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05 December 2022 | Policy Analysis
Recent advances in financing of PHC services in Slovenia, 2017–2022 -
01 June 2022 | Policy Analysis
Entry points for the strategy for the development of primary health care 2022–2031 -
01 March 2020 | Country Update
Chronic care nurses transferred to other postings in COVID-19 response
5.3. Primary care
Primary health care is organized by municipalities for their own territory, or jointly with other municipalities when the municipality is too small to organize its own provision.
Primary care provides patient-centred, integrated health care by multidisciplinary teams consisting of family medicine, primary care paediatrics and gynaecology, emergency medical aid, general and youth dentistry. They also provide laboratory and other diagnostic services; physiotherapy, occupational therapy, speech therapy and mental health services; community nursing; health promotion and health education programmes; and selected secondary level specialist ambulatory practices. The organization and operation of primary care follows a community-oriented model and offers a wide range of preventive, diagnostic, curative, rehabilitative, palliative and health promotion services (see sections 2.2, 5.1 and Table5.2) close to patients’ homes. The majority of primary care is delivered by a network of 63 CPHCs, owned and managed by municipalities (covering around 76% of physicians and 42% of dentists working in primary care in 2015) (see sections 2.1, 2.2, 5.1 and 7.2).
Table5.2
Primary care provision is also supplemented by individual or group practices of private practitioners, who are contracted by the ZZZS (concessionaries) (see sections 2.2, 3.3.4 and 3.7.2), though private practitioners usually work in single-handed practices and provide only one type of service. Out of 2214 doctors working in primary care in 2019 in Slovenia (NIJZ, 2020b), a total of 475 (21.5%) worked in independent practices as concessionaries. Most dentists at the primary level are private practitioners, mostly working in solo practices (638 publicly salaried versus 762 private).
Every insured person must register with a primary care physician. The choice is free and not bound by residence or by employer location; a personal doctor can be changed yearly. In this system, primary health care teams operate registered lists of patients and physicians. Providers in all four categories (family medicine, primary paediatrics, primary gynaecology, general and youth dentistry) are considered personal doctors and are responsible for the provision of services to the enrolled patients on the list. They also act as gatekeepers to secondary level specialist care.
Additionally, CPHCs are important in providing comprehensive preventive services (see section 5.1). They were the original location of HECs, established in early 2000s to support lifestyle interventions, following the launch of the screening programme for the early detection of risk factors for CVD (see section 5.1). These centres, working with small groups and individuals with a common risk factor or problem, are led by registered nurses, who schedule visits and carry out both individual preventive check-ups as well as health promoting workshops and group interventions. They are gradually being scaled up in the form of HPCs, introduced in 2017 (see sections 2.1 and 5.1).
CPHCs also house Family Medicine Practices, formerly called “family medicine model practices”. These focus on prevention and care coordination for patients with chronic diseases and entail an additional 0.5 full-time equivalent registered nurse to perform screening, intake and management of at-risk patients (see section 5.1).[8] For information on the geographical distribution of primary health care resources, see section 4.1.1 and Box4.1.
Box4.1
Box5.3 provides assessment of strength of primary care in Slovenia.
Box5.3
- 8. The whole list of chronic diseases observed includes: arterial hypertension, benign prostatic hyperplasia, coronary disease, diabetes, COPD, depression, osteoporosis, asthma. ↰
Despite good health outcomes, a PHC model characterized by multidisciplinary teamwork, strong links to public health and universal financial coverage for health services, Slovenia’s PHC faces myriad challenges.
Demographic and epidemiological transitions, technological advances, and adjustments to service delivery have changed patient expectations and increased the demand for (longer) clinical visits at PHC for more complex patients. Meanwhile, personnel challenges hamper the PHC system’s ability to meet population needs and ensure quality and safety of care.
There is a shortage of PHC physicians: around 120,000 adults are not registered with a PHC team due to lack of capacity. This shortage is getting worse due to an ageing PHC physician population (about 30% to retire in the next 5-10 years) and difficulty in attracting/ retaining physicians because of, e.g., dissatisfaction with salaries, working conditions, and inadequate professional development and support. Consequently, existing PHC physicians face high workloads but are still expected to increase the services they provide.
Meanwhile, there isa twofold spillover effect. First, those without a primary provider use emergency care, which both overburdens the emergency care—itself lacking adequate staffing levels—and raises healthcare costs. Second, saturated PHC teams refer patients to secondary ambulatory care for treatment that could be managed at PHC given more capacity. This generates long waiting times for non-urgent hospital ambulatory care services.
Between
2017 and 2022, Slovenia introduced several piecemeal financial
interventions to immediate effect to address workforce challenges and
other tenacious issues plaguing PHC.
Project to shorten waiting times in hospital ambulatory healthcare and improve medical service quality at primary level (2017; €36 million)
- Publicly employed PHC providers can be remunerated additionally based on performance up to 25% of base salaries in family medicine and primary pediatric practice
- Dedicated funds are provided from the national budget, not from the health insurance institute (HIIS)
- Requires use of the newly introduced eHealth services
Decision for special programs on PHC (2019; approx. €9 million provided from the national budget of the RS)
- Introduces a scale awarding certain percentages of additional remuneration for exceeding the 1,895-capitation quotient in family medicine and primary pediatric practice
- Extends office hours by minimum 1 hour to ensure enough time for patients
Special government project on family medicine and primary pediatric practice (2021)
- Introduces shift of funding from national budget to HIIS and fee-for-service purchasing for all services provided that exceed the monthly plan
Measures to ensure healthcare system resilience (2022)
- Supplements
for healthcare employees at all levels introduced and financed from
state budget, e.g., for increased workload, and for working in
less-developed geographic areas and municipalities with a lower degree
of economic development
Together the measures established a new precedent for increased funding of healthcare services from the state budget. Evaluations have yet to be performed, but anecdotally family physicians seem better satisfied with their incomes since implementation. However, PHC performance isn’t improved and over 100,000 patients are still not registered with a PHC physician. Thus, the impact on waiting times and emergency care persist. Additionally, interest for PHC jobs among young physicians has not improved either.
Authors
References
Albreht T, Polin K, Pribaković Brinovec R, Kuhar M, Poldrugovac M,
Ogrin Rehberger P, Prevolnik Rupel V, Vracko P. Slovenia: Health system
review. Health Systems in Transition, 2021; 23(1): pp. i–188.
Act on emergency measures in the field of healthcare: Official Gazette of the Republic of Slovenia, no. 112/21 (http://www.uradni-list.si/1/objava.jsp?sop=2021-01-2452), 189/21 (http://www.uradni-list.si/1/objava.jsp?sop=2021-01-3726), 206/21 (http://www.uradni-list.si/1/objava.jsp?sop=2021-01-4283) – ZDUPŠOP and 132/22 (http://www.uradni-list.si/1/objava.jsp?sop=2022-01-3114). http://www.pisrs.si/Pis.web/pregledPredpisa?id=ZAKO8360.
Innovations
brought by the Act on emergency measures to ensure the stability of the
health care system. Slovene Medical Chamber. 21 July 2022. https://www.zdravniskazbornica.si/informacije-publikacije-in-analize/obvestila/2022/07/21/novosti-ki-jih-prina%C5%A1a-zakon-o-nujnih-ukrepih-za-zagotovitev-stabilnosti-zdravstvenega-sistema.
Strengthening primary health care (PHC) has been on the policy agenda in Slovenia for the last decades. In 2016, the process to prepare a PHC strategy was launched. In 2019, the WHO Regional Office for Europe and NIJZ/NIPH conducted an analysis of root causes of challenges in PHC to inform this new strategy. On 26 March 2021, the Ministry of Health (MoH) nominated the Working Group of Primary Health Care Experts, which prepared the document “Entry points for the strategy for the development of primary health care 2022–2031” in dialogue with stakeholders, local representatives, and with professional support from WHO. In autumn 2021, a delegation visited Catalonia to observe their PHC system. The strategy was supported univocally by the Health Council but has not yet been adopted by the National Assembly due to changes of government.
In line with the recent European Strategy for Primary Health Care, the document outlines the following strategic goals:
- Equal access to comprehensive care as close as possible to the population
- Focus on the user and their empowerment
- Comprehensive and integrated treatment
- Quality and safe treatment
- Focus on preventive services
More specifically, it plans changes across several policy areas, including:
Leadership and management
- Outlines establishing an internal structure for PHC with representatives of PHC to strengthen the strategic role of the MoH and a national body for professional support for the development of PHC.
- Plans to define more precisely the roles of other stakeholders for the coordinated development of PHC.
Financing of PHC activities
- Outlines increased public funds for health at the primary level.
- Identifies the introduction of new financing models based on the efficiency and quality of patient treatment for fairer financing of PHC.
- Identifies updating infrastructure and equipment at the primary level.
Provision of human resources and improving working conditions
- Identifies the immediate continuation of existing measures to ensure sufficient personnel resources and appropriate working conditions as a priority.
- To ensure health care access at the primary level for all residents, the strategy identifies (1) updating the network of primary care providers (in the Master Plan of Healthcare Providers) with a needs assessment, (2) introducing rural clinics and (3) improving the care of vulnerable groups through better cooperation between health care providers and local organizations.
- Plans an upgrade of PHC teamwork structures to ensure comprehensive and integrated treatment, including through the expansion of graduate nurse competencies and the establishment of a system of effective cooperation mechanisms between different levels and professional groups.
Digitization and strengthening research to improve quality and safety of care
- Describes the need to further digitalize healthcare through provider and patient e-Health tools like an EHR, tools to support clinical decision-making, and development of data visualizations to support management, quality improvement and governance.
- Outlines the necessity of (1) defining quality indicators for PHC, (2) introducing a system of internal audits and reporting by providers, and (3) establishing a system of monitoring to improving quality and safety at the national level to ensure high-quality and safe medical treatment.
- Prioritizes a user-friendly portal to gather and provide information on the use of health services to empower and involve individuals, including by supporting decision-making when choosing providers.
Certain individual activities are also defined, including the establishment of the tertiary level institute of family medicine.
Authors
References
New pan-European strategy set to transform primary health care across the Region (who.int): https://www.who.int/europe/news/item/13-06-2022-new-pan-european-strategy-set-to-transform-primary-health-care-across-the-region
Albreht T, Polin K, Pribaković Brinovec R, Kuhar M, Poldrugovac M, Ogrin Rehberger P, Prevolnik Rupel V, Vracko P. Slovenia: Health system review. Health Systems in Transition, 2021; 23(1): pp. i–188.
Integrated, person-centred primary health care produces results: case study from Slovenia. Copenhagen: WHO Regional Office for Europe; 2020. Licence: CC BY-NC-SA 3.0 IGO. https://apps.who.int/iris/bitstream/handle/10665/336184/9789289055284-eng.pdf
Bregant T, Horvat Krstić A, Koprivec J, Ravnikar R, Rotar-Pavlič D, Vračko P. Naj bo primarna raven spet privlačna zdravnikom in dostopna bolnikom. Isis: glasilo Zdravniške zbornice Slovenije. [Tiskana izd.]. Apr. 2022, leto 31, št. 4, str. 21-25, tabele.
Potrjena izhodišča za strategijo razvoja zdravstvene dejavnosti na primarni ravni do leta 2031. Vlada Republike Slovenije. 30 May 2022. https://www.gov.si/novice/2022-05-30-potrjena-izhodisca-za-strategijo-razvoja-zdravstvene-dejavnosti-na-primarni-ravni-do-leta-2031/
In the face of an ageing population and increasing (multiple) chronic diseases, Slovenia has worked to strengthen its management of chronic diseases and noncommunicable disease risk factors. In 2018, Family Medicine Practices were nationally scaled up to improve prevention and care coordination for patients with stable chronic diseases. The practices include a new staffing standard in primary care, particularly in the CPHCs, in the form of an additional 0.5 full-time equivalent of registered nursing support. Patients who visit a practice receive a consultation with a specially trained nurse who assesses their current lifestyle and screens for risk factors and provides regular advice and follow-up.
Due to the shortage of nursing staff across the health system, which was acutely felt during COVID-19, most of the nurses employed in Family Medicine Practices were re-deployed to nursing homes, some hospital departments (if they had previous hospital experience), vaccination points and to perform COVID-19 testing to bolster the frontline response to the virus. This undermined the health system’s key tactic for managing and reducing chronic diseases, weakened primary care’s community-oriented working methods, and, for the nurses, represented a worsening of working conditions as the hours required of them in these seconded posts were much more than in their usual jobs. Previously well-managed preventative programs for chronic care were effectively stopped.
Authors
References
- Emergency instruction of the Ministry of Health to Primary Health Centres from 25 October 2020 – instruction on the possibility of repositioning nurses to other posts within the PHCs and to other providers.
- Order of the MoH on the temporary measures to contain the epidemic of COVID-19 enacted in a legal act adopted on 13 November 2020.
- Order of the MoH on the temporary measures to contain the epidemic of COVID-19 enacted in a legal act adopted on 15 November 2021.
- Explanation on provision of preventative health programs during the times of the epidemic of COVID-19, issued by the MoH on 20 October 2020