STA, 22 March 2019 - Threats by dozens of general practitioners around the country to quit in the face of a recent decision to increase the number of patients GPs are expected to cover have been making headlines in recent days. Matters seem to be spiralling out of control, as medical students have also been showing no interest to pursue a career in general practice.

While tensions over increasing red tape for GPs and their general workload have been mounting for years, the situation seems to have escalated as a result of the financing and organisational plan for public healthcare in 2019.

The plan, put forward by healthcare purse manager ZZZS and confirmed by the government, raises the permitted number of patients per GP. The increase also affects health centres that have been performing above that national average, which has been scrapped as a reference point.

More Slovenian doctors start to protest

The first to protest were 21 doctors in Kranj, who already stopped accepting new patients in February. They also addressed a letter to Samo Fakin, who in the meantime resigned as health minister due to ill health, in which they threatened to quit by the end of March.

All of the 15 GPs at the Celje Health Centre issued a similar threat earlier this week, while three doctors at the Nazarje Health Centre have already resigned.

Moreover, on Thursday doctors at the Ajdovščina Health Centre, which has seen a number of retirements in the recent period, announced they would no longer perform overtime work.

Doctors' organisations are demanding solutions that will allow GPs to do their job in line with professional standards. They say that the recommended patient index is 1,500, that the currently valid ceiling is 1,895, while the actual Slovenian average stands at 2,406.

However, the ZZZS argued that enforcing the ceiling would mean 325,000 people in Slovenia remaining without primary healthcare.

A threat to the constitutional right to healthcare

"Every stakeholder in the system shares some responsibility for solving this problem together. It however cannot be solved in the way proposed by some doctors, by starting to reject patients at 1,895, since this would even violate the constitutional right to healthcare," the ZZZS said.

Solutions highlighted by the ZZZS include appropriate education policy planning, meaning securing enough GPs, and a reduction of administrative burdens. It is also looking for ways to secure more funding.

"The management of health centres also have a number of tools at their disposal and can above all use reallocation to secure a more equal distribution of burdens among doctors," the ZZZS wrote.

There are currently 950 GPs in Slovenia along with 315 GP trainees and according to February data, the workload of 42% or of 595 family and children's doctors did not exceed the Slovenian average.

The Health Ministry, which is being run temporarily by Prime Minister Miro Šarec since Fakin's resignation, says it is drawing up measures that will resolve things in a systemic manner.

It announced fewer administrative tasks, a new financial model for primary healthcare that will be stimulative, and a call for applications for 80 to 90 GP speciality training spots in this year.

Healthcare in Slovenia faces growing problems

The problem however is that interest for a career in general practice has been very modest. Only 13 application were filed for 64 spots made available in a call last spring and eight in the autumn call that offered 60 spots.

What is more, health centres did not manage to find new GP staff even though additional funding had been secured for the purpose.

The head of the family doctors' trade union Praktikum, Igor Muževič proposed the impasse could be bridged with the inclusion of foreign doctors. He however added that no dialogue exists between the union and decision makers.

The situation was meant to be discussed today by the parliamentary Healthcare Committee, but the session was cancelled because it was not certain the representatives of the Health Ministry would be able to attend.

All our stories on healthcare in Slovenia can be found here

STA, 25 February 2019 - A dentist from north-eastern Slovenia has been found guilty of discriminating against an HIV patient in what is the first such ruling in Slovenia, a decision considered a key milestone in discrimination case law.

This is the first time a healthcare employee was found guilty of discriminating against an HIV patient, the newspaper Večer says on Monday about the court case that was closed to the public.

The dentist was ordered to pay EUR 2,700 in compensation to her former patient by the Maribor Higher Court in mid-2018.

The HIV-infected man saw the dentist in March 2016 and told her during the first visit that he was being treated for HIV. The dentist sent him for a dental x-ray.

The next week, when he came back for treatment, she told him he should get a new dentist. In court, the dentist claimed that she sent him away because she had only one set of particular instruments, which she could not sterilise in one afternoon.

However, both the first and the second instance courts ruled against her. The patient was eventually admitted by another dentist working at the same health centre, Večer reports.

The man reported the incident to Patient's Rights Ombudsman Vlasta Cafnik, who turned for help to the Medical Chamber but did not receive any response despite sending several emails and letters to several people in the organisation.

The patient also turned to the healthcare inspectorate, which responded that the Medical Chamber was in charge of such issues. He wrote to the chamber as well but received no answer and ultimately opted to hire a lawyer.

A mediation with the dentist was launched. It took a year before she wrote him an email, saying that she was aware that her treatment was demeaning and discriminatory.

The patient, who felt that the apology was not sincere, decided to take the dentist to court after her malpractice insurance company rejected his complaint.

She was found guilty at the first instance in April 2018. She appealed but the Higher Court upheld the first instance ruling in July 2018 and she ultimately paid the EUR 2,700 fine.

In response to the newspaper report about the case on Monday, the Medical Chamber said it was unacceptable to turn away a patient infected with a contagious disease.

"It needs to be taken into consideration, however, that such a case may affect organisation of work in the sense of rescheduling the appointment of the patient or other patients to ensure safe treatment of everyone present.

"All health staff has a duty to act in a way so as not to expose other patients to the risk of infection," the chamber said in a release.

The chamber said that it had received queries about the case from the patents' rights ombudsman in the previous term. In this term oversight was conducted with the dentist but "no departure from expert doctrine or work in comparable doctor's offices was established".

STA, 25 February 2019 - A nurse from the UKC Maribor hospital is being investigated for forging more than 200 prescriptions for medicines in high demand on the black market. She and a male accomplice are suspected of defrauding the national healthcare insurer ZZZS from 3,000-5,000 euros.

The Maribor criminal police assistant chief, Andrej Kolbl, told the press on Monday that a healthcare worker and an accomplice had been temporarily detained while the police searched six houses, commercial offices and cars on Friday.

The pair is suspected of fraud, a crime that carries a three year sentence, but the investigation will also look into other potentially criminal activities such as illicit sale of medicines, and the reason for the crime.

The police will also investigate whether any other persons were involved in the scheme.

The suspect allegedly forged more than 200 prescriptions since 2017, using the green-coded prescription pads used to prescribe medicines fully or almost fully funded by the ZZZS.

The suspect had made the prescriptions out to herself and the accomplice, forging the signatures of some 20 doctors in the process.

More than 600 cartons of Sanval, Zaldiar, Lexaurin and Doreta have been issued by several pharmacies based on the prescriptions.

Kolbl said these medicines, which are mostly tranquillizers or insomnia drugs, were in high demand in particular among drug addicts.

It was a pharmacist who had suspected the signature on one prescription did not belong to the doctor who had issued it, explained Roman Košir, UKC Maribor's emergency unit head, who spoke to the press later in the day.

The pharmacist also realised the person to whom the prescription had been issued, received very large amounts of tranquillizers, and notified the doctor in question.

Košir explained UKC Maribor had been notified of the suspicious activity a week ago by the community centre for which the doctor worked.

They had checked with several doctors to establish the signature on the prescriptions were not theirs, and reported the case to the police.

The nurse had mostly forged signatures of doctors from the community centre who regularly helped at the emergency unit, according to Košir.

He also explained it was not unusual for a nurse to have access to prescription pads or stamps.

"This is how we do things. Doctors, nurses, prescriptions, stamps are available at any moment due to the very nature of the work process."

Košir said the nurse had worked for the emergency unit for more than two years and the procedure to dismiss her had already been launched.

He said UKC Maribor was not harmed financially by the wrongdoing, as prescription drugs are paid by the national health care insurer.

It is yet to be established how much the two suspects have gained from the illegal activity.

STA, 21 February 2019 - The government confirmed on Thursday the financing plan for public healthcare in 2019, which includes additional funding and incentives for reducing waiting lines and an extra EUR 104m to cover the recent pay rise for healthcare staff.

The government confirmed what is termed "the general agreement for healthcare" and the financial plan of the healthcare purse ZZZS which envisages revenue and expenditure to level out at EUR 3.054bn. The figure is EUR 172m higher than in 2018.

A total of EUR 55m has been earmarked - coming on top of EUR 35m left from last year - to address waiting lines, which have been the main and persistent issue of the public healthcare system.

The funding framework adopted today was presented as giving the green light to some of the measures meant to cut the waiting times, one novelty being bonuses for hospitals and health centres for every medical examination beyond the number set down by standards.

"These examinations will be paid separately. They can start with them immediately, they just need to increase the number of doctor's offices ... I know that the system is rigid and that things will take time. But progress can be reached within a year," Health Minister Samo Fakin told the press.

He added that the results will be most obvious if the waiting lines are tackled at the country's largest hospitals, in Ljubljana, Maribor and Celje. If the response is slow, private providers will show interest, Fakin warned.

The ZZZS budget for 2019 envisages EUR 2.14bn going for healthcare services, 5.6% more than this year.

The financial plan entails an expansion of the primary healthcare network, providing funds for more GPs and paediatric surgeries since access varies greatly across the country.

The plan earmarks EUR 366.6m for sick pay (+7.5% over 2018), while EUR 54.2m is to be spent for healthcare provided abroad (+2.4% y/y).

Moreover, the insurer wants to preserve the same level of accessibility to innovative drugs. In total, EUR 444.5m will be available for drugs, medical aids and vaccines next year, 7% more than in 2018.

The government was also briefed on a report on the year-long project aimed at cutting waiting times that was adopted by the previous government as part of a strike deal with doctors and concluded on 31 March 2018.

The report found that out of EUR 18m earmarked for the purpose only EUR 8.15m was actually spent. The money went for performance bonuses for doctors and other healthcare staff putting in extra work to reduce waiting times and provide better care to patients.

All our stories on healthcare in Slovenia can be found here

STA, 6 February 2019 - A debate on problems in primary healthcare is heating up. Overburdened and understaffed, health community centres are looking for solutions but the one most recently proposed by the health minister has upset trade unions as well as nurses.

The problem of GPs being overburdened and underpaid has escalated to the point that in one health community centre, in Kranj, primary healthcare can no longer be provided to all residents.

Last week, the community centre notified citizens that GPs cannot accept new patients there and advised them to find their GP outside their city.

Responding to the situation there, Health Minister Samo Fakin proposed yesterday that GPs be paid according to the number of patients they have. "We already have this model in private healthcare and it's working," he said.

Although Fakin said trade unions had informally agreed with the proposal, the FIDES trade union of doctors and the Praktikum trade union of GPs rejected this.

Moreover, the minister upset nurses, who felt the minister ignored their problems completely, as well as the Association of Private Doctors and Dentists, who said that more patients always meant poorer quality of treatment.

Praktikum said that a new system of rewarding had been mentioned as a possible solution at one of the meetings with Fakin but "we told the minister this could be seen as an initiative to conduct work less professionally".

"No pay will reduce the burden on GPs. We will also propose to the minister to restrict the financing of work that exceeds professional standards," Praktikum said in a press release.

The trade union also proposes changes to the system of financing, cutting the red tape, and flexible hiring, especially in rural areas.

"We understand the minister is in a tough spot, being restricted by the political will in parliament and being unable to offer systemic solutions by himself. We need systemic measures to increase interest in family medicine and improve the chances of GPs staying in an area."

FIDES too called for honouring standards and norms with vice president Janusz Klim saying that the ministry, the ZZZS public health fund and health institutes had failed to take the necessary steps to implement the standards and norms from the 2017 strike-averting agreement.

Commenting on the situation at the Kranj community health centre, Fakin said that 51 students would finish their GP specialisation this year, just as many next year and another 31 in 2021. Half as many GPs will retire so that the gap should gradually close, he said.

The last resort will be to follow the example of other European countries and open the door to doctors from EU and third countries, he said. According to Fakin, the ministry is also working on changes to the management of public health institutions act.

But FIDES and Pratikum believe that the situation will further deteriorate with the natural retirement of doctors. "With every specialist that leaves, we have 1,500 patients left without quality care."

This causes burnout among doctors in primary healthcare, which prompts doctors to leave their job and discourages young doctors from becoming GPs.

The trade unions therefore expect decisive measures from the government.

The opposition New Slovenia (NSi) has already called for an urgent session of the parliamentary Health Committee, where it also expects concrete solutions.

"Unless the government and the health minister tackle the situation soon, the whole system of primary healthcare could collapse in a few years," the NSi said, noting this would be the biggest problem in Slovenia's history.

STA, 11 January 2019 – Gynaecologists (ginekologi)  in Slovenia have too many women enlisted as their patients, which leads to lower-quality examinations and longer waiting times. They thus urge authorities to reduce the number of women per gynaecologist to preserve the achieved high level of gynaecological care.

Medical Chamber representatives told the press in Ljubljana on Friday that a shortage of gynaecologists and ever new generations of women entering the system had affected access to gynaecologists.

They believe at least 30 new gynaecology teams would be needed to cope with the shortage and take the pressure off overburdened gynaecologists.

In 2018, a gynaecologist had an average of 4,800 women enlisted as their patients, while the college of gynaecologists and obstetricians maintains 4,000 would still be an acceptable figure.

However, some gynaecologists had even more than 7,000 women enlisted, explained Domžale Medical Centre gynaecologist Petra Meglič, who treats some 6,200 women.

All women, including girls aged at least 13, are entitled to choose their personal gynaecologist in Slovenia.

Since some 700,000 women have their personal gynaecologist, gynaecologists carry out more than 1.5 million medical examinations a year.

Another burden is a number of administrative tasks gynaecologists are obliged to carry out, which further shortens the time they have for their patients.

An aging and shrinking profession

Gynaecologists are, moreover, getting older; in 2017, out of a total of 361 active gynaecologists, 160 were older than 50 and 82 older than 60.

Some 300,000 women could remain without their personal gynaecologist due to retirements in the coming years.

"Young specialists prefer to work at hospitals, as working in a gynaecology office is extremely specific, with constant high pressure to process a mass of women," said Meglič.

She also said her office rejects 10 to 20 women who have not yet chosen their personal gynaecologist a day.

According to gynaecologist Renata Završnik Mihič, young doctors are eager to specialise in gynaecology, yet not enough residencies had been opened over the past years to make up for the shortage that would stem from retirements.

The system is working only because gynaecologists assume ever more work, which leads to burn-out.

They thus called on authorities to overhaul the standards governing the number of women patients per gynaecologist, which were adopted in 1994, taking into account population ageing and new discoveries in medicine.

In this way, the country will preserve its quality gynaecological care, few unwanted and teenage pregnancies, relatively few abortions and a low rate for cervix cancer.

STA, 7 January 2019 - The URI Soča rehabilitation centre in Ljubljana launched on Monday a new device for gait rehabilitation for severely impaired neurological patients. The Lokomat device provides supported, automated and computer-guided training for persons with impairments of the central and peripheral nervous system who are not able to stand or walk independently.

"The robot connected with virtual reality enables gait training for patients who would otherwise not be able to start it so early into rehabilitation," URI Soča medical director Helena Burger told the STA at the ceremony.

The device will make rehabilitation and its effects faster, as it ensured highly intensive learning with numerous repetitions of a steady and symmetric gait.

URI Soča director general Robert Cugelj added that they wanted to establish a centre of modern technologies by 2020, which would provide patients with services in line with the European rehabilitation guidelines.

The centre would provide rehabilitation with robotised equipment and virtual reality equipment at one place.

A patient using the Lokomat praised the device he uses three times a week for 30 minutes. He said the exercise was exhausting, but beneficial, as it helped him get closer to walking independently, which had seemed impossible at the start of the rehabilitation.

The purchase of the EUR 400,000 device was financed by the Health Ministry. Minister Samo Fakin said that the introduction of new medical technologies and therapeutic methods was important if patients in Slovenia were to be provided with best treatment.

Cugelj meanwhile noted that the biggest problem for URI Soča at the moment was development of neurological rehabilitation, as they needed a new facility. Waiting lines are manageable, but they are long when it comes to treatment of chronic pain.

The public healthcare fund ZZZS has already approved a new programme and Cugelj expects that the waiting times in this field will be completely eliminated in a few years.

STA, 27 December 2018 - The Constitutional Court has annulled the part of the health services act which stipulates that concessionaires should spend the surplus of revenue over expenditure for the performance and development of healthcare. The court agreed this encroached on the legal position of the petitioners and on their right to free business initiative.

The annulment, announced on Thursday, is related to the part of article 3 of the act which regulates the use of surplus generated by private companies and physicians with licenses to perform public healthcare services.

It says that public healthcare service "is being performed as a non-commercial service of general importance in a non-profit way, with the surplus of revenue over expenditure being spent on the performance and development of healthcare services."

The petition for the constitutional review of the act was filed by the Association of Private Practitioners and Dentists of Slovenia at the end of December 2017.

"This is only the beginning of a long period that will see us winning the battle in court and proving to the government that the concepts it advocates are not what the patients or those working in healthcare would deserve," the association's head Igor Dovnik said in response.

The Medical Chamber also welcomed the decision as confirming the provision harmed public services.

The chamber expects the court will also annul other contentious provisions in the act, in particular those limiting the scope of work for young doctors and for doctors employed both in private and public clinics, as well as provisions retroactively affecting already awarded concession licences.

As it received the petition, the Constitutional Court said that the provision limited the concessionaires and directly encroached upon the legal position of the petitioners.

The Constitutional Court said that the introduction in the national legislation of the term non-commercial service of general importance, which is a term in the EU law, did not mean that a public healthcare provider from the aspect of national law is no longer a non-commercial service.

"The term non-commercial public service under the Slovenian law is wider than the term non-commercial service of general importance under the EU law," the constitutional judges wrote.

When the amendments to the act were being adopted in parliament, reservations were also expressed by the parliamentary legal service, which wondered whether the definition of healthcare service as a non-commercial service of general importance was compliant with EU case law.

It had also noted that the Slovenian legal order did not define the term non-commercial service of general importance.

The Constitutional Court also assessed the provision from the aspect of the right to free business initiative, as it stipulates that public service should be non-profit and that surpluses from the operations should be kept in the public service.

"By preventing private entities from using the surplus from the activity for their personal needs, the legislator actually turned them into a non-profit legal form," it added.

"Limiting the freedom to dispose of the surplus very intensively narrows down the field of entrepreneurial freedom of private entities and encroaches upon their business initiative."

According to the court, such a measure is surely in the public interest to provide universal access to public healthcare services, but such an intensive limitation undermines one of the key incentives to perform the concession service.

As the reviewed encroachment upon the human right to free economic initiative outweighs the public benefit from it, the court has annulled the provision.

The association had also challenged article 42 of the act, which deals with the awarding of concessions and says that a concession is not a subject of inheritance, sale, transfer or any other form of legal transaction.

The court has ruled unanimously that the provision is not in violation of the Constitution. It said that a "concession to perform non-commercial public service is a right and not an authorisation in the sense of the law of obligations".

Asked by the STA to comment on the ruling, the Health Ministry said that it would comment once it received and examined the 26-page document.

STA, 11 December 2018 - Giving up on the National Institute for Congenital Heart Disease, which was scheduled to become operational in May this year, Health Minister Samo Fakin announced on Tuesday that the child heart cardiology programme would continue to be run by the UKC (Univerzitetni klinični center) Ljubljana hospital, albeit as part of a separate organisational unit.

The announcement comes a year after the government founded the National Institute for Congenital Heart Disease in response to a dysfunctional programme at Slovenia's main hospital.

While UKC, seeing a series of departures by surgeons and management staff involved in the programme in recent years, has been trying to make do with foreign specialists, the institute has failed to get off the ground, also being denied funding from the health purse operator ZZZS.

Tensions were also reported between UKC and the institute and the head of the institute's board Igor Gregorič resigned last week. The acting director Brane Dobnikar, who spoke last week of a blockade of efforts to get the institute going, also drew up a resignation statement.

Fakin told the press today that he would propose to the government to abolish the institute, which he expects will take a few months to process.

A lack of staff remains an issue

"I was assured at UKC that the programme is organised optimally and that young specialists were being secured in all categories," the minister said.

He noted that Slovenia would remain dependant on foreign experts, since 100 children with congenital heart disease are not enough to make the programme feasible logistically.

Fakin said efforts were under way to set up a regional centre, to also involve Croatia and Bosnia-Herzegovina.

"We were in Croatia yesterday and met with their health minister and heads of clinics and agreed we would have a talk after New Year's. They have 200 children, we have 100. If we include Bosnia, we can set up an internationally comparable centre and team," the minister announced.

UKC Ljubljana director-general Aleš Šabeder said that the first steps would already be made at the hospital next week towards establishing a new separate unit within UKC, which would combine the children's cardiology, heart surgery and intensive care units.

"I believe we've set up a stable system that can be upgraded into a well-functioning programme. It is presently still running with the help of hired specialists from neighbouring countries, but we expect younger specialists will join too. Relations are also better, stable," Šabeder said.

UKC medical director Jadranka Buturović Ponikvar explained that for now surgery on children in Ljubljana would be performed by domestic surgeons under the supervision of Czech surgeons from Prague's Motol hospital.

While praising the cooperation with Prague, Buturović Ponikvar noted that centres abroad also have staffing crises, which is why it is not good to rely only on one.

Following the announcement today, Fakin and Prime Minister Marjan Šarec met with the representatives of parents of children with congenital heart disease.

Talking to the press after the meeting, Petra Aleš expressed satisfaction that they ensured her that independent oversight, involving a foreign institution, would be introduced for the new programme.

"The oversight will allow parents to decide once and for all whether we can trust the programme," she said, adding that the parents regretted the decision to shut down the centre "but this story has ended and it's time to move on".

STA, 26 November - The international research project Implant Files has revealed that most Slovenian hospitals have no digital records on implants they put in patients. There is also no proper system of informing the Agency for Medicinal Products and Medical Devices on implant-related complications.

The only hospital in Slovenia with detailed digital records on all implants used is the Orthopaedic Hospital of Valdoltra in Ankaran, while other hospitals mostly still have them only in the paper form, including the National Institute of Public Health.

The digitalisation of medical data at Valdoltra started in the late 1990s and the hospital started building its own implant registry in 2002. According to the data from the ZZZS health insurance fund, the hospital conducted almost a quarter of all hip implant operations and almost a third of all knee replacements in Slovenia last year.

Statistical data show that there were no complications during most of the hip and knee surgeries, said journalists Anuška Delić and Maja Čakarić of the Oštro centre for investigative journalism in the Adriatic region.

But Delić and Čakarić warn that in Slovenia data on complications involving implants are difficult to find, as the system of reporting to the Agency for Medicinal Products and Medical Devices does not seem to be working properly.

In the last three years, the agency was notified of 258 complications related to implants and only 10% of these reports came from medical institutions, which are obligated by law to report to the agency within 24 hours after any complications.

In a response to the report, the agency said it was aware of the risks for patients, adding that as the competent body it had supervisory mechanisms at its disposal for the protection of health of Slovenian and EU citizens.

Its inspectors are performing supervision over producers and retailers and wholesalers of medicinal products and are overseeing their use in hospitals, healthcare centres, retirement homes and other institutions providing medical care.

The pharmaceutical inspection so far has not established major departures from the standards which would suggest that medicinal products on the Slovenian market are ineffective or pose a risk for users, the agency added.

It noted that the relevant EU regulations would be updated and enter into force in 2020, with the main advantages being better quality, safety and reliability of medicinal products and better transparency of information for consumers.

According to unofficial information, doctors more frequently report about problems to the implant manufacturers, although reporting to them is voluntary.

Most medical implants in Slovenia come from four companies

Data on implants by Valdoltra, UKC Ljubljana, UKC Maribor and the general hospitals of Celje, Jesenice and Novo Mesto show that more than half of the implant market in Slovenia is controlled by four big manufacturers: Zimmer Biomet, Johnson&Johnson, Stryker and Lima, the newspaper Večer reports in today's spread on the topic.

The 250 journalists from 36 countries participating in the research project found that 1.7 million injuries and almost 83,000 deaths in the last decade could be linked to implant fractures, decay, bending or other malfunctions. For Slovenia no such data is available due to poor record-keeping.

A national registry of implants should, however, be set up by Valdoltra as of next year. The hospital's current detailed records show that on average some 12% of hip implants and some ten knee implants have to be replaced a year.

Once the registry is completed, the data on implants will be available in an on-line application. According to the National Institute of Public Health, the digitalisation and the forming of the registry would cost EUR 30,000 and just as much should be spent annually for updating and maintaining the registry.

But for the time being, Valdoltra expects no additional costs as its existing staff is expected to work on the project.

The Implants Files international project website can be found here