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Хроники медреформы. Год спустя

Немного отвлечемся от выборов президента и поговорим о выборе семейного врача. На днях исполнился год с тех пор, как для всех жителей Украины началась реформа здравоохранения. Начиная с апреля 2018 года, каждый может выбрать для себя врача первичной помощи – семейного или терапевта, а для своего ребёнка – семейного или педиатра. 26 миллионов украинцев воспользовались этой возможностью. И это много – год назад в Минздраве предполагали, что таких будет не более 30% населения страны.

О том, как реализуется реформа, что получили, а что потеряли пациенты, о реальных зарплатах врачей “первички”, о перспективе реформы пережить выборы и других интересных перспективах – в тексте LB.ua.

Что получили пациенты

На данный момент – только возможность выбрать своего врача первичного звена. Это семейный врач, терапевт или педиатр. Узкие специалисты – лор, кардиолог, невропатолог и т.д. – это “вторичка”, там реформа ещё не началась. Реформа высокоспециализированной помощи тоже пока не началась – то есть, в больницах реформы ещё нет, и если вы попали в больницу, то всё вокруг – это не реформа.

В права пациента на первичке сегодня входит: консультация у выбранного врача в клинике по записи и если нужно дополнительно – по телефону или вайберу, вакцинация, бесплатные анализы – если врач выдаст на них направление. Также врач может выписать рецепт на “Доступные лекарства”.

Все эти услуги бесплатны, хотя в некоторых поликлиниках медсестры, которые берут анализы, по-прежнему просят дать “на реагенты”. Давать не обязательно – вернее, обязательно не давать, если вы хотите, чтобы ваша поликлиника переходила на цивилизованные методы работы. Если в ней вдруг действительно кончатся реагенты, эту проблему должно решать руководство, а не медсёстры.

Частные клиники

Действительно новое и неожиданное – теперь получить бесплатное медобслуживание можно не только в государственных учреждениях, но и в частных. Не во всех – только в тех, которые подписали договоры с Национальной службой здоровья. Мы на LB.ua постоянно публикуем их список.

Год назад никто не ожидал, что частные клиники войдут в реформу. “За 370 грн в год? – хмыкали эксперты. – Да в частной клинике один визит к педиатру дороже стоит”. Оказалось, что да, но нет. И это большая заслуга Национальной службы здоровья Украины, в которую, к слову, тоже никто не верил.

Подробнее о том, как работает реформа в частных клиниках, скоро расскажем в отдельном тексте.

Перестали ли врачи посещать пациентов на дому?

Как ни странно, нет. Когда внедрялась реформа, в Минздраве говорили, что походы на дом не отменяются и не запрещаются, просто теперь они будут осуществляться по усмотрению врача. В итоге оказалось, что многие врачи, которые привыкли навещать пациентов на дому и считают, что так делать правильно, продолжают это делать. По крайней мере, нам удалось найти пациентов, к которым, как и раньше, приезжают их врачи. И, что интересно, врачей они выбрали своих “старых” – участковых.

Из частной клиники врач на вызов бесплатно, конечно, не приедет. В любом случае пациенту нужно обсудить это со своим врачом перед подписанием декларации. Можно спросить: “А вы приедете ко мне, если у меня будет температура?” И выбрать врача, ответ которого вам понравится.

Нехватка врачей

Правда, за год выбор врачей заметно сузился – у многих из них уже набран лимит пациентов и они могут отказать новым. В скором времени можно будет превысить лимит, но не все на это пойдут, потому что две тысячи людей – и так большая нагрузка для совестливого врача.

В Киеве, конечно, всё равно есть из кого выбирать (тем более, что столица отстаёт по количеству подписанных деклараций), но если речь о небольшом населённом пункте – могут быть проблемы. Может быть даже такое, что подписать декларацию не с кем – свободные врачи закончились. Не говоря уже о том, что нет возможности перебирать врачами.

От того, хватит ли врачей на первичке, во многом зависит успех реформы. Так как именно врач первички – центральное звено в новой системе здравоохранения. К своему врачу пациент должен обращаться в случае любых проблем со здоровьем (а не идти сразу к узкому специалисту, как мы все привыкли), семейный врач должен мониторить хронические заболевания, проводить вакцинацию, поддерживать среди своей паствы здоровый образ жизни и смысл.

В Минздраве неоднократно заявляли, что решать проблему нехватки врачей должны местные власти. Так мы подходим к главному правилу реформы: хорошо будет там, где хорошо сработают местные власти. Это касается блага и пациентов, и врачей. Второе правило реформы: хорошо будет тем, что умеет отстаивать свои права. Об этом – ниже.

Когда будет реформа вторички?

Системная задача врача первички – снизить нагрузку на вторичку (услуги которой будут стоить государству дороже) и на экстренную помощь.

Тем временем Минздрав и Нацслужба здоровья начинают пилотный проект по реформе вторичной медицинской помощи – он проходит в Полтавской области. В 2020 году мы должны увидеть реформу вторички в действии во всех регионах страны.

Как это будет? Получив направление от своего семейного врача к узкому специалисту, пациент может обратиться к любому специалисту этого профиля в любом медицинском учреждении Украины (из частных – только в те, которые участвуют в реформе). А НСЗУ выплачивает деньги за каждую оказанную этим специалистом услугу – деньги, как и в случае с первичкой, выделяются на учреждение здравоохранения.

Если у нас будет, как в Великобритании, чьей системой здравоохранения вдохновлялись наши реформаторы, то получить направление будет непросто. Семейный врач там стоит не только на страже здоровья пациента, но и на страже государственного бюджета. Может показаться, что это плохо, но есть и хорошая сторона – на сэкономленные деньги должна оказываться действительно высококлассная и высокотехнологичная помощь тем, кто в ней нуждается.

По крайней мере, в Великобритании так.

Как вторичка работает сейчас?

Так же, как и раньше, но уже только по направлению врача. То есть, попасть напрямую к лору или эндокринологу невозможно, разве только обратиться в частную клинику. Или же в государственную, но в частном порядке – достать телефон врача, договориться с ним и заплатить за приём. Рабочая и проверенная временем схема.

Как объяснил LB.ua один из членов команды по внедрению реформ, у них есть большие сомнения, что в 2020 году узкие специалисты получат зарплаты больше, чем то, что они сейчас имеют “на карман”. Не говоря уже о заработках врачей в больницах – например, хирургов. Пока неизвестно, сколько предложит реформа “спецам”, но точно известно, что многие из них зарабатывают неплохо.

Что получили врачи

Все медицинские учреждения, которые участвуют в реформе, получают деньги за каждую подписанную с пациентом декларацию (это 370 грн в год, умноженные на возрастной коэффициент). Соответственно, чем больше деклараций – тем больше денег. Но распоряжаются этими деньгами учреждения по-разному.

Так, Ульяна Супрун в интервью Радио Свобода говорит, что средняя зарплата врача в Украине составляет 15-25 тысяч гривен. Но столько получают не все врачи и не везде. Кроме того, зарплата врача не всегда зависит от количества деклараций. Она зависит от коллективного договора, заключенного внутри медицинского учреждения. То есть, от руководства ЦПСМД (центра первичной медико-санитарной помощи) и того, насколько врачи готовы воевать с ним за свои зарплаты.

В марте разгорелся скандал: семейный врач из Днепра Оксана Панькович показала свою зарплату – 3748 грн. Она также заявила, что главврач отказался доплачивать им за заключенные декларации. Так выяснилось, что не у всех врачей первички теперь классные зарплаты.

Терапевт из Киева (имя и учреждение по её просьбе не называем) рассказывает LB.ua, что её зарплата – 6-7 тысяч гривен при 800 подписанных декларациях. Её коллеги рассказывают, что зарплаты действительно стали больше, но не по 25 тысяч гривен (речь о Киеве).

Оказалось, что ни в Минздраве, ни в Нацслужбе здоровья, ни на уровне областных, районных или городских департаментов здравоохранения данные о зарплатах не аккумулируются. Потому мы разослали запросы по нескольким медучреждениям Киева, выбранным наугад (Минздрав и Нацслужба обычно показывают зарплаты своих “чемпионов” по количеству деклараций и росту зарплат).

ЦПМСД №1 Подольского района ответил, что у них работает четыре семейных врача, зарплаты у которых зависят от количества подписанных деклараций и составляют от 9200 до 18 700 грн. Количество подписанных деклараций – от 468 (видимо этот врач и получает 9200) до 1805 (а этот, очевидно, зарабатывает 18 700).

ЦПМСД №3 Подольского района работает 87 врачей первичного звена. Их зарплаты – от 9700 до 26 700 (не уточняется, при каком количестве деклараций).

В ЦПМСД №2 Дарницкого района ответили табличкой, из которой следует, что их врачи-педиатры (27 человек) получают от 10 до 22 тысяч гривен при количестве деклараций от 587 до 1376. Оклад состоит в том числе и из “поощрения” за подписанные декларации.

В ЦПМСД №1 Святошинского района работает 71 врач первички, уровень зарплат – от 9 тысяч до 18 тысяч 686 грн. При количестве подписанных деклараций от 117 до 1818.

В ЦПМСД №2 Святошинского района работает 62 врача первичного звена, которые получают от 68 993 до 22 383 грн. Количество деклараций – от 682 до 2000. То есть, за максимальное количество деклараций врач получает 22 тысячи с хвостиком.

То есть, по Киеву средняя зарплата скорее всё же 15, а не 25. Впрочем, это не так уж и плохо – точно больше, чем было до реформы.

Также удалось получить цифры из Закарпатья (наша благодарность Закарпатью, все остальные регионы в ответ на аналогичный запрос сообщили об отсутствии данных).

Перечинский районный ЦПМСП: средняя зарплата врача первички – 12 тысяч, 60% получают более 15 тысяч гривен. Это примерно в два раза больше, чем было у этих врачей в прошлом году.

В самом Перечинске, в городском ЦПМСП средняя зарплата врача первичного звена – 10 951 грн. До реформы было около семи.

ЦПМСП Тячева сообщает, что по состоянию на март средняя зарплата врача первички – 12 649 грн. В то время как в октябре она составляла 7100 грн.

В ЦПМСП Мукачевского района отвечают, что средняя зарплата врача первички – 11 300 грн, с октября она насчитывается за подписанные декларации и увеличилась также примерно в два раза. А в ЦПМСМ г. Мукачево средняя зарплата врача первички уже 17 345.

Тем врачам, зарплаты у которых не выросли или выросли недостаточно, в Минздраве советуют давить на руководство и управление здравоохранения (которое может, например, разорвать контракт с главврачом из-за того, что тот обижает персонал учреждения). Если и это не поможет – менять место работы.

К сожалению, в среде медиков “качать права” не принято, и в тех поликлиниках, где врачи обижены на руководство, революций пока не намечается.

Чем недовольны люди

Первая причина для недовольства: то, что врачи теперь не обязаны приезжать на дом (хоть многие и приезжают, как мы писали выше). Вторая: что теперь нельзя самому решить, к какому узкому специалисту тебе нужно. А мы ведь все умные и лучше знаем, что нам нужно. Потому третья причина для возмущения: то, что антибиотики будут продаваться только по рецепту.

Парадоксально, но именно не очень хорошее положение дел в медицине привело к тому, что наши граждане сами назначают себе антибиотики и походы к спецам. И теперь будет очень трудно убедить людей, что они на самом деле часто ошибаются и правильно решать такие вопросы через терапевта, педиатра или семейного врача.

По поводу недовольства также напомню, что ДО реформы система здравоохранения тоже всем не нравилась, и один поход в поликлинику давал блоггеру материала минимум на три постика и две тысячи лайков.

Декларация раз в год?

Ходит очень живучий миф, что переподписать декларацию с другим врачом можно только раз в год – якобы потому, что деньги за пациентов Нацслужба здоровья выплачивает раз в год. На самом деле, деньги выплачиваются дважды в месяц, а подписать декларацию или переподписать её можно в любой момент.

Для этого нужно просто записаться на приём к тому врачу, которого вы выбрали. Взять с собой паспорт и идентификационный код – и подписать декларацию. Если ранее у вас уже была подписана декларация, процедура никак не меняется, вам не нужно приходить к своему бывшему врачу и говорить, что вы больше его не любите.

Что будет после выборов

У медреформы хорошие шансы на выживание. Оба кандидата в президенты высказывают поддержку и Супрун, и её реформе.

С парламентскими угадать, конечно, сложнее. Но уже приняты и действуют ключевые законопроекты, создана и работает Нацслужба здоровья, вся первичка получает финансирование по новому принципу. Гипотетически можно всё это законодательно отменить, но это было бы слишком странное самоубийство.

Другой вопрос, что реформа вторички может так и не начаться, если в Верховную Раду придут силы, которые называют медреформу геноцидом.

Будет ли реформа успешна

Как уже говорилось, успех реформы будет зависеть от людей на местах. Наймут ли местные власти достаточное количество врачей, обеспечат ли им такие условия, что бы они не разбегались? Где-то да, а где-то нет.

Хорошо будет тем, кто умеет отстаивать свои права. Причем это касается не только медицинской реформы, но и всех остальных – очень легко манипулировать человеком, который не знает своих прав и делает выводы о реформе на основе отрывков сведений от родственников и телевизора. От такого человека можно потребовать деньги за бесплатное и отказать в гарантированном.

В завершение расскажу потрясающую историю о правах и свободе выбора от знакомой пациентки. Молодая девушка очень возмущалась реформой: семейный врач, к которой она пришла подписывать декларацию, потребовал сто гривен за свои услуги. Угадайте, подписала ли она с ним после этого декларацию? С трёх раз.

Источник: lb

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