Efforts of the Ministry of Health, the National Health Fund and the National Institute of Geriatrics, Rheumatology and Rehabilitation were uncoordinated and fragmentary. As a consequence, there are still no laws in place defining standards of geriatric care, its organisation and functioning. The Comprehensive Geriatric Assessment has been mainly designed to evaluate the patient’s condition and to plan a comprehensive therapy and rehabilitation. Only half of the audited hospitals fully used that tool, though.
The NIK audit showed that from 1 January 2017 to 6 October 2021 in five provinces the key geriatric care availability ratios remained unchanged or got even worse. In one province there was one specialist per over 60 thousand elderly persons. Geriatric care was best organised in Śląskie Province (in the South of Poland). At the same time, though, this is where waiting times were the longest (even more than two months). For NIK, it means that elderly persons are willing to take benefit of geriatric care if it is provided near their place of residence.
According to specialists, geriatric care – presenting a more holistic approach - is more effective than conventional medicine which is traditionally focused on individual diseases. It helps elderly persons to function in a more comfortable and independent way for a longer time as it:
- reduces the risk of the elderly person’s death (by 22% after a year of hospital intervention, by 14% for all);
- makes it more probable for the elderly person to continue living in their own home (by 47% after a year of hospital intervention, by 26% for all);
- reduces the risk of the elderly person’s hospital readmission (by 12%);
- increases chances to improve the elderly person’s functional condition following hospital intervention (by 72%).
Statistics show how important it is for geriatrics to become a priority branch of medicine. For 30 years now, Poland has experienced a demographic development slowdown and significant changes in the age structure of Polish citizens. In line with the data of the Central Statistical Office, there were approximately 38.3 million people in Poland at the end of 2021, including 22.3% of individuals in the post-productive age (60+), in 2020 it was less than 17%. According to the demographic development forecasts, nearly ⅓ of Polish citizens in 2050 will be 65 or more.
Doctors not interested in geriatric specialisation
The primary problem in geriatrics – still unsolved – is the shortage of specialists. The expertise prepared for NIK indicated that in the EU countries the number of geriatricians per one million citizens ranges from 16 to 50, whereas in Poland it is less than 13.
In line with the data of the Chamber of Physicians and Dentists of 30 June 2021, there were 518 professionally active geriatricians in Poland. Only 101 physicians completed the specialisation programme in the last five years (until July 2022) as the interest in this branch of medicine has gone down in that period. In 2017-2019, only two resident doctors chose geriatric specialisation, three in 2020 and only one in 2021. That is why in 2017, 52% of professionally active geriatricians were 50+ years old, in 2018 it was 55% and 56% in 2020.
The NIK audit results confirmed that the number of geriatricians was insufficient in the audited period. Doctors working in the audited facilities under civil law contracts often performed their duties for over 24 hours without any break (usually from 31 to 35 hours). In an extreme case it was 10 days without a break. NIK stands in a position that this situation may have an adverse impact on the quality of medical care provided by geriatricians and pose a threat both to patients and doctors. As opposed to full-time employees, in case of persons working under civil law contracts, laws concerning the amount of working time and related norms do not apply.
The NIK audit revealed that the number of geriatricians and qualified nurses was insufficient. In the audited period as much as 60% (6 in 10) of the audited hospitals did not meet the headcount requirement. The shortage of nurses, who often take care of elderly, dependent persons could pose a threat to the patients’ safety.
The shortage of geriatric doctors and nurses in geriatrics was particularly noticeable in five provinces in the audited period. In Świętokrzyskie Province, there was one geriatrician per over 60 thousand inhabitants.
According to the former national consultant, there should be 3000 geriatricians in Poland as a target. In his opinion, considering the doctors’ decreasing interest in this specialisation (observed since 2017), the staff shortages issue cannot be solved, even in part, if the effective healthcare services pricing schemes and organisational solutions are not changed at several levels: the government, the parliament, the Ministry of Health and the National Health Fund.
Unequal access to geriatric care
The shortage of geriatricians was the key barrier to proper care of the elderly. As of 1 September 2021, there were only 1140 geriatric beds available for patients 65+, which is 15% of the forecasted demand. In order to achieve the target assumed in the Roadmap of healthcare needs in hospital treatment for Poland, the number of hospital beds would have to be nearly seven times higher by 2029.
In all the audited provinces, the regional healthcare policy priorities highlighted the need for the geriatric care development. That was not reflected in the level of funds earmarked for geriatric care services, though. In the audited period, all the geriatric units covered by the audit earmarked PLN 90.5 million in total for that purpose, of which PLN 86.2 million for hospital treatment (these are only estimates as a hospital network was under construction at that time) and PLN 4.3 million for geriatric care services in outpatient clinics.
The cases of not providing services under contracts were mainly related to ambulatory specialist care. Their value in the audited period in individual provincial branches of the National Health Fund ranged from PLN 128 thousand to PLN 1 million. According to the branches’ directors, the services were not provided mainly because patients did not turn up for appointments.
The most frequently identified medical conditions of geriatric patients included: arterial hypertension (60%), depression (52%), urinary incontinence (48%), collapses (41%), dementia (35%), diabetes (31%), heart failure (27%), peptic ulcer disease (22%), protein-calorie malnutrition (20%), delirium (19%), iatrogenic syndrome (17%), chronic kidney disease (17%), Parkinson's disease (16%) and cancers (9%).
In the audited period the biggest number of patients took advantage of geriatric care in Śląskie Province (Silesia). Besides, that region had the highest ratio of patients in relation to the number of the province inhabitants entitled to geriatric care. In Śląskie Province it was 4%, whereas in other provinces this ratio ranged from 1% to 2%. On the other hand, in Śląskie Province the elderly had to wait the longest for admission to geriatric unit or appointment in geriatric outpatient clinic. In 2020, the waiting times exceeded two months in stable cases and in urgent cases they reached 39 days. The availability of geriatric care was also limited in the audited period due to the COVID-19 epidemic. As many as eight in ten audited hospitals had to limit or suspend treatment in geriatric units.
Recommendations
To the Minister of Health to:
- create a system of organisational and financial support for medical facilities, to help them decide to create new geriatric units and outpatient clinics;
- make geriatrics a more attractive specialisation for doctors;
- implement geriatric care standards as universally binding provisions of law, under the Act on Medical Activity.
To governing bodies of medical facilities to:
- take measures to eliminate cases where doctors working times were too long (even several days without any break) under civil law contracts.
