Losing a declaration is worse than ID
Anastasia signed a declaration with her former district doctor. But, having come for a prescription for lenses, she found that the document was canceled, because the family doctor no longer works in the outpatient clinic. Other doctors do not recruit new patients - they have a declaration limit. These four are patients from nine former sections of her densely populated area. So the receptionist advised Anastasia to apply for paid services.
The problem of the shortage of medical personnel in primary care is especially acute in rural areas, where there were not enough doctors even before the reform - there was one pediatrician per three districts. Now the situation has become even more aggravated in connection with the pandemic.
Increasingly, Ukrainians have to pay for services despite their right to free medicine. Those who cannot pay for this medical care have to travel tens of kilometers in search of institutions that would give a chance for state-guaranteed medical care. And these attempts are not always successful.
One of the program orders of the Ministry of Health lists the reasons why the declaration can be terminated, but not a word is said about what the patient should do if his doctor quit, went on maternity leave, fell ill or moved to permanent residence.
There are several ways in which you can find a primary care physician online in order to conclude a declaration with him. But in practice, they don't work very well.
Via the National health service (NHS) website. There is information about whether the doctor has reached the limit, or if he has free places. The database contains doctors in all localities of Ukraine. The main drawback is when you click on the full name. The site redirects the selected doctor to the data of the outpatient clinic. The stationary registry number is indicated. There is no personal data of the doctor, there is no possibility of getting to him at once (to discuss the possibility of concluding a declaration).
Via local administration website. You can choose an outpatient clinic with a convenient location on the map. This is where the convenience ends. When redirecting to the institution's page, we find landline numbers, most of whose lines are busy or do not answer. There is no catalog of doctors, a description of their workload and the limit of declarations.
Via HELSI. After entering the search query "family medicine doctor", a list of 774 doctors with the "private clinic" checkbox drops out. When a patient tries to make an appointment, the system warns that the doctor provides a paid service, without indicating its cost. The patient pays, of course, not the NHS. But what is noteworthy is that only registered users of the site with a personal account can make an appointment even to a doctor in a private clinic. You can register in the system only upon concluding a declaration with a primary care physician. Well, this is at least an opportunity for those who have lost their declaration and had the opportunity to use the services of medicine paid for from the state budget, to get at least a paid appointment.
Lack of primary doctors for everyone
Two years ago, district polyclinics disappeared in Ukraine, the reforming Ministry of Health sent to the dustbin of history and the system of district pediatricians/therapists, to whom thousands of patients were assigned by the right of registration. Earlier it was possible to get an appointment with the doctor of the district polyclinic only from the first line. If a person changed his place of residence and registration, he also had to register at a new clinic.
Even then, doctors were sorely lacking for all. District therapists and pediatricians, in order to receive at least some additional payments to beggarly salaries, took on 2-3 sites. Patients had to sit for hours in crowded corridors in order to banally close the sick leave.
At the time of the start of the reform, there were only 15,000 doctors in Ukraine with the specialization of family doctors. The whole country needed 25-30,000 of such doctors. The Ministry of Health got out of the situation - with a light stroke of the pen, made doctors with the specialization of pediatricians and therapists as primary care physicians. We will return to the consequences of such a decision later.
According to the NHS, today the database includes 21,475 physicians providing first aid. The Family Medicine Association estimates that the system lacks at least another 4,000 family doctors.
At the same time, the service pays for 28.16 million declarations, that is, not every Ukrainian has an agreement with a primary care physician.
For most doctors, the number of declarations significantly exceeds the limit set by the ministry. At the same time, the salaries of primary care physicians are still low. A qualified family doctor who has a "full package", all places are filled, can receive up to 500 USD. Pediatricians receive less than 300 USD – they have less declaration limit.
It is not surprising that Ukrainian doctors are migrating abroad. In neighboring Poland, their colleagues receive a salary equivalent to 3,500 USD. In Britain, another top country where doctors leave Ukraine, the salaries of doctors are even higher.
In this regard, the Association of Family Medicine proposed setting the maximum workload for primary care physicians - 1,200 patients in rural areas and 1,500 in the city, with a higher pay.
It was assumed that there will be more family doctors at the second stage of the medical reform - by reducing the number of doctors in secondary medicine. However, these plans were disrupted by the pandemic.
Finding a family doctor is difficult
As already mentioned, in Ukraine, family doctors were supposed to replace the "intermediate" specialists who worked at polyclinics.
What country can afford an army of cardiologists. Who gives a referral for an ECG, then sends them to an echogram of the heart, then collects all these pieces of paper and prescribes pills that a family doctor should prescribe?
Britain, whose experience, in particular, is being copied by Ukraine, at one time really achieved an improvement in the quality of medicine by increasing the number of qualified family doctors and reducing the number of narrowly specialized specialists. However, in our country, the effect is the opposite.
The Ministry of Health, in an attempt to increase the number of family doctors, made primary care physicians specializing in pediatricians and general practitioners. The President of the Family Medicine Association emphasizes that their functionality is much narrower than that of a family doctor: percussion, auscultation, palpation, listening with a phonendoscope.
Family doctors are trained by the multidisciplinary department. They go through a two-year internship. As a result, a family doctor must be a specialist in outpatient surgery ("small" operations in various fields of medicine that can be performed on an outpatient basis. They are performed under full local anesthesia or in combination with intravenous anesthesia, which "turns off" consciousness, but does not require artificial ventilation. They are used for diagnoses of lipoma, fibroma, nevi (moles, warts, etc.), ingrown nail, furuncle, carbuncle, abscess, trophic ulcer, wounds). He can stop bleeding, sew up blood vessels, make postoperative dressing, provide assistance to palliative patients, etc.
It is not clear how a pediatrician or a therapist who mainly treated angina and acute respiratory viral infections, without appropriate knowledge, could lead a pregnancy or diagnose tuberculosis. But according to the plan, at the second stage of the medical reform, women's clinics and institutions specializing in the diagnosis and treatment of tuberculosis were to be closed.
Today, most of the institutions that have changed the signboard of the district polyclinic to an outpatient clinic do nothing to stimulate doctors to upgrade their qualifications to the level of an advanced family doctor - the salary is the same for everyone.
How, then, can you be sure that even after a grueling search for a family doctor, you will be provided with quality service?
Further - worse
After the second stage of the medical reform, an even greater reduction in the number of doctors can be expected.
According to the report of the Center for Medical Statistics of the Ministry of Health of Ukraine, at the end of 2019, almost 188 thousand full-time medical positions were registered in the system of the Ministry of Health. Based on this, the staffing rate with doctors was 82.7%. In physical terms, the shortage of medical personnel in Ukraine amounted to almost 36 thousand. The staffing of staff positions in medical institutions (including family medicine outpatient clinics) was 78.3%.
The indicator of staffing of medical posts in Ukraine is 81%. This means that only 80 people work in 100 medical posts in Ukraine. Working as a physician in Ukraine is not motivated by salaries. At a hospital doctor – 250 USD per month, for a beginner – 160-170 USD. The situation in Ukrainian hospitals is saved only by Covid - many doctors and nurses are motivated by a 300% bonus for work in coronavirus departments.
According to the professor, the real scale of the situation is even direr. The favorable picture that the Statistics Center gives in the reports is drawn by reducing the number of staff members.
The number of doctors decreased by 6,900, and the number of nurses decreased by 22,500. But the statistical indicator of staffing has not changed - it was 82.7% last year, it became 81.1%. that the rates of people who worked in the system and left it were simply reduced. Thus, the statistics have not changed, and the physical shortage of medical workers has grown significantly.
2,000 Ukrainian doctors and about 3,000 nurses are in the queue for employment: in Poland
Many doctors are retiring. Quite a few retirement age health workers have quit for fear of contracting Covid in the absence of adequate protection measures.
Taking into account this trend, it will soon be a joy for every patient that at least a former local therapist/pediatrician agreed to conclude a declaration.