Iceland’s Doctors Drowning in Paperwork

Iceland’s Minister of Health will meet with the chair of the Icelandic Association of Family Doctors to discuss doctors’ criticism of excessive paperwork cutting into their time with patients. Doctors sent the Minister a list of demands last month and have now been invited to a meeting tomorrow.

“This means of course that the minister is listening to what we are asking of him,” Margrét Ólafía Tómasdóttir told RÚV, though she said she is keeping her expectations in check. “We’ve previously gotten to speak with the minister about these issues back and forth without anything changing.”

Preventing doctor burnout urgent

Margrét says doctors have been discussing the issue of excessive paperwork, particularly referrals, that are required within the healthcare system since 2016, but no administrative changes have been made. “It is clear that it’s first and foremost the paperwork that is wearing down doctors, not interaction with patients.”

Margrét says doctors want to eliminate all referrals and paperwork that “does not involve a true doctors’ professional assessment.” Doctors in Iceland are often required to write referrals for patients so they can see other healthcare professionals such as physiotherapists, speech pathologists, and others, or so that their appointments with specialists are covered by health insurance.

System demands referrals and certificates

GP Indriði Einar Reynisson recently wrote about the various certificates and referrals he is regularly asked to provide in a public Facebook post. Indriði stated that schools and workplaces sometimes require multiple doctor’s certificates from students and employees for the same illness. He also stated that the Social Insurance Administration (Tryggingastofnun, or TR) often required patients to send renewed doctor’s certificates every two months, although their situation was unchanged. In the case of one disabled patient, Indriði was required to send separate certificates confirming the patients’ status to over six different institutions.

Iceland Review has regularly reported on Iceland’s shortage of doctors as well as other healthcare professionals. Margrét says that patient interactions are what provide doctors with fulfilment on the job, “But when the majority of the working day becomes meaningless paperwork where your professional knowledge doesn’t get to be used, it must burn you out and cause people to leave the profession.”

Health Minister Pushes for Swift Regulations of Cosmetic Fillers

The Minister of Health, Willum Þór Þórsson, is pushing for regulations on the use of fillers in Iceland following concerns raised by the news programme Kompás. While the exact timeline remains uncertain, the Minister aims to have the regulations established this year, Vísir reports.

Hopes to implement regulations this year

The Minister of Health, Willum Þór Þórsson, is taking steps to implement regulations on the use of fillers in Iceland, aiming for clear restrictions by this year. This move comes after the investigative news programme Kompás highlighted the risks associated with the current lack of regulations on who can administer fillers.

As noted by Vísir, doctors have long advocated for such regulations, but their calls have gone unanswered. Yesterday, Minister Þórsson acknowledged the urgency, stating, “I have instructed the ministry to promptly utilise the regulatory authority found in the Medical Devices Act, alongside looking into the Health Professionals Act. The Directorate of Health would then oversee this, determining who is authorised to use these substances and ensuring they have the necessary expertise. That’s what’s missing.”

“Simultaneously,” the Minister added, “I’ve requested that we look at comprehensive legislation, similar to Sweden’s approach, though it might take longer.”

When asked about the specifics, the Minister couldn’t provide an exact date but emphasised the need for swift action. He hopes the regulations will be in place this year.

Welfare Committee Chair Calls for Regulation of Cosmetic Fillers

Injectables

The Chairperson of the Parliament’s Welfare Committee has formally inquired with Health Minister, Willum Þór Þórsson, about his plans to regulate the use of fillers and substances that dissolve them. Her concerns were prompted by an investigative report aired on Kompás this past Monday.

The “Wild West” of fillers

In an interview with Vísir yesterday, Bjarkey Olsen Gunnarsdóttir, Chair of the Parliament’s Welfare Committee, expressed her concerns about the use of fillers, a topic recently highlighted by the investigative news programme Kompás. The programme described the unregulated use of fillers as the “Wild West,” interviewing an Icelandic woman who suffered life-threatening complications from a misinformed treatment.

As noted by Kompás, in Iceland, substances are being used illicitly for cosmetic procedures, and there’s no oversight of unqualified individuals who often operate under misleading job titles.

“Even though one might have noticed on the streets, young girls with rather broad and large lips, knowing that substances were obviously being injected, the extent of this ‘Wild West’ situation was surprising,” Bjarkey commented.

Seeking clarity on potential regulations

Bjarkey also revealed to Vísir that she has reached out to Health Minister, Willum Þór Þórsson, seeking clarity on potential regulations for these substances: “I’m keen to understand the oversight in terms of use and importation. It’s unclear if these substances can be sourced from foreign online platforms. I’m also wondering if the Director of Health has mechanisms to track this and if there are records of medical interventions related to these substances. This is a grave concern, and I believe we must act,” she stated.

Bjarkey hopes that the discussion won’t fade in the coming days now that it has started.

What are fillers?

As noted by the American Board of Cosmetic Surgery, dermal fillers are “gel-like substances that are injected beneath the skin to restore lost volume, smooth lines and soften creases, or enhance facial contours.”

Fillers, especially those made of hyaluronic acid (a naturally occurring substance in the body), can be dissolved using an enzyme called hyaluronidase.

According to the American Society of Plastic Surgeons, the potential dangers of fillers include acne-like skin eruptions, asymmetry in the treated areas, bleeding from the injection site, bruising, damage to the skin leading to wounds and possible scarring, infection at the injection site, formation of lumps, the filler being felt under the skin, skin necrosis which involves ulceration or loss of skin due to disrupted blood flow, itchy skin rashes, skin redness, swelling, and the under- or over-correction of wrinkles.

“In very rare cases, the filler may accidentally be injected into your blood vessels instead of under your skin. This can block blood flow. What happens if your blood flow is blocked will vary depending on where the block is. If your skin is affected, you might have skin loss or wounds. If your eye is affected, you might lose your eyesight or go blind.”

Experts Alarmed by Surge in Daily Drinking Rates

bar beer alcohol

According to a physician at the National Centre of Addiction Medicine (SÁÁ), the surge in online alcohol sales poses a concern for public health. Over the past four decades, the daily alcohol consumption rates among patients admitted to the Vogur Detox Centre and Rehabilitation Hospital with alcohol-related issues has more than tripled, Vísir reports.

Improved access, increased consumption

At a Nordic conference on alcohol and public health held yesterday, the impact of increased access to alcohol on consumption rates was a focal point of discussion.

In his opening remarks, Health Minister Willum Þór Þórsson expressed concerns over the rising levels of alcohol consumption, emphasising the irrefutable evidence that greater accessibility leads to higher usage rates. “Undeniably, better access results in increased consumption. This is an empirical fact that we must acknowledge and confront, particularly in our preventive efforts,” Minister Willum asserted.

Daily alcohol consumption on the rise

Lára G. Sigurðardóttir, a physician at the National Centre of Addiction Medicine (SÁÁ), echoed the minister’s sentiments in an interview with Vísir. She highlighted statistics that indicate a significant surge in daily alcohol consumption.

Read More: IR speaks to Dr. Lára Sigurðardóttir about nicotine pouches

Data from the Vogur Detox Centre and Rehabilitation Hospital reveals that around 1990, approximately 17% of patients admitted for alcohol-related issues consumed alcohol daily. Fast forward to last year, and that figure has skyrocketed to 66%. “Moreover, over 70% of patients aged 50 and above are daily alcohol consumers. The trend is particularly pronounced among older demographics,” Dr. Lára noted.

Dr. Lára also expressed concerns over legislative pressures to privatise alcohol sales, a move she and other experts warn could exacerbate the issue. “That’s the alarm that all the experts today have been sounding,” she added, noting that the online sale of alcohol has greatly increased public access.

In conclusion, Dr. Lára advocated for the retention of a state monopoly on alcohol sales, citing its proven efficacy in preventive measures. “A state monopoly remains the most effective sales model for mitigating the public health risks associated with alcohol consumption,” she stated.

This article was updated at 08:56

Opioid Crisis: Over 1,730 Doses of Naloxone Distributed

A procedural change to the delivery of naloxone, a medication used to reverse or reduce the effects of opioids, has greatly increased its distribution; over 1,730 doses of naloxone nasal spray have been distributed to companies and organisations assisting individuals struggling with opioid addiction since the new procedure was implemented last year.

“Life-saving” medicine

As noted in a press release on the government’s website, a life-saving nasal spray containing naloxone is now more accessible nationwide as a first response to opioid overdoses. The revised delivery arrangement allows individuals to obtain the medicine at no cost. Opioid-containing substances, such as heroin, methadone, fentanyl, oxycodone, buprenorphine, and morphine, are examples of drugs where naloxone can be administered.

As noted by the press release, naloxone previously required a prescription directly from a doctor to the patient. Following a modification to the procedure last year, doctors have been allowed to prescribe the drug to companies or organisations assisting individuals struggling with opioid addiction and/or their relatives.

Furthermore, the Ministry of Health has covered all costs of the drug through a tender by the National University Hospital (Landspítali), responsible for inventory and distribution. Various entities, including health institutions, police departments, homeless shelters, the Icelandic Red Cross, and Reykjavík City’s Welfare Division, have benefitted from this arrangement. “Over 1,730 doses of naloxone nasal spray have been distributed to these parties since the new procedure was implemented.”

The press release further notes that to combat the growing problem of opioid overuse, the government recently announced that it had approved Minister of Health Willum Þórs Þórsson’s proposals, including an increased budget for expanded distribution of naloxone nasal spray.

“Following successful examples from other countries, the Ministry of Health aims to replicate their success in reducing opioid overdose deaths. Emergency responders and service providers assisting individuals with opioid addiction are encouraged to keep emergency doses of naloxone on hand for immediate treatment while emphasising the importance of seeking medical care afterwards for further treatment.”

Amendment Aims to Increase Reporting on Domestic Abuse

Nurses Hospital Landsspítalinn við Hringbraut

Health Minister Willum Þórs Þórsson’s bill to amend the Healthcare Practitioners Act has been approved by Parliament. The amendment clarifies the authority of healthcare professionals to report cases of domestic violence to the police.

Clarifies the authority of healthcare professionals

As noted in a press release on the government’s website yesterday, a bill proposed by Health Minister Willum Þór Þórsson to amend the Healthcare Practitioners Act has successfully gained approval from Parliament. This amendment is aimed at providing clarity regarding the authority of healthcare professionals to report cases of domestic violence to the police. The consultation process with the victim, who seeks medical assistance at a healthcare facility, is emphasised in the amendment. It clearly outlines the information that may be shared with the police, enabling them to take appropriate measures to ensure the victim’s safety and provide the necessary support.

As highlighted in the press release, healthcare facilities serve as crucial points of contact for victims of domestic violence, with healthcare professionals often being the first and sometimes only individuals to become aware of such incidents. Conversely, the majority of cases reported to the police stem from calls made from homes, while only approximately 2% of domestic violence reports originate from healthcare institutions, as stated in the amendment’s notes. Findings from a doctoral study conducted in 2021 revealed that, on average, one woman seeks assistance at the National University Hospital in Fossvogur every other day due to physical injuries resulting from domestic violence. Records from the hospital indicate, however, that out of the cases involving women admitted between 2005 and 2019 with physical injuries caused by domestic violence, the police were involved in only 12% of those incidents.

Increased flow of information

The Health Minister’s amendment aims to enhance the exchange of information between the healthcare system and the police, with the primary objective of safeguarding and supporting victims of domestic abuse while reducing the likelihood of recurring violence. Moreover, this amendment aligns with the recommendations put forth by the Council of Europe’s Convention on preventing and combating violence against women and domestic violence. The Convention recently proposed that the Icelandic government establish a clear channel for healthcare practitioners to report instances of domestic violence to the police.

The press release highlighted the welfare committee’s stance on the need to strengthen collaboration between health institutions and the police in their joint efforts against domestic violence. This amendment plays a pivotal role in advancing that cause, emphasising the importance of “breaking down barriers to information sharing across different sectors.” By doing so, the authorities would be able to better ensure the safety of victims and enhance their trust in the available resources.

Standardised procedures for receiving victims of domestic violence

The press release concludes by highlighting the ongoing efforts to establish a standardised procedure within the healthcare system for receiving victims of domestic violence. These procedures are slated to be adopted in the coming fall and subsequently implemented across all health institutions in Iceland.

The primary objective is to ensure that victims receive appropriate healthcare, which entails not only the involvement of a doctor and nurse but also establishing stronger connections with social workers and trauma teams. Simultaneously, these procedures aim to ensure that all domestic violence cases are consistently registered and handled in a comparable manner, guaranteeing that victims receive equitable services regardless of their place of residence or financial status.

It is important to note that the implementation of these procedures is separate from the aforementioned amendment to the Act on Healthcare Practitioners. However, both endeavours share a common goal of enhancing the handling of domestic violence cases, supporting the work of healthcare professionals in such situations, and improving services provided to victims.

 

Risk of Overdose Rises Following Closure of Iceland’s Only Safe Injection Site

Iceland’s only safe injection site, a temporary project operated by the Icelandic Red Cross, shuttered on March 6. A Red Cross employee told RÚV such sites decrease the risk of overdose among intravenous drug users in addition to saving funding within the healthcare and social service system. Over 100 individuals used the safe injection site within the last year, many of them unhoused, during over 1,200 visits.

Ylja, as the safe injection site was called, opened in May of last year and was a temporary pilot project operated by the Icelandic Red Cross. Like safe injection sites abroad, Ylja offered a safe environment for those 18 years of age and older to inject intravenous drugs under the supervision of trained nurses, who ensured sanitation, safety, and infection prevention practices were followed. Safe injection sites are a harm reduction service that can prevent overdose and death among users of intravenous drugs. They can also connect clients to other essential services they may require.

Assists a marginalised group and saves public funds

“We need housing and the funding to pay for it, in order to operate a safe injection site. There is a lack of political will to approve it,” stated Marín Þórsdóttir, the department head of the Icelandic Red Cross’ capital area department. In 2015 and 2022, the Icelandic parliament shelved bills to decriminalise drug possession for personal use. Minister of Health Willum Þór Þórsson promised to submit a new, revised bill last autumn but has yet to do so.

Marín adds that with Ylja’s closure, the Red Cross loses staff that is specialised in harm reduction, primarily nurses. While operating a safe injection site requires considerable funding, Marín says it ultimately saves public funds. “We are tending to a very marginalised group that receives little service, experiences perpetual discrimination in society, and it’s just savings, both within our healthcare and social services system by having a safe injection site and assisting people with harm reduction resources.”

Read more: In Harm’s Way

Economic and social factors appear to impact drug use in Iceland, according to the research of Dr. Arndís Sue-Ching Löve, an assistant professor at the University of Iceland. Her studies show that cocaine use decreased in Iceland during the COVID-19 pandemic, but increased again last year to around pre-pandemic levels. The increase may be partially explained by increased prosperity: a similar pattern was seen before the banking collapse in Iceland.

Enrollment in Opioid-Substitution Treatment on the Rise

Individuals receiving opioid-substitution treatment have significantly increased over the past years. According to Minister of Health Willum Þór Þórsson, 276 people were enrolled in the treatment in 2019, compared to 438 in 2021.

A formal enquiry before parliament

Following a formal enquiry by MP Diljá Mist Einarsdóttir – on whether doctors would be granted greater authority to prescribe opioids to those struggling with addiction – Minister of Health Willum Þór Þórsson gave no indication before Parliament that greater authority would be granted.

Read more: In Harm’s Way: Opioid Addiction in the Age of Harm Reduction

Willum Þór explained that opioid-substitution treatment is provided primarily by three institutions in Iceland: SÁÁ (the National Centre of Addiction Medicine), the University Hospital of Iceland (Landspítalinn), and the Akureyri Hospital in North Iceland. The main drug employed during treatment in Iceland is Buprenorphine, both in tablet and injectable form, which is a licensed drug (“costly and/or must be treated with care”) administered at no cost to patients and supervised by the University Hospital’s Medicines Advisory Board.

The use of Buprenorphine in injectable form, Willum noted, is restricted to healthcare institutions (H-label) while Buprenorphine in tablet form must be prescribed by doctors with knowledge and experience of addiction (Z-label). This means that physicians specialising in addiction treatment, who have secured a license and can demonstrate experience, outnumber psychiatrists when it comes to the prescription of Buprenorphine.

Willum also noted that Buprenorphine is primarily administered to patients at Vogur’s MAT (medication-assisted treatment) clinic in Reykjavík (in accordance with an agreement regarding opioid substitution treatment signed by Icelandic Health Insurance and SÁÁ) although a number of patients retrieve their drugs in tablet-form at pharmacies.

As noted by the National Library of Medicine, opioid-substitution therapy (OST) is an “evidence-based intervention” for opiate-dependent individuals, which replaces “illicit drug use with medically prescribed, orally administered opiates such as buprenorphine and methadone.”

OST/MAT programme responsible for reducing overdose rates

As noted in the Minister’s response before Parliament, individuals receiving opioid-substitution treatment (OST) have “increased significantly over the past years.” According to the minister, 276 people were enrolled in the treatment in 2019, compared to 438 in 2021.

SÁÁ’s medication-assisted treatment (MAT) clinic at the Vogur treatment centre has gradually expanded over the years and as of late summer treats 250 patients – most of whom have injected opioids or have suffered serious consequences as a result of their addiction. According to Dr Valgerður Rúnarsdóttir, the Medical Director of SÁÁ, MAT patients receive methadone, buprenorphine pills, or injections, which reduce withdrawal symptoms and cravings for opioids.

“There’s a low threshold for participation,” Valgerður stated. ‘We’d be seeing a much higher overdose rate if it weren’t for this programme. We also collaborate with other healthcare and social services to help people become sober. If we want to improve the lives of these people, these factors must be entwined.”

Although most of the patients in Vogur’s MAT are either sober or aspiring toward abstinence, there are also some who are not ready to quit. It is important to provide services to these individuals, and the City of Reykjavík, according to Valgerður, has greatly improved access to housing for this group of people over the past years. “Things are much better today compared to ten years ago,” she stated, adding that besides offering treatment and other services, removing stigma is also vital.

Orthopedist: Surgical Waiting Lists for Children “Unacceptable”

Press photo of the year 2020

An orthopedist at Landspítalinn hospital has told the Minister of Health that surgical waiting lists for children are unacceptable. “I can’t get them into surgery within an acceptable time frame,” Sigurveig Pétursdóttir told Willum Þór Þórsson during an annual meeting of the Icelandic Medical Association in October.

“I’m on my knees”

Sigurveig Pétursdóttir, 64, has been employed as a doctor for 38 years. She’s spent 30 years working with disabled children as a paediatric orthopedist. At an annual meeting of the Icelandic Medical Association, held on October 14, Sigurveig told Minister of Health Willum Þór Þórsson that the state of the hospital “has never been worse.”

Read More: Mass Resignations at the University Hospital

“I’ve got children who’ve waited a year,” she called out from the assembly hall, according to a transcript of the meeting published by the Icelandic Medical Journal: “A disabled child who walks with one leg crooked for an entire year because there’s no space in the operating room. And why is there no space? Well, because the staff has quit. It’s not a matter of not having the staff. They quit. The hospital’s a mess. It’s a mess right now. It’s not going to become a mess tomorrow. It didn’t happen yesterday.”

Sigurveig preempted familiar bureaucratic talking points with the statement that all talk of analysis and assessment was unacceptable: “I’ve heard it a hundred times, but the situation has never been worse than now,” she stated. “It means nothing to me, being told that I did so well during the pandemic, not having missed a day of work.”

“I’m on my knees,” she continued. “I’m giving up, and I’m not the kind of person who gives up when things get rough. But no one will be able to walk in my shoes. No one!”

Increased funding required

Those present at the annual meeting urged the government to heed the will of the public and to increase healthcare funding. They also announced their disappointment in next year’s budget bill, urged healthcare institutions to ensure the safety of their staff, and called for actions to be taken to deal with the failing health of doctors and the growing number of healthcare professionals who are resigning from their jobs.

In late October, sixteen middle managers employed at the National University Hospital of Iceland received letters of termination. The terminations stemmed from the adoption of a new organisational chart intended to improve the hospital’s operations.

“The main purpose is to get a handle on the hospital’s management and operations, to strengthen our clinical services, and to harmonise other key services,” Runólfur remarked in an interview with RÚV.

Plans to Raise Mandatory Retirement Age for Healthcare Staff to 75

Iceland’s Health Minister Willum Þór Þórsson wants to speed up plans to raise the mandatory retirement age for healthcare workers to 75, RÚV reports. Public employees may not work past the age of 70 according to current regulations. Willum has stated that the move is intended to help relieve staffing issues that plague Iceland’s healthcare system, though more needs to be done.

If the regulations are amended, healthcare workers will still be dismissed upon reaching the age of 70, but would be eligible to be rehired on a new employment contract until the age of 75. Willum stated that such employees may be subject to a skills assessment.

Read More: Chairman of Medical Association Warns of Doctor Shortage

The Health Minister stated that although raising the mandatory retirement age would hopefully relieve staffing issues, it would still be necessary to make various medical professions more accessible to young people and improve recruitment across the field.