children's health issues go unnoticed as a large number of children are not taken in for routine medical checkups. While 88-96 percent of children up to age 2 underwent regular medical checkups, this figure dropped to just 6 percent among children aged 3-6, with 43 percent of children in that age group going completely unseen by a healthcare professional for years.

Refusals to vaccinate children are on the rise in Estonia, which can lead to the reemergence of dangerous diseases. As a result of previous successful vaccination, several dangerous diseases have almost disappeared from Estonia. Refusal to vaccinate against e.g. diphtheria, polio or pertussis has increased, from 1.9-3.5 percent in 2014 to 3.8-7.8 percent in 2021, depending on the vaccine.

Patients with increasingly complex conditions are ending up in inpatient nursing care as well, due to the insufficient availability of specialized and family medical care. Another issue in nursing care is the high copayment involved, due to which people can't always afford nursing care services when they want or to the extent they need. The availability of home nursing surfaces has increased, which is positive, however the further expansion thereof is limited by the shortage of nurses.

Better prevention would help reduce more serious consequences in cancer treatment as well. According to the National Audit Office, participation in cancer screenings is low, and the start of cancer treatment is delayed. Low participation in health screening is one reason why malignant tumors are detected too late. The participation rate in screenings falls considerably below the 70 percent target included in Estonia's Cancer Control Plan, reaching just 59 percent for breast cancer, 51 percent for cervical cancer and 48 percent for colorectal cancer in 2021.

According to the Cancer Control Plan, the duration of the patient's clinical pathway from suspecting cancer to first treatment should be no longer than 63 days. In reality, however, only breast cancer patients started cancer treatment within this timeframe, averaging within 52 days. Cervical and lung cancer patients, meanwhile, averaged 100 days from suspicion to treatment, while colorectal cancer patients averaged a 122-day wait.

The development of various e-solutions and remote services, the establishment of health centers, the specification of the conditions of dental care benefits as well as the review of clinical pathways have helped alleviate concerns regarding the unequal availability of health services, the National Audit Office noted in its annual report.

Such changes help solve problems in the short term, but as long as fundamental decisions at the systemic level are not made, the impact of individual development projects will be limited, and temporary solutions can end up becoming permanent, it warned.

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Editor: Aili Vahtla

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