According to Dr Gregor Prosen, Head of the University Medical Centre Maribor’s Emergency Care Unit, who chairs the working group on the transformation of the emergency medical care network, physicians working at emergency care units support the proposal that in the future, there would only be 12 emergency care centres and between 15 and 20 satellite emergency care units in the country, while the remaining emergency care units would be abolished. On the other hand, such a reorganisation and the abolition of more emergency care units is opposed by some medical centres, local communities, and also by some healthcare professionals in the field of emergency medicine. “During the times of freedom, the rural parts of the country will therefore be left without an emergency care unit. Didn’t the Social Democrats party (Socalni demokrati – SD) promise us something else?” Andrej Kosi commented on the recent developments.
According to the Sobotainfo web portal, the Ministry of Health wants to abolish as many as 28 emergency care units – a reader who works in the field of emergency medicine informed them about the changes in connection with the reorganisation of emergency care units, which was announced by the Minister of Health, Danijel Bešič Loredan, for the beginning of 2023. Currently, there are just over 50 emergency care units in Slovenia, which operate all days of the week. “Doctors from these emergency care units work in the unit, take calls for consultations during their on-call hours, and also respond to 112 emergency calls and go out into the field in an ambulance to provide emergency care to patients or the injured,” the reader explained.
According to the web portal, the system is well organised for now, which means that all Slovenian citizens have the possibility to receive emergency medical care when they need it. But this could change very soon if the reorganisation plan, which includes the abolition of as many as 28 emergency care units, is implemented. According to unofficial data, the following towns are expected to lose their on-call doctors under the new system: Gornja Radgona, Ljutomer, Lenart, Slovenske Konjice, Ormož, Črna na Koroškem, Dravograd, Šentjur, Žalec, Laško, Nazarje, Rogaška Slatina, Kozje, Hrastnik, Zagorje, Krško, Radeče, Metlika, Radovljica, Bled, Bohinj, Kranjska gora, Tržič, Kamnik, Trebnje, Ribnica, Logatec and Cerknica.
“The reorganisation plan significantly reduces the number of emergency care units with doctors. This will leave many towns without a doctor on duty and will significantly deprive the citizens of care in the event of a deterioration in their health. If they call 112, they will be attended to, but an emergency medical team will have to come from a much more distant place, where an emergency centre or a satellite emergency centre will be set up under the new system,” wrote a reader of the Sobotainfo web portal, who is employed in emergency medical care. She added that such help will arrive later than it does now, which, of course, leads to significantly worse treatment results or, in truly urgent cases, such as cardiac arrest, even to a difference between survival and death.
“Of course, as a result of the abolition of many emergency care units, the wait times in the already existing emergency rooms will be even longer, patients will have to wait even longer before being treated,” the reader warned – and to some extent, this is already happening, as we have already written that people are mostly visiting only the eleven best-equipped emergency care centres. It is well known that because we do not have enough general physicians, the on-call doctors also treat a number of patients who may not have their personal general physician at all or who may not get to them in a reasonable time. “Even these patients who do not always need emergency care will now find it even more difficult to access health services,” said the staff member working in emergency care. According to Dr Gregor Prosen, head of the University Medical Center Maribor’s Emergency Care Unit, physicians working at emergency care units support the proposal that in the future, there would only be 12 emergency care centres and between 15 and 20 satellite emergency care units in the country, while the remaining emergency care units would be abolished. This would allow the number of doctors on call to be consolidated to half the current number. Prosen also pointed out that, otherwise, people will eventually be left standing before the closed doors of emergency rooms. “Urgent care centres are already a half-sunken ship,” he added.
The Ministry confirmed to several media outlets that it is preparing a reorganisation of the emergency care units. “As the reorganisation is still in the coordination phase, it is still too early to talk about any changes at this point in time. The public will be informed about the upcoming changes in due course,” they said. According to the Sobotainfo web portal, the Ministry justified the changes mainly on the grounds of lower costs and a reduced workload for general physicians, who are in charge of part of the on-call service. “The Ministry is preparing the changes without public discussion, and the profession is not informed about the changes, except for a small circle of select people. In the last week, information and documents have come to light that speak about all of the above, and the vast majority of the profession disagrees with the changes and wants them to be announced publicly before they are put into effect, and a new law on emergency medical aid is adopted,” emphasised the Sobotainfo reader.
A similar proposal years ago was met with strong opposition from local communities and parts of the political spectrum
According to the Slovenian Press Agency, a working group chaired by Dr Gregor Prosen, head of Maribor’s emergency care unit, has been set up at the Ministry with the aim of reforming the network of emergency care units. In the summer, Minister of Health Bešič Loredan told the Slovenian Press Agency that the project to reorganise the emergency care network would be presented to the Ministry of Health after the local elections. If they find a consensus with stakeholders, the systemic solutions would be implemented next spring. The working group has already drafted a proposal for a comprehensive overhaul of the emergency care system in Slovenia and sent it to Minister Bešič Loredan in early November. The document obtained by the Slovenian Press Agency shows that it is an elaboration of the analysis of the situation and the proposals for necessary measures. The idea of setting up satellite emergency care centres dates back to the mandate of Health Minister Milojka Kolar Celarc. At the time, the idea was to organise ten emergency care centres across their countries, which would be supplemented by satellite emergency care centres – scaled-down emergency care centres with a permanent presence of staff, triage, basic equipment and medicines to care for the critically ill. The proposal was met with strong opposition from local communities and some politicians, so it was not implemented, except for the new emergency care centres which were introduced at the time. The satellite emergency care centres then partially started to operate in May 2020, when the government also provided for the financing of triage in nine centres – in Kočevje, Postojna, Tolmin, Ilirska Bistrica, Šmarje pri Jelšah, Kranj, Idrija, Sevnica and Velenje.
The current emergency care units, which are part of health centres that would not become satellites, would no longer operate at night
Under the reorganisation proposal, acute clinics for urgent conditions, i.e., on-call clinics, would be organised in all health centres on weekdays from 7 a.m. to 8 p.m. In the event of an emergency within a health centre, a nurse and a doctor from this clinic would provide urgent medical assistance to the individual until the arrival of an ambulance. In urgent and satellite emergency care centres, such clinics would operate around the clock, including at night and at weekends. The current on-call clinics would therefore be abolished at night in health centres that would not become satellites. In other words, an individual from a non-satellite health centre would have to go to a satellite emergency centre or to an emergency care unit in another town between the hours of 8 p.m. and 7 a.m., if he or she needed the help of an on-call doctor. Doctors working as primary care physicians would, according to the group’s proposal, be required to assist both in the satellite emergency care units and in the acute outpatient clinics of health centres for urgent emergencies, and a similar thing would also apply to paediatricians.
The group initially proposes lower criteria for the inclusion of a health centre among the satellite emergency care centres
However, after a year or two, to become a satellite, a health centre would have to be at least 40 minutes away from another urgent care or satellite urgent care centre or cover an area of at least 45,000 inhabitants or at least 24,000 inhabitants in an area of 400 square kilometres. Still later, all mobile emergency care units, helicopter emergency medical services and the health dispatching service would be integrated into their own organisational unit, the group proposes. The group has also drawn up a seven-phase plan for integrating the emergency care providers into the health dispatching service, which will bring new challenges with it.
Kamnik announces that it will use all legal means to protect the emergency care unit there; they are also critical of the fact that the document was prepared in secret
Slovenian Press Agency also reports that the proposal of the Health Ministry’s working group on the reorganisation of the emergency medical care network has been criticised in some municipalities, where the proposal would mean that doctors would be brought in from another location for field interventions and that emergency care units would be abolished. Kamnik is therefore announcing that it will use all legal means to protect its emergency services. Although the proposal mentions the separation of family medicine from emergency medicine, there is no mention of this in the proposed solutions, Sašo Rebolj, Director of the Kamnik Health Centre and a general practitioner, told the Slovenian Press Agency. The proposal would abolish Kamnik’s emergency clinic altogether and replace it with an acute clinic for urgent and emergent cases, a kind of on-call clinic that would operate on weekdays from 7 a.m. to 8 p.m. Under the proposal, ambulances with paramedics would be available around the clock at the Kamnik Health Centre, which has so far this year carried out almost 1500 interventions, while doctors would be transported to interventions from the planned satellite emergency centre at the Domžale Health Centre. “Paramedics are an indispensable part of the team, but they don’t have the rights to administer medicines, for example,” Rebolj stressed. “We have the feeling that overstretched emergency care centres would like to usurp our staff by closing peripheral emergency care centres, which I do not find acceptable,” he added. He is critical of the fact that the document was written in secret and that the group did not explain in the paper why the proposal is better for people. He now expects clarifications from the Ministry. Rebolj’s criticism is echoed by the Mayor of Kamnik, Matej Slapar. As he wrote on the Kamnik municipality website, removing access to an emergency doctor would be unacceptable, as Kamnik is a hilly and rugged municipality. Therefore, just like in 2015, they will once again use all legal means and all forms of pressure to keep the emergency care unit in Kamnik, he announced.
Per the proposal, the Slovenjske Konjice Health Centre would also not become a satellite emergency care unit. Although Dejan Verhovšek, the Director of the health centre in question, supports the efforts to regulate the emergency care units, he does not yet support the unofficial proposal. The area covered by the municipalities of Slovenske Konjice, Zreče and Vitanje would lose a doctor on duty at night and on weekends and holidays, which he told the Slovenian Press Agency was unacceptable, despite the arguments that doctors would be relieved of their workload.
“We have not yet been officially informed of the possible measure. When they tried to make similar changes to the organisation of the emergency care unit a few years ago, we argued that it did not make sense and could be harmful to the citizens of the Gornja Radgona Administrative Unit. We feel the same way now. The nearest emergency centre for the critically and uncritically ill would probably be the General Hospital Murska Sobota. As I said, we have not received an official document on the reorganisation, so I cannot comment on the details yet,” explained the representative of the Gornja Radgona Health Centre.
A satellite emergency care unit
Small emergency care units would be set up in places without a general hospital and an emergency centre. According to the proposal of the Ministry of Health’s working group, a triage nurse would be present at all times in a satellite emergency care unit. The satellite emergency care unit would have a resuscitation room and at least one surgical outpatient clinic.
These are the proposed locations for a network of satellite emergency care units:
– Kranj
– Škofja Loka
– Tolmin
– Idrija
– Ajdovščina
– Sežana
– Ilirska Bistrica
– Vrhnika
– Postojna
– Domžale
– Kočevje
– Črnomelj
– Sevnica
– Šmarje pri Jelšah
– Lendava
– Slovenska Bistrica
– Radlje ob Dravi
– Litija
– Ivančna Gorica
– Velenje
Urgent care centre
The urgent care centre is an independent department of a hospital dedicated to helping the potentially critically ill or injured. This includes triage, as well as disease, trauma and emergency care units. Urgent care centres also include mobile emergency care units.
These are the proposed locations for a network of urgent care centres:
– Ljubljana*
– Maribor
– Celje
– Brežice
– Izola
– Jesenice
– Murska Sobota
– Trbovlje
– Slovenj Gradec
– Novo mesto
– Nova Gorica
– Ptuj**
* The Urgent Care Centre in Ljubljana is not yet operational, as the Ljubljana emergency room is still separated into several units, including the University Medical Centre Ljubljana’s Internal Medicine Emergency Care Unit and the General Emergency Medical Services of the Ljubljana Health Centre.
**The Ptuj Urgent Care Centre has not yet been built.
Source: Ministry of Health, proposal of the Ministry’s expert group on the reform of the emergency medical care network
While reorganisation is necessary, certain interventions could make the situation even worse. Among other things, we should find the reason why young people do not choose to specialise in emergency medicine – even though they are usually interested in it. The fact is that the profession of an emergency doctor is a demanding one, and it is difficult to be an emergency doctor for the whole of one’s career – in the UK, a study of the deaths of 8556 doctors found that the length of a doctor’s life is correlated with his or her specialty: general practitioners live the longest – 80.3 years, surgeons 79.9 years, anaesthesiologists 75.5 years, and emergency doctors have the lowest life span, at just 58.7 years. Prosen told the Delo newspaper some time ago that it is essential to introduce relief measures for emergency doctors and nurses so that they can cope with the rigours of their work throughout their 40 years of work. He also said that 500 specialists in emergency medicine would be needed to fill all the positions in emergency care centres and pre-hospital emergency care. Unfortunately, no amount of reorganisation will make up for the shortage of doctors, and we also need to figure out why there is a shortage of family doctors, a specialty that is much more respected abroad.
Sara Kovač
