Late last month, the Ministry of Social Affairs submitted for approval draft regulations set to change requirements for health centers.

Family medicine has become increasingly team-based, and nearly half of family doctors with practice lists operate in health centers where several family doctors plus additional services can be found under one roof.

One draft regulation notes that while the principle of having a dedicated personal family doctor and list-based care still applies even in health centers, some activities could benefit from shared responsibilities.

"One example is appointments for urgent patients," the document states. "In case of an acute health condition, the patient should be seen the same day they call." The document likewise stipulates that health centers with multiple service providers must conclude a cooperation agreement.

According to the draft, in many cases there is no need for in-depth intervention, and when it comes to an initial consultation and opening sick leave, more important than the list-based approach is that the service is available quickly.

"Since continuity of care is important in family medicine, the draft specifies that a patient's family doctor must be informed if a patient on their practice list receives care from another list's doctor," the letter of explanation states. "This notification can be treatment case-based, but may also be agreed upon as part of a health center's working arrangements."

Family medical care may also be provided to an individual not on one's list if the patient belongs to a practice list lacking its own confirmed family doctor or substitute. Such situations are exceptional, however this change will help ensure that these individuals are not left without care.

Under current rules, a family doctor would not be compensated for such work, but this planned change will see it added to the list of services covered by the Estonian Health Insurance Fund (EHIF), allowing for it to be paid for from the latter's budget.

EHIF will likewise start paying for the service where a family will see patients from a colleague's practice list while their colleague is on vacation.

Ministry sees need for family doctor on-call service

The letter of explanation highlights that hospital emergency rooms are overloaded, which is why the need exists for an on-call service at the primary care level as well.

"Such a service could be offered by family doctors in regional cooperation, meaning that the service would be provided to patients from other lists and institutions as well," the document explains. "This service may be needed outside of regular working hours, as well as, for example, during virus season, when there are a lot of patients and some family medicine centers may have difficulty getting all of their patients seen same day, while a nearby health center could temporarily take on that load."

This would also help address the concerns of patients who live far away from their family doctor's practice and therefore can't receive timely care from their own family doctor.

"Such a solution requires a more detailed description in terms of responsibilities and information flows as well as funding," the ministry notes. "However, this paragraph would enable the flexible provision of this service now already if needed."

At the same time, the draft regulation emphasizes that the goal isn't to create a system where all family doctors can see patients regardless of whose practice list they are on.

"The general principle in terms of both funding and service provision will remain list-based," the ministry confirmed.

Also to remain in force is the paragraph of the regulation allowing for emergency care to be provided to people living or temporarily staying in a given service area but are not included on a family doctor's practice list.

Some nurses to be given additional rights

The draft regulation will also expand the rights of certain nurses. Specialist nurses, i.e. those who have completed an additional master's degree in certain fields or obtained a specific competence from a dedicated commission, will be given the right to write referrals for patients to see other specialists for outpatient consultations, e-consultations, testing, hospital admissions or transfers to nursing care facilities.

According to the letter of explanation, specialist nurses have greater clinical competence, and if they are given the right to write referrals, it will help services work better. The same reasoning applies to granting them the ability to provide e-consultations, allowing the state to save on healthcare worker resources.

"A specialist nurse must have the ability to determine during their appointment whether and to whom a patient needs to be referred; a specialist nurse has the clinical competence to do so," it states. "The right to write a referral will allow the specialist nurse to consult with doctors, other specialist nurses as well as other necessary specialists."

A specialist nurse's more specific abilities to refer patients for testing will be determined by the care team based on international and national treatment guidelines, patient needs and their patient journey as well as a healthcare provider's capabilities.

For example, a specialist nurse may refer a patient for medical radiation, if it is conducted under the responsibility of a doctor and based on agreements made during the patient journey. A similar principle will apply to referring a patient for hospitalization or nursing care.

The Ministry of Social Affairs sent the draft regulation to officials and relevant institutions on July 26, but during the ten-day feedback period, the drafts awaiting approval had mistakenly been classified "for internal use only." This classification, attributed by the ministry to human error, has since been removed.

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