This fee rose from €5 to €20 at the start of April, as did the visit fee for emergency medicine departments, with the hope being that this would reduce the number of people presenting at ER with non-emergency issues.

However, hospitals say they are operating in much the same way as they did before the visit fee increase, with no significant change in the number of patients attending ER in the intervening months.

A change in the profile of referrals has been observed, however, at the North Estonia Regional Hospital (PERH), said Marit Märk, its ER head.

"Older patients with chronic diseases now prefer to receive services from their family doctor, where it is free. A working-age patient still comes to our emergency department with a minor health concern and is prepared to wait longer to receive this service on the same day. They have not even contacted their family doctor or the family doctor's advice line in advance; they come based on their self-assessment that it is a serious health concern to get help from us," Märk said.

The number of referrals to PERH is still very high, she added, with an average of over 200 patients passing through ER per day.

About half of these come by ambulance, the remainder are self-referrals, most of whom have relatively minor health problems which do not require emergency care.

PERH for this reason also instigated a new system at its ER in May, where patients with milder concerns receive help and advice from specialist nurses on hand.
"It's not easy and the numbers of patients are very large, so I can't say at the moment that our workload has become significantly lighter. That's why we see that further changes are necessary," Märk noted.

Across town at the East Tallinn Central Hospital (ITK), a similar pattern has been seen – the hike in visit fees has not had any discernible impact, Kristiina Mäemets, head of ER, said.

However, summer always brings more patients, with doctors on vacation and people getting out and about more, including to play sport, Mäemets noted, and this summer has been no exception.

ITK too is developing a specialist nurse reception system to reduce the burden on doctors.

Both PERH and ITKH say they hope to add cooperation with family doctors to this, so that in the future patients with minor health problems can be referred to the family doctor system after being examined by a triage nurse. However, this still requires coordination.

Märk said, "this is still a decision across healthcare and cooperation is definitely with the primary care level, the Ministry of Social Affairs. We will have these negotiations in August to first map out what kind of patient population we can refer back to the family doctor from triage, and secondly, whether we have enough competent nurses to work in triage so that we can do it responsibly."

Hospitals hope to refer non-urgent ER patients to family doctors on weekdays, but Mäemets noted this depends on family doctors being both prepared and available to handle the extra workload.

Mäemets said ER departments still "have to receive all" patients and assess the urgency of their condition, but many cases could be handled by family doctors instead — if patients made contact first.

She noted, however, that some don't try at all, while others say they "can't reach" their doctor or feel the doctor "doesn't want to see" them.

Tartu University Hospital is also creating a similar system. Aime Keis, acting head of the ER department, said: "This has also been an option in the past for nurses to send people away with simpler problems, such as dressing abrasions or counseling for viral diseases, for example."

Keis said many people come to the ER with minor issues like a cough or runny nose due to "serious health anxiety" or fear of pneumonia, even though family nurses often respond quickly via phone, email, or the perearst24 system. She stressed the need for greater public awareness about what qualifies as an emergency and how to properly access the family doctor system, which usually starts with contacting a nurse.

Marit Õun of Pärnu Hospital meanwhile said ER visit numbers haven't changed much year-on-year, but summer always brings more cases due to traumas, heatstroke, and alcohol use — alongside a growing number of elderly patients facing social issues like isolation and lack of care.

Märk noted that warmer weather and humidity have led to the spread of viruses, with more chronically ill patients developing serious infections like pneumonia and arriving by ambulance. She added that alcohol-related ER cases also rise in summer, especially on weekends, saying: "In winter, it's more around paydays or retirement days, but in summer it's tied to events and weekends."

The fourfold hike ER specialist visit fees, to €20, introduced in April, did not immediately alleviate wait times or patient numbers, West Tallinn Central Hospital (LTKH) chief doctor Arkadi Popov said at the time.

Ilona Pastarus from Tartu University Hospital said in late April that patients now expect faster service for the higher fee.

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