Iceland’s Universal Healthcare (Still) On Thin Ice

One year ago, Iceland’s lauded universal healthcare system seemed to be teetering off the edge. Doctors’ wages had stagnated after the economic crash, and following a bout of failed negotiations, they went on strike for the first time ever. While they coordinated their actions to avoid endangering patients’ lives, the doctors’ message was clear: if demands were not met, they would seek employment elsewhere.

Coupled with years of tough austerity measures, faltering morale, and an infrastructure in dire disrepair, there was not much slack to give. In an in-depth analysis, we at the Grapevine tried to figure out what, exactly, was going on, and where we were headed.

Not much has changed since our healthcare feature ran in December of 2014. Sure, Landspítalinn—the National University Hospital—is still standing, and its employees are still working. Nevertheless, it’s been a tough year. Here’s a rundown of what’s happened since.

Collective agreement, systematic failure

The doctor’s strike came to a close on January 7, eleven weeks after it commenced, with a new agreement promising wage increases and better working conditions, such as time off in lieu of paid overtime. The strike worked.

Last year we spoke to Dr. Íris Ösp Vésteinsdóttir, then head of the Icelandic Association of Junior Doctors, who was worried about what would happen if job prospects remained dour for newly specialised doctors, as 35% of Icelandic specialists are slated to retire in the next decade.

At the time, she said that Icelandic wages were far from competitive, and with modern technology it was increasingly easy to stay in touch with loved ones from abroad. She said: “Since the economic crisis started, healthcare professionals have been driven hard for a long time, and now they are tired and want something in return.”

Dr. Íris has a more optimistic outlook on the current situation. She says that the contract benefits some wards more than others, with base rate wages increasing 11-27% over a three-year period.

“What’s bad about this situation, however,” Dr. Íris says, “is that the payroll comes out of the hospital’s budget, and the directors say they didn’t receive increased funding to accommodate these changes. They are therefore restructuring the shifts, as they can’t grant doctors the time off their contract commands.”

Despite this, the word on the street is that doctors are happy with their new contract, Dr. Íris tells me, with number of doctors making arrangements to return from studies or positions abroad.

Strike after strike

While doctors were successful in their negotiations with the state, the rest of Iceland’s healthcare workers’ attempts to secure better wages and working conditions proved less fruitful. Negotiation efforts saw numerous unions with ties to Icelandic healthcare banding together, forming a wave of strikes. BHM (The Association of Academics), to which radiologists and many other hospital workers belong, undertook a particularly long strike, with coordinated work stoppages occurring from October 27, 2014 to October 28, 2015. In May, the Icelandic Nurses’ Association voted to strike if their demands were not met. The government came down hard, forcing through legislation that effectively banned any further strike actions on the nurses’ behalf. Thoroughly unamused, Iceland’s nurses responded by resigning en masse.

As summer drew to a close, an arbitration committee ruled in the nurses’ favour, determining that they deserved a 21.7% wage increase over the next four years. However, the damage was already done.

Thoroughly unamused, Iceland’s nurses responded by resigning en masse.

Ólafur G. Skúlason, chair of the Icelandic Nurses’ Association, tells me that out of the 300 nurses that resigned from Landspítalinn, some did not return to work. In fact, he says that even though there are funds to hire an additional 100 nurses at the hospital, there are simply not enough applicants left in the country.

“This staff shortage adds even more pressure onto the nurses working at the hospital,” he says, “and it will only get worse, as around 900 nurses countrywide will reach retirement age over the next three years.
“Research shows that well-manned shifts lead to better patient care, a lower mortality rate, fewer complications and shorter hospital stays, as well as being more cost-effective,” he says. “It’s obvious that a healthcare system that doesn’t have enough nurses cannot ensure the same levels of patient safety as a well-staffed one.”

Retired GP Dr. Haukur S. Magnússon, who has practiced medicine since 1961, concurs, adding that both research and experience show that when the primary care and family medicine facets are well manned and easily accessible, general health improves across the board, alleviating pressure from the rest of the system.

Cumulative effects

The eleven-week doctors strike led to the delay of 790 elective surgeries. The spring strikes resulted in 900 more being postponed. Statistics provided by Landspítalinn show that in October, 4,023 individuals had been awaiting operations for three months or longer, compared to 3,058 at the same time last year—a 32% increase.

Dr. Íris says this year has seen numerous outpatient appointments delayed, and the shelving of diagnostic operations such as X-rays and blood tests. While she maintains that essential tests are being performed, she struggles with answering whether or not people’s lives have been at risk. “There have certainly been instances where I have wished I’d seen a blood test earlier, or known about something sooner, or seen a person get somewhere quicker.”

“If we got a chance to work in peace and made a concentrated effort, we could cut the waiting times down, but right now it’s like we’re always chasing our own tail.”

Some departments were particularly badly affected, such as the hospital’s gynaecology ward, which disclosed in November that a chronic shortage of surgical nurses meant they could only keep two out of three operating rooms running. Some 275 women await pelvic floor operations at present—and the department has only been able to perform thirteen such operations per month this year, as opposed to eighteen in 2014, resulting in waiting periods stretching upwards of two years. Speaking to newspaper Fréttablaðið, senior physician Dr. Kristín Jónsdóttir remarked: “If we got a chance to work in peace and made a concentrated effort, we could cut the waiting times down, but right now it’s like we’re always chasing our own tail.”

Priorities

At this point, healthcare workers’ salary negotiations have been settled for the time being, and most of them are back to work, with no strikes on the horizon. However, those tasked with running Iceland’s healthcare system are still struggling with a weighty problem: securing the funds to keep it running.

Like every facet of Iceland’s healthcare system, Landspítalinn has already been subjected to numerous cost-cutting measures, even as records demonstrate that it is even more cost-efficient than the Swedish Karolinska University Hospital, a facility three times the size. Indeed, the hospital had been forced to operate on a shoestring budget even before the economic collapse. Naturally, frustrations at Landspítalinn have been steadily growing, resulting, among other things, in its former director, Björn Zoega, resigning in protest two years ago, declaring that he refused to take part in running the hospital into the ground

Last year, Landspítalinn’s operating budget was increased by one billion ISK, its first budget increase in over five years, with funds also allocated for the renewal of medical equipment and other functions. The 2016 budget, however, has drawn more ire than praise from the hospital staff. In the last two weekly newsletters to his staff, University Hospital director Dr. Páll Matthíasson, PhD, criticised the government’s proposed 2016 budget for not being proportional to the tasks at hand. The problem, he argued, is threefold.

Firstly, there is the exorbitant cost of maintaining the hospital’s 130,000 square metre facilities, which spread out over 100 buildings. Secondly, the allocated funds fail to reflect foreseeable changes in Icelandic society’s composition, leading to a de facto 1.7% yearly retrenchment since 2010. Thirdly, payroll estimates from the Ministry of Finance seem to be the product of wishful thinking rather than the reality at hand, being routinely lower than the actual costs.

Páll also made it clear that the system’s ever-growing waiting lists would not get any shorter without the allocation of additional funds.

However, Páll praised the proposed budget for its stated intent of increasing funds for elderly care and the metropolitan healthcare clinics, which he believes will lessen the burden on Landspítalinn. Additionally, in early November, ground was broken for the first part of a long-promised state-of-the-art hospital, slated for completion in 2020. Páll estimates that the new hospital will save around 2.63 billion ISK per year once operational.

As before, the fate of Iceland’s healthcare system seems largely up to politicians and their priorities.

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See Also:

Squeezing Blood From A Turnip: Iceland’s Universal Healthcare At Risk
At present, the Icelandic healthcare system is arguably going through its most tumultuous period yet. The nation’s first doctors’ strike is in full effect. Medical staff are overworked and exhausted following prolonged austerity measures. Some hospital buildings are infested with mould. And so on.

Labour Legislation And Mass Resignation Of Icelandic Nurses
Residents of this country, as well as visitors to it, followed the news closely throughout May and into the early days of June, as talks of rolling work stoppages and an indefinite general strike loomed.