The State Audit Office of Latvia has concluded in the audit that palliative care is not a full-fledged part of healthcare in Latvia because the prerequisites have not been ensured to create a palliative care system in accordance with the needs of patients, and it is not provided effectively at all levels of healthcare.
BRIEFLY:
- Palliative care includes treatment where pain relief is important, hospice care during the last six months of a patient’s life, social, psychological and spiritual support, as well as support for the patient’s loved ones during his or her illness and mourning.
- This year, a mobile team service was introduced at a place of residence, which is essentially a hospice care service.
- In 2022, 12 thousand people received state-paid palliative care, but in reality, the number who would need this service is almost twice as high.
- Outpatient palliative care services are critically insufficient, as a result of which most patients end up in hospitals whose capacity is already insufficient.
- Different palliative care services and conditions for receiving them result in unequal treatment of patients with the same healthcare needs.
Palliative care is a set of multidisciplinary services that improve the quality of life of patients and their families who face a life-threatening and incurable disease, preventing the further development of the disease as much as possible, as well as preventing and alleviating physical pain and moral suffering. As a disease progresses, treatment loses its importance gradually, while the need for palliative, including end-of-life or hospice care increases. Palliative care and hospice care share the same goal, so these terms are often used interchangeably. However, hospice care is only provided during the last six months of a patient’s life.
“Considering that in the case of a life-threatening and incurable disease, a patient’s rights do not end and that one of the most essential needs is pain relief, the right to palliative care is both a moral requirement and a human right. Palliative care is provided by general practitioners (GPs), other medical personnel in both outpatient clinics and inpatient hospitals, as well as social service providers, but a scope of specialized services is extremely limited in practice and no one is really liable in general. Therefore, the well-being of many palliative care patients depends on determination and ability of their relatives,” emphasised Ms Maija Āboliņa, Council Member of the State Audit Office of Latvia.
Palliative care is not provided to all patients who might need it. For example, 12,000 patients received state-paid palliative care in 2022 while according to the estimate of the State Audit Office of Latvia, at least 21,000 people would have needed it. The audit has found that this is once again the case when the Ministry of Health does not have data, that is, data about the needs of palliative care in the country. It only has data on palliative care patients who have already received some service.
According to international best practice, the need for palliative care for a specific patient is determined taking into account his or her health condition and symptoms of a disease. In its turn, in Latvia, palliative care is attributed to certain diagnoses, whose list lacks several of the most common diagnoses indicated by the World Health Organization, whose patients might also need palliative care. In addition, there are specialised palliative care services (for example, in hospitals) in Latvia that can only be received by patients with certain diagnoses.
The State Audit Office of Latvia also indicates that there were only 15 certified palliative care specialists in the country in 2023, 10 of whom were of working age, but only one has indicated work in the palliative care specialty as their main job. It is predicted that a number of specialists will have decreased to seven by 2030.
Outpatient palliative care services are critically insufficient. Although palliative care patients receive healthcare services in GPs practices in general, only a fifth of these patients received more extensive healthcare (e.g., glucose regulation, wound care, blood pressure measurements). For palliative care patients who are becoming dependent on others gradually, healthcare at home (for example, medication administration, enteral tube feeding, urinary indwelling and stoma care) is an essential service, but no more than 3% of these patients received it. In more complicated cases, a little more than 100 people a year received specialized palliative care from a palliative care specialist or in a palliative care office; moreover, regional coverage is very limited and most consultations are provided in the capital, Riga.
A mobile team service at a place of residence is one of the solutions for improving the availability of outpatient palliative care that was introduced this year, which is a hospice care service upon its merits. The State Audit Office of Latvia welcomes the expansion of the range of palliative care services, but it is currently too early to judge its effectiveness, and the service is planned for a small number of patients in 2024 (3,078 palliative care patients).
Due to insufficient outpatient palliative care services, patients end up willy-nilly in hospitals. International practice confirms that only a small percentage of palliative care patients require complicated examinations and manipulations that can only be provided in hospitals. In its turn, a data analysis carried out during the audit shows that a total of 50% of palliative care patients were placed in hospitals (in palliative care and other profile departments) in Latvia, and most of them received specialized palliative care in higher-level clinical university hospitals. However, the capacity of hospitals is not sufficient that is evidenced by queues, an actual number of hospitalizations, which is lower than planned at the beginning of a year, and unspent funding. Currently, palliative care services are provided by seven of the nine hospitals that qualify to provide these services, but the National Health Service has not identified the capacity of all of them to provide palliative care services, which is essential for regional access.
At the same time, the audit estimated that a required number of beds for palliative care, including hospice, could be from 94 beds (only for the care of oncology patients) to 188 beds in Latvia, but there are only 92 beds in total in hospitals currently.
The content of palliative care (especially in hospitals) is not standardized, so it varies in practice. Only this year, the comprehensive definition of palliative care included in the Medical Treatment Law took effect, to which only a mobile team service at a place of residence corresponds among the existing palliative care services. In addition, this is the only service available directly to palliative care patients that includes both healthcare and social components.
Besides, the State Audit Office of Latvia draws attention to the fact that there have not been adequately registered palliative care clinical guidelines for adult patients for a long time in Latvia, which could be applied in treatment, quality control and supervision. It is not defined what kind of staff should be provided, what services should be provided, whether the palliative care unit should be provided with continuous medical supervision, what privacy requirements should be ensured, etc. In addition, there are no plans to determine mandatory quality indicators for palliative care in hospital, thus preventing the assessment and targeted improvement of this service. In contrast, appropriate quality indicators are essential to prevent the trend according to the recommendations of international organizations that evaluating the quality of healthcare in hospitals by mortality rates encourages the avoidance of treating dying patients.
“Different palliative care services and the conditions for receiving them create confusion not only for patients, but even for service providers and raise questions about equal opportunities for palliative care patients,” stated Ms Āboliņa.
Adequate funding cannot be planned without data on an actual number of palliative care patients. The Ministry of Health also does not have information on the actually spent funding for providing palliative care. According to the auditors’ estimate, an average of 1.1 million euros was spent annually in 2020-2022 to pay for outpatient palliative care services, and according to the information provided by the National Health Service, an average of 2.4 million euros annually was paid for the provision of hospital palliative care services. In its turn, funding of 6.8 million euros is planned for the new mobile team service at a patient’s place of residence (not including the social component) in 2024.
According to the auditors’ estimation, the provision of outpatient palliative care services is generally more cost-effective compared to inpatient hospital services. When the palliative care service is organised correctly, a patient can receive the most suitable care for him or her at the given time and it would cost less to the government in general. At the same time, excessive costs of the palliative care office and a small number of unique patients (an average of 38 patients per year) create a basis for deciding on the future operation of palliative care offices.
In addition, the State Audit Office of Latvia draws attention to deficiencies in the calculation of healthcare tariffs and the bureaucratic terms and conditions for payment of healthcare services. In the case of inpatient palliative care, a tariff for the treatment of one patient determined by the Cabinet of Ministers is not calculated according to the methodology of the National Health Service. As a result, hospitals have lost almost a million euros in four years. The audit has discovered at the same time that university and regional hospitals actually provide different palliative care services, therefore, in the opinion of the State Audit Office, it is not economically justified to set the same payment. According to the calculations of the State Audit Office, savings of 58,000 euros would have occurred over a three-year period in the case of a differentiated tariff, which, for instance, would have enabled 40 patients to receive palliative care at a university hospital.
The audit has also found consecutive hospitalization of patients under palliative and chronic patient care programs. This is explained both by a fixed payment determined in the case of palliative care, regardless of the duration of the care for a patient, and by the lack of targeted monitoring of service provision. Due to the mentioned reasons, hospitals re-register a patient in the next program in practice when a number of bed days included in the tariff calculation “runs out”. Thus, hospitalization statistics is increased by creating an incorrect impression of institution’s workload and service demand and by affecting the funding for the current and future periods because one patient is paid for and allocated funding in several service programs in fact.
Recommendations of the State Audit Office #PēcRevīzijas
After the audit, two recommendations were issued to the Ministry of Health, which if implemented no later than by 2029 will result in (1) the public sector having complete and up-to-date data on patients who, according to their needs, would need palliative care and who actually receive it; (2) at least 69% of the population will be able to receive palliative care before death similar to other developed countries; (3) developed outpatient palliative care, which will be the most suitable and cost-effective for patients, and thus reduced workload of hospitals, similarly to other developed countries by hospitalising no more than 20% of palliative care patients.
Additional information: audit report summary
About the State Audit Office of Latvia
The State Audit Office of the Republic of Latvia is an independent, collegial supreme audit institution. The purpose of its activity is to find out whether the actions with the financial means and property of a public entity are legal, correct, useful and in line with public interests, as well as to provide recommendations for the elimination of discovered irregularities. The State Audit Office conducts audits in accordance with International Standards of Supreme Audit Institutions of the International Organization of Supreme Audit Institutions INTOSAI (ISSAI), whose recognition in Latvia is determined by the Auditor General. Upon discovering deficiencies, the State Audit Office of Latvia provides recommendations for their elimination, but it informs law enforcement authorities about potential infringements of the law.
Additional information
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