Based on a questionnaire sent to all healthcare centres in Slovenia, the Ombudsman found unacceptable differences in responsiveness between general and family medicine clinics and thus consequently in accessibility of healthcare services. The Ombudsman determined that it is difficult to monitor the suitability of access since there are no unified standards and criteria as to what good accessibility means. The Ombudsman informed the Ministry of Health of its findings and recommendations for the improvement of the situation. The Ministry communicated these forward to healthcare centres on the primary level. After their first responses that the concept of necessary/equal accessibility needs to be very clearly defined so that all aspects of all stakeholders will be considered, the Ministry decided to organise a consultation on the subject. The Ombudsman believes that the consultation can be an opportunity to exchange opinions and search for solutions to improve accessibility to clinics on the primary level, as well as for the transfer of best practices in this field which already exist in individual healthcare centres with the purpose of ensuring equal access to patients, since the existing situation is inadmissible.

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The Human Rights Ombudsman of the Republic of Slovenia (Ombudsman) received several complaints from patients complaining about poor accessibility of clinics on the primary level. These complaints included, for example, non-functioning electronic systems for making appointments or the complexity of using them, (too) long response time of clinics to patients’ e-mails, clinics not responding to e-mails, clinics not answering telephone calls during working hours, constant occupation of clinics’ telephone lines, etc. Hence, at the beginning of 2023, the Ombudsman sent a questionnaire to all healthcare centres asking about the accessibility or availability of their general and family medicine clinics (clinics). The Ombudsman was primarily interested in which communication channels patients can use to communicate with the clinics and how communication over an individual channel is arranged (in person, over the telephone, via e-mail, through the provider’s webpage or portal). A total of 46 (79%) healthcare centres responded to the questionnaire.

The replies of healthcare centres revealed that great differences exist between clinics in the manner of how patients can access clinics or in what way they can communicate with them and what they can arrange in this manner.

Almost all healthcare centres stated that the clinics are available for patients via telephone throughout working hours (which is in accordance with the Rules on the referral of patients, the management of waiting lists, and the maximum permissible waiting times), but that actual accessibility depends on the current workload of the clinics, the nature of their work, and their organisation. If unavailable, clinics act differently: the majority keep records of unaccepted calls and return them, while there are some who do not call back with an explanation that calls in such cases are (generally) transferred elsewhere (e.g. to the clinic’s reception office, to information, to the call centre). If by the time they stop working the clinics do not manage to return the call, most of them return calls the next day.

However, complaints received by the Ombudsman show a different picture. Patients frequently complain to the Ombudsman that they do not manage to get through to their clinics (even after several dozen attempts) and that clinics do not return calls. Thus, the Ombudsman proposed to the Ministry of Health (MZ) to form guidelines for healthcare centres which will unify the actions of clinics in case of unavailability over the telephone. Presuming that clinics will actually return unaccepted telephone calls, the Ombudsman suggested that an automated response would inform patients that their call will be returned or that it can be returned and by when and that in the next step the patient could choose whether they want the clinic to return their call (because occasionally patients choose a different communication channel if the clinic is not available over the telephone). The Ombudsman believes that this could reduce the pressure on telephone lines, while patients would not be left unsure of whether they will be able to contact the clinic or not.

Healthcare centres have mostly abandoned or significantly limited communication via e-mail. For safety of communication and appropriate traceability they have started communicating via their websites or portals. One of the problems with e-mails is how to check the identity of the e-mail sender. Most of the healthcare centres have a deadline in which a clinic is supposed to react to a patient’s e-mail and answer it; most often it is three working days, while the longest stated response time was three to five working days. Some healthcare centres do not have a deadline determined for replying to a patient’s e-mail. Therefore, the Ombudsman believes that the response time to a patient’s e-mail should be defined and unified and that patients should be notified about it in an automated reply, with which the healthcare centre also confirms receipt of the e-mail.

Patients can arrange for sick leave or order a prescription or a referral via the provider's website or portal. Most clinics also make it possible to make an appointment for an examination in the portal. It also enables (depending on an individual healthcare centre) the sending of messages, an e-consultation, exchange documentation, ordering transfer of medical records to another doctor, order a laboratory appointment, etc. The healthcare centres use different portals. As a rule, patients can send an order/message 24 hours a day, seven days a week, but there are also exceptions to this rule. Healthcare centres mainly differ in whether they enable the patient the possibility to submit a new order or start a new e-consultation if the previous one has not yet been processed by the clinic or if it has not yet been concluded. The most frequent expected (defined) response time of clinics to such a message submitted over the website or portal is the same or the next working day or three working days. The longest expected response time stated by one of the healthcare centres was (from one) up to seven working days. Some healthcare centres inform the patient when submitting an order/message over the webpage or portal about the time in which the order/message will be processed, while others do not. In some cases, the patient can follow the status of the order/message, while other healthcare centres do not offer this possibility. One third of the healthcare centres that answered the Ombudsman’s questionnaire monitor response times of their clinics. Monitoring is conducted in different ways, while findings of the healthcare centres are similar, i.e. that there are no particular discrepancies or that there are practically no backlogs. The Ombudsman believes that at least the longest (admissible) response time should be unified. The response time of seven days is too long and hence unacceptable. At the moment they submit an order/message patients should be informed with an automated response not only about the fact that their order/message has been received but also about the maximum time in which it will be answered or processed. The Ombudsman believes that a patient should be enabled the possibility to submit an order/message 24 hours a day, seven days a week, to monitor the status of the order/message, and to submit a new order/message even if the processing of the previous order/message has not yet been concluded.

Every communication channel undoubtedly has its advantages and disadvantages. The advantages of communicating through a portal can, for example, be quick and safe forwarding of test results, traceability, the possibility of insight into one’s own medical records, and an overview of prescriptions, issued referrals and medical-technical aids, sick leave, etc. All this improves the awareness of a patient and, in the opinion of one of the healthcare centres, reduces the administrative burden on medical staff. Since not all doctors decide to use the portal, even though they have this possibility, the Ombudsman suggested that doctors, who (still) do not use the portal even though they have that possibility, be encouraged to use it.

Only a third of healthcare centres monitor the response time of their clinics. Therefore, the Ombudsman recommended the duty of monitoring the response time of individual communication channels, with the option of supervision (for example for checking the grounds of potential complaints from patients about the unresponsiveness of a clinic).

Healthcare centres reported to the Ombudsman about a different share of patients using a healthcare centre’s website or portal to communicate with the clinics. The smallest estimated patient share is under 1%, while the largest is 70% of all patients of a healthcare centre. Approximately one third of the healthcare centres estimated a share up to 10% and a half between 20 and 50%. Answers to the question of how a healthcare centre provides assistance to patients with registration and use of the web portal varied: a patient is assisted at the clinic, over the telephone and e-mail, in the reception office, at the info point or via the call centre (of the healthcare centre or the portal provider). Written forms of assistance are brochures and website instructions and help. Some of the healthcare centres find that older patients are not skilled in using newer information-communication technology or do not have it at their disposal, therefore they cannot communicate with the clinic in this manner. Considering this, the Ombudsman believes that it is crucial to improve telephone responsiveness of clinics and thus enable equal accessibility to those patients who are not computer literate. The Ombudsman believes that cases when, due to telephone unresponsiveness of a clinic, patients have poorer access to a doctor or a clinic are unacceptable. In addition, the Ombudsman thinks that the number of communication channels patients have at their disposal with an individual healthcare service provider is not as important as the responsiveness of a healthcare provider and the possibility to communicate with the healthcare staff when a patient needs it.

The Ombudsman also asked the healthcare centres about the number and content of complaints they received in 2022 regarding accessibility to clinics. The answers revealed that the most complaints pertained to telephone (in)accessibility, patients most frequently complained due to the occupation of telephone lines. Based on the complaints received, the Ombudsman estimates that patients generally prefer direct communication with a healthcare provider over the telephone, since they consider such communication more appropriate and more efficient from other communication channels. Considering everything stated above, the Ombudsman believes that more attention should be devoted to the accessibility of clinics, most specifically the improvement of telephone communication. The healthcare centres state as one of the main reasons for problems in clinic accessibility over the telephone to be the lack of staff and consequently the existing staff are overworked. Along with the option of diverse manners of making appointments, which the healthcare centres consider an advantage, they also warned that there is a significant lack of staff for efficient management of all appointment systems and the normal course of business in clinics. Regarding this, the Ombudsman is of the opinion that for the good operation of the healthcare centres (or clinics) and the healthcare system as a whole, the search for solutions in the field of staffing is crucial.

A summary of the Ombudsman’s recommendations and opinions:

1. The Ombudsman detects great differences in the responsiveness of clinics and thus consequentially in accessibility to healthcare services which need to be eliminated.
2. The Ombudsman proposes to the MZ that guidelines be formed for healthcare centres with which the actions of clinics in the event of their unavailability over the telephone will be unified. The Ombudsman proposes that patients be notified using the automatic telephone response whether their call will be returned or that it can be returned and by when and that in the next step the patient selects whether they want a return call from the clinic.
3. The Ombudsman believes that the response time of a clinic to a patient’s e-mail should be defined and unified and that patients should be informed of it in an automated reply, with which the healthcare centre confirms receipt of the e-mail.
4. The Ombudsman believes that the longest (admissible) response time of a clinic for the order/message of a patient sent over the website or portal should be unified. Patients should be informed with an automated response immediately after the submission of an order/message not only about the fact that the order/message was delivered but also about the maximum time in which it will be answered or processed. The patient should be enabled the possibility to submit an order/message 24 hours a day, seven days a week, to monitor the status of the order/message, and to submit a new order/message even if the processing of the previous one has not yet been concluded.
5. The Ombudsman suggests that doctors who do not (yet) use the portal, even though they have the possibility, be encouraged to use it.
6. The Ombudsman recommends the duty of monitoring the response time according to an individual communication channel, with the option of supervision in case of checking the grounds for potential complaints of patients regarding the unresponsiveness of a clinic.
7. The Ombudsman believes that it is essential to improve telephone responsiveness of clinics and thus enable equal access to healthcare services for those patients who are not computer literate. The Ombudsman believes that cases when, due to telephone unresponsiveness of a clinic, patients have poorer access to a doctor or clinic are unacceptable.
8. The Ombudsman believes that for a good functioning of healthcare centres and the healthcare system as a whole, the search for solutions in the field of staffing is also crucial.

The Ombudsman estimates that the consultation can be an opportunity for the exchange of opinions and search for solutions for the improvement of accessibility to clinics on the primary level, as well as for the transfer of best practices in this field, which are already undertaken by individual healthcare centres, and thus welcomes the ministry’s decision. 9.4-54/2023