The emergency medicine is only the beginning of the story. In reality, every aspect of the Estonian healthcare system is crumbling.

In medical terms, it is a serious chronic disease that is worsening rather than an acute viral illness that might go away in a week, Ragnar Vaiknemets from the Health Insurance Fund (Haigekassa/Tervisekassa) told ERR.

"If one of the circuits in the medical system fails, the operations of ambulance and the emergency room are also compromised."

"Different hospitals have different worries. We know that many problems start towards the end of the workday, when patients are unable to see doctors, but cannot say with certainty whether it is a nighttime or weekend issue," Vaiknemets continued.

"We have to analyze not only emergency rooms and ambulances, but also the health care system as a whole."

One issue is Tallinn's outdated hospital facilities; for example, the emergency room at West-Tallinn Central Hospital is so small that it is physically impossible to add more beds, a problem that has undoubtedly been exacerbated by the pandemic.

Vaiknemets said that this begs the question of how the this situation could have been avoided and what will happen in the next crisis, as many wards are already at their full capacity.

On Friday, the health board laid the groundwork for an ER monitoring procedure, and within a few months it should be more clear why the capital's hospitals are stuck.

Agris Peedu, head of the North Estonia Medical Center (PERH), said that they have tried to alleviate the ambulance crisis by hiring extra nurses.

"We have tried to shorten ambulance queues by having the nurses attending the patients not only when the ambulance brings them inside, but already at the emergency entrance," Peedu said.

While the ER on the ground floor of the regional hospital struggles to find beds for patients on higher floors, the hospital director said that the hospital administration has gone above and beyond what would be expected of a top-tier facility.

The PERH now has 80 beds closed due to a lack of nurses and would instantly recruit 100 extra nurses if there were enough people to hire.

Peedu said that when he became hospital director six years ago, he was worried about finding doctors for the Hiiumaa hospital; now even Mustamäe [district in Tallinn] is struggling to do so.

"We have seen in recent years that it is difficult to find doctors here [in Tallinn] if young people study in Tartu for many years, whether as doctors in basic training or in residency, and if the center of their life is in Tartu due to family, children and home," Peedu added.

Nikita Panyushkin, an adviser at the department of health system development at the Ministry of Social Affairs, said that the ministry is also questioning why there is no room in the hospital's other departments for ER patients.

"However, we are relying on hospitals and the EHIF (Haigekassa/Tervisekassa), which is also our operational manager, to develop quick responses to the issue. Our own solutions are more strategic in kind, as we are a policy-making body, and so our decisions are not instantly reflected in practice," he said.

The Ministry of Social Affairs commissioned the University of Tartu to conduct an analysis of pre-hospital care. According to a preliminary report on the ministry's website, there are three potential future scenarios.

• In larger cities emergency clinics could be attached to health centers.
• The establishment of one-, two- and three-member ambulance brigades requires patient's co-payments on unjustified calls.
• The current doctor and nurse brigades could be transformed to paramedics only system.

The analysis will be presented to the ambulance development board in early February.

"We will work with them to determine which of the proposals and findings of this analysis can be implemented in the Estonian healthcare system and which are not," Panjuškin said.

While now the shortage of doctors is the immediate concern, there will be more looming issues with payment for treatment in a few years due to aging population.

"If we want to continue offering services at today's levels, we will need more funding in three or four years," Marko Tähnas, head of the Health Insurance Fund's partnership department, said.

This is not the responsibility of hospital managers or officials, but of politicians.

Estonia spends six percent of its gross domestic product on healthcare.

"Is six percent enough for healthcare in Estonia? This has been much debated and it is brought up with each new government, whether it is five percent plus co-payment /.../ The European Union average is 10 percent," Vaiknemets added.

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