You've now been a minister for just over three weeks. From your new position in government, have you been able to get a clearer picture of the priorities? What are the urgent issues in Estonia's healthcare and social systems that need to be addressed?

We previously had a very strong minister of social protection who initiated several important reforms, which we certainly intend to continue. But as a doctor and someone from the healthcare field, I can see just how deep the crisis in our healthcare system really is.

This isn't just a matter of calling it a crisis — it is a deep crisis. In just a few years, our healthcare budget is projected to be in deficit by several hundred million euros. We have a short window of time to make decisions that will lead us out of this crisis. What exactly those decisions are, that's what we're working on.

I've also convened what you might call a medical council — because when a patient, in this case healthcare, is in a critical condition, doctors don't usually make decisions alone. They call in their most experienced colleagues and decisions are made together.

In your view, which area of this crisis affects ordinary people the most severely?

We see and hear a lot — both in the media and on social media — about what people are experiencing. First and foremost, they say they can't get an appointment with a doctor or a nurse. They can't reach their family health center. And if they do manage to get referred somewhere, they often can't see a specialist in time. On top of that, the quality of care is inconsistent. One clinic might provide a broad range of high-quality services, while another similar clinic might not offer the same standard at all.

Is the quality of the family doctor system currently lacking?

I wouldn't say that the quality of family doctor care is poor. In fact, most family health centers operate at a very high level — there are smart doctors and skilled nurses working there.

Over the years that I've been a family doctor, a lot has changed. For example, the role of nurses has grown significantly and the responsibilities of family doctors have steadily increased as well. The field has become much broader, and with that expansion comes a growing need for additional resources.

At the same time, it's true that there are still shortcomings in some centers. For instance, children might not be monitored properly or prescriptions initiated by specialists might not be renewed.

The quality definitely needs to be more consistent. And a third issue we're seeing more often is that in many places, family doctors are being replaced by substitutes — who aren't actually family doctors, but rather general practitioners or doctors from other specialties. In such cases, they simply can't provide the same level of care as a family doctor who has completed four years of residency. A family doctor is effectively a specialist.

Is it still important to maintain personal contact with your family doctor? Or are we increasingly moving toward a system where more responsibilities are delegated — to nurses and assistants, for example — who don't actually have the same level of expertise?

Does someone really need to see a family doctor for a cough or a runny nose if a nurse is perfectly capable of helping them?

We're not just talking about coughs and runny noses.

But I am talking about coughs and runny noses — because those are the most common reasons people turn to family health centers. The second most common is lower back pain, and in those cases too, nurses are often very well equipped to provide guidance.

Of course, there are other health concerns as well, but what's crucial is that people with less serious issues get help from a family nurse. If there's no serious illness and no need for the doctor to intervene, that's actually a good thing — it means the person's health is in relatively good shape and they should be glad about that.

However, when a problem becomes more serious, it's essential that the family doctor is accessible. Many centers now use tools like e-consultations, Teams or Skype. A nurse may see the patient first, but if needed, they'll consult with or bring in the family doctor. Often the doctor will step in, assess the patient and provide recommendations.

What matters most is that the person receives appropriate, high-quality care. The outcome is what counts — whether the person gets better, whether their condition improves or whether the illness is brought under control. And while people know their own bodies, they might not always be able to judge whether the care they received was medically optimal. That's why we have to look at outcomes — not just how it felt, but where the treatment led.

How do you explain the fact that some family doctors seem to work only four or five hours a day? What are they doing with the rest of their time?

We really need to clearly define what the work of a family doctor actually involves. It might seem like if a hospital doctor sees patients in an outpatient clinic for four hours a day — or a total of ten hours a week — that that's all the work they do. But that's simply not the case.

The same applies to family doctors. Their work doesn't end when patient appointments are over. That's when the paperwork begins — for example, they need to review whether patients in their registry with certain conditions have received the necessary medications or tests. Nurses assist with monitoring chronic illnesses, but a great deal of responsibility still falls on the doctor.

Family doctors write referrals, conduct background research on complex cases, communicate with specialists, provide consultations and often continue learning themselves — reading medical journals, reviewing new treatment guidelines. This is all work the patient doesn't see, but it results in, say, a follow-up email or phone call from the doctor with lab results or a treatment plan.

Officially, we might write down that the consultation hours are four hours a day, but in reality, that time often stretches — especially during flu season, when there are more patients. So the idea that a family doctor only works four hours a day is outdated and simply not true.

No family doctor who does their job thoroughly and with quality can work just four hours a day. It's typically at least eight hours and often twelve.

Has communication with doctors become too reliant on online platforms?

The way contact between a doctor and a patient develops depends a lot on both the individual and the doctor. But one thing is certain — human connection must not disappear. We cannot end up in a situation where all work is done 100 percent online. That's neither good nor quality family medicine.

At the same time, we have to acknowledge that many patients themselves say today's system is convenient — for example, they can send a prescription request or question in the middle of the night. In the past, they had to wait until the health center opened in the morning and then call. Now they can write down their concern at any time and the family doctor or nurse will respond when they're available.

Many issues can be resolved conveniently this way — online. But not everything. High-quality care also requires that the patient be seen and heard. For instance, in our health center, we have a policy that no one is referred to a specialist before they've had an in-person consultation, the doctor has examined them and they've had a thorough conversation.

Referring someone to a specialist based only on a written message or phone call — that's not a sign of quality care.

But should a patient be able to reach their family doctor by phone?

You mean, should family doctors have designated phone hours?

No, I mean being able to contact the family doctor with a concern, explain the issue over the phone and have the doctor advise whether an in-person visit is necessary or whether the matter can be handled by the nurse.

The first point of contact should definitely be the family nurse — or, in some cases, a clinical assistant — who can initially assess the patient's needs. For example, if someone says they can't make it to their appointment on time, that's not something that necessarily requires the doctor's involvement. Or if someone asks what time the center is open — those are everyday questions that don't always need a physician.

The family nurse is well equipped to determine whether a person needs to see a doctor or if a nurse's appointment is sufficient.

Nurses know exactly what they can and cannot handle. And if it turns out a doctor's input is needed, the family doctor can always follow up and call the patient directly. That said, the exact setup can vary from one family health center to another, but at Kivimäe Health Center, for instance, and in many others, this is how it typically works.

What do you say to those people who don't have strong digital skills or digital literacy? I'm thinking especially of older individuals, pensioners, who struggle to navigate online communication?

First of all, even some younger people have limited digital skills — for example, they might not use email or web applications. But right now, all family health centers offer multiple ways to get in touch: by phone, online or by visiting in person. It may be that not every center allows you to book an appointment on-site, but that's something I still need to look into.

In general, though, we do take into account that people have different levels of digital ability. Even though Estonia is known as a digital country, all systems are designed so that people can manage well even without strong digital skills.

In your opinion, isn't the current system — and communication with family doctors — too web-based and too complicated?

It really depends on the family health center, and ultimately the patient is the one who can best assess that. If there are concerns, the first step should definitely be to contact your own health center — write to the center's manager and explain the issue, whether it's trouble getting in touch or something else.

The center manager can explain how things are organized and help guide the patient to the right place. But if the health center doesn't provide the necessary help, then it's possible to turn to the Health Board or the Health Insurance Fund, who are responsible for resolving these kinds of issues.

It's probably important to find a balance — so that inconveniences, obstacles and patient frustration with the system don't drive people to seek help from other sources or channels that may not be evidence-based. It could also lead to patients giving up on addressing their health issues altogether, which, in the long run, would only increase costs for the healthcare system.

First of all, satisfaction surveys have been conducted, and in fact, patients are generally satisfied with their family doctors. If I recall correctly, the satisfaction rate was over 80 percent. So we can't claim that people are broadly dissatisfied. Of course, there are those who aren't happy, but we also know that dissatisfied individuals tend to voice their opinions more loudly.

The second point is that, as I've already said, healthcare is in a deep crisis and we have to realistically assess what we're actually able to offer people. We can't base everything solely on patient satisfaction — we also need to ensure that healthcare workers can keep going, that they don't burn out. Healthcare professionals must want to do their jobs, but they shouldn't have to, for example, focus on calming a patient down if that's something someone else could handle.

We can't build the system around satisfaction alone.

Who should be handling that calming or reassurance?

For example, a neighbor.

We shouldn't forget the role of family and community, nor expect the state to do everything for us — that's simply unrealistic. Family doctors are often criticized for not talking enough about healthy lifestyles, but do I really need to spell that out? The truth is, we do talk about it. I usually approach the conversation by asking the patient: "Can you tell me what changes you think you should make in your lifestyle to improve your health?"

Not one person has ever said they don't know. People do know these things. They just need to take personal responsibility for making healthier choices. And when we talk about budget constraints and the crisis in healthcare, we have to consider what exactly we can offer people.

Our priority has to be those who need help the most — those with serious illnesses, those in poor health. People who are looking for advice on, say, losing weight might be better off consulting a trainer or thinking through how they're managing their diet and exercise themselves.

That said, we actually welcome those kinds of visits — when someone asks how to lose weight, it's a positive sign for us. But I would still encourage people to really reflect on what they can change in their own lives, because ultimately, that responsibility lies with each individual. No one else can do it for them.

In an interview a few weeks ago, you said the following, and I quote: "Medical care doesn't always have to be immediate. We need to make sure people see a doctor at the right time, but individuals don't always know how to judge that themselves. Sometimes, you may have an appointment scheduled two months out, but if your condition worsens, you should reach out again — and then we can speed things up." My question is this: what kind of health concerns can actually wait two months?

For example, let's say I have a spot on my face — a skin rash that's been there for two months already. That can absolutely wait another two months. That doesn't mean it's not a concern, but if it's a harmless rash that doesn't match the signs of melanoma, it's not urgent. People can often recognize such things themselves — sometimes even just by Googling. I always encourage people to Google responsibly.

If someone is capable of critically evaluating the information they find, they'll recognize when something might be serious. In fact, tools like Google — or even ChatGPT, which has become very popular can offer pretty good guidance. Of course, if there's any doubt, our 24/7 family doctor advice line is always available.

Let me give you an example. Suppose someone has hip pain: a 30-year-old man or woman who's had pain for a week after running five kilometers. They can still walk and they're used to running 10 or even 20 kilometers. Now compare that to an elderly person who also has hip pain — but it's so severe that they can't even get out of a chair or bed. Who needs medical attention more urgently?

In older adults, joint degeneration is common and, in rare cases, it can lead to necrosis. That person needs help as soon as possible because the pain can severely disrupt daily life. But for a younger person, the issue is more likely to be temporary — something that could improve with the help of a physical therapist. If a young patient is referred to an orthopedist and the wait is a couple of months, that's usually acceptable. In many cases, the issue may resolve before they even need to see a specialist.

For the younger patient, a family doctor might start by referring them to a physiotherapist. But the elderly person whose mobility and daily life are seriously affected needs faster action. And younger, more digitally literate patients can usually navigate the system more efficiently and get appointments sooner.

Family doctors could start using e-consultations more, providing specialists with a detailed description of the patient's condition. The specialist can then decide whether the issue can be handled by a physical therapist or if further investigation — like an MRI — is needed. If the pain worsens, the patient can be referred for emergency care.

In some cases, the specialist might even schedule a same-day urgent appointment, especially if it's clear the patient has a serious mobility issue. The specialist will already have all the background and test results, allowing them to give informed advice or refer the patient for surgery. I've had patients in my own practice who were taken directly to the hospital and fast-tracked for surgery.

Through all these steps, the most important thing is that care is delivered at the right time. Patients should absolutely be involved in the process — but the most qualified person to decide on the appropriate care is still the doctor or nurse.

Another question concerns prescription writing — especially renewals. Some people have criticized that certain family doctors don't properly assess the development of a patient's health condition when renewing prescriptions. Could this be interpreted as the patient essentially prescribing medication to themselves on a regular basis? Is this a problem and how should it be addressed?

If a person has a chronic condition — like high blood pressure or diabetes — then they really should be seen at least once a year, even if it's just by the family nurse. Family doctors are part of a quality monitoring system where the Health Insurance Fund provides a list of all patients with certain diagnoses. If a patient comes in for another reason, it's possible to either schedule a separate appointment or address their chronic condition during the same visit. The treatment plan can be reviewed, blood pressure or blood sugar levels checked and so on.

This system is in place and most family health centers follow it. But if someone has been receiving prescriptions for years without any contact with a healthcare provider, then they really should insist on a visit. And if that proves impossible, then it's appropriate to turn to the Health Insurance Fund or the Health Board for help.

What's the most effective way to "insist" on getting an appointment? A lot of people are probably listening closely to this right now.

People with chronic conditions usually take responsibility for making sure they see the family nurse at least once a year — that's quite common. A lot depends on the individual's own initiative and sense of responsibility.

But if it turns out that someone hasn't made it to an appointment in over a year, we review those lists at the end of the year and invite those patients ourselves.

If a family health center isn't doing this, then the kind of situation you described can happen — where a patient hasn't been able to get an appointment. In that case, the first step should be to reach out to the health center through the usual channels. But if someone with a chronic illness truly hasn't had contact with the healthcare system for years and still can't get an appointment, then I would recommend raising it as a quality-of-care issue with the Health Insurance Fund or the Health Board.

For a healthy person, would it make sense — and is it even feasible within Estonia's healthcare and family doctor system — to go in for a routine health check once a year or once every two years? Or would that be considered a waste of healthcare resources and an unnecessary burden on the system?

There are several factors to consider here. First: what are the person's risk factors? Some people have a genetic predisposition to serious conditions like cancer or heart disease. Others may have lifestyle-related risks — such as smoking, being overweight or a lack of physical activity. It's also important to note that being overweight isn't always solely due to lifestyle; there are often other contributing factors as well.

Assessing risk is key. If a person has no symptoms and no risk factors, then for someone under 50, the main things to monitor are body weight and diet. Naturally, alcohol and tobacco use also matter. When it comes to tobacco, the recommendation is clear: zero. As for alcohol, my impression is that people have begun drinking more moderately — which is a good thing.

The individual's own effort plays a major role here. Random testing without a clear purpose isn't really worthwhile — it may not provide any useful information. People often say, "All my test results were fine." But what does that actually mean? What tests were done and what did they show? The truth is, you can't detect cancer with a standard blood test. The same goes for many other serious illnesses.

So just having "normal" test results doesn't automatically mean a person is healthy.

Many of the issues and challenges we've discussed in this interview stem from the shortage of family doctors — a problem Estonia has been facing in recent years and will continue to deal with in the near future. Do you have a vision for how this issue could be resolved?

The shortage isn't limited to family doctors. We're seeing the same issue with psychiatrists, and emergency departments (EDs) are severely overburdened. But in fact, the greatest shortage we're facing is in nursing — and that absolutely needs to be addressed.

As I mentioned earlier, there are family health centers where doctors from other specialties or general practitioners are covering for family doctors. A general practitioner is someone who has completed medical school but hasn't gone on to specialize further — for example, in family medicine, cardiology or any other specific field. One possible solution is to integrate general practitioners more systematically into the healthcare system. They're fully capable of handling many health issues that may be too complex for a nurse but don't require a specialist's involvement either.

In our own Kivimäe Health Center, we have a general practitioner on staff. The Health Insurance Fund has also launched several pilot programs where general practitioners work alongside family doctors. This way, simpler cases go to the general practitioner, while more complex ones — such as patients with multiple chronic illnesses or symptoms that span across specialties — are handled by the family doctor. A family doctor is trained to treat the whole person across the entire lifespan, from children to the elderly, and across both physical and mental health. A general practitioner does not have that same breadth of specialization.

We have to find smarter ways to use the resources we already have. Strengthening primary care is critical. And when it comes to emergency departments, they really should be reserved for true emergencies. How we regulate that — whether through the Health Insurance Fund or state policy — is a topic for further discussion.

I've worked in an ED myself and seen firsthand how people come in with non-urgent issues — like a runny nose that started that morning. Yes, they need care, but that care should come from a different place. That's exactly why we have resources like the family doctor advice line, 1220.

Of course, none of this is easy — and it's likely going to get even harder in the coming years. We don't have a magic wand that can turn, say, a talk show host into a family doctor overnight.

Could you give a brief overview of what you've discussed and either agreed upon or are in the process of agreeing upon with your colleague Diana Ingerainen from the Eesti 200 party during the coalition negotiations?

Diana isn't the only one we've been holding discussions with. Our team also includes Professor Irja Lutsar and financial experts, because healthcare funding is one of the most painful and complex issues we're facing.

We're looking into how private funding could be brought into the healthcare system in a way that doesn't undermine the existing solidarity-based model. In certain areas, greater use of private funds is entirely feasible and private clinics do have a legitimate role within Estonia's healthcare system. Neither I nor Dr. Ingerainen are opposed to private clinics.

Another key agreement involves reviewing the structure of the healthcare network. We need to assess whether services are located in the right regions. For example, in sparsely populated areas, service quality might suffer. That's why our focus is on three pillars: quality, funding and the healthcare network. These must be developed in balance.

We can't say that healthcare will be "fixed" in two years — but we do need to set a clear direction for steering it out of crisis. The situation will likely get more difficult before it improves, but our goal is to move toward greater stability.

When we look at Estonia's healthcare spending as a percentage of GDP, it's clear we're below the European average. More investment will be necessary in the future — that will be a task for upcoming governments. But before asking for more funding, we need to clarify exactly where the current money is going.

That will be our core task in the coming years: to track spending and assess the system's efficiency. Ultimately, this will mean better, higher-quality care for people — care that they can actually access when they need it.

And finally — where should a person turn if they feel like they've fallen through the cracks of the healthcare system? If they can't get help for their health concern, their family doctor is unavailable and there's no neighbor to ask for advice. You mentioned the Health Insurance Fund and the Health Board, but, for example, if someone calls the Ministry of Social Affairs, they might get a secretary on the line who can't help. How can people actually reach the right people?

Unfortunately, even though I'm a trained doctor, I'm not in a position right now to provide medical services or solve individual health issues directly. But that's exactly why the Health Board and the Health Insurance Fund exist — their general contact points, both email addresses and information hotlines, are definitely worth using if someone needs help.

Social workers also frequently encounter cases where people have been left without support, and they're often well positioned to direct individuals to the right specialists — whether that's a doctor or a local family health center.

--

Follow ERR News on Facebook and Twitter and never miss an update!