At the beginning of April, there were about 2,000 people on waiting lists for special care homes. Of those, around 800 would have been prepared to move into a special care home essentially the very next day if a suitable place had been available. What is the situation now, at the beginning of June?
In fact, the figures are more or less the same. That applies to those who specifically need places in special care homes, but there are also people who need support services that enable them to live in the community.
I understand that we are talking more about places in special care homes, since establishing them is more expensive and takes more time. However, I think it is also very important to keep in mind that we need community-based support services first and foremost.
That means that if a person with special needs is born with a disability or develops one as a result of illness, they should have access to assistance close to home where they can receive support and care.
In fact, the National Audit Office published a report in the fall showing that the number of people on waiting lists for special care services in Estonia nearly doubled between 2018 and 2024. Despite growing demand, however, the number of places has actually decreased. How did that happen?
Alongside the National Audit Office’s review, the Social Insurance Board (SKA), which is responsible for organizing the provision of these services, has consistently collected information and shared it with the public showing that not all of these people want to enter care immediately after their need for the service has been identified.
The SKA has now personally contacted everyone on the waiting list by phone and it has emerged that many people say they do not wish to begin receiving the service right away. A useful comparison for listeners is a place in a kindergarten: when a child is born, they are immediately placed on a waiting list so that once the parental benefit period ends and the parent wants to return to work a couple of years later, the child can move from the waiting list into kindergarten.
For that reason, there has not been an approach of saying, “We need to start building care homes immediately.” There are simply many people on the waiting list who say they are not ready yet, that they need more time or that their parents are not yet willing to place their adult child in a care home. Clarifying the actual situation has therefore taken time.
At the same time, we also have around 100 vacant service places. People no longer want to move far away from their home area, nor do they want to receive services in outdated, dormitory-style care homes. They want modern, private and dignified accommodation.
Just to clarify, when the National Audit Office said that the number of people on waiting lists for special care services in Estonia increased between 2018 and 2024, was it mistaken?
No, it was not mistaken in that sense. What we are saying is that the fact that people have put themselves on a waiting list does not necessarily mean that they actually need a place immediately. We need to determine how many of them are on the list, so to speak, just in case, because there is a widespread perception that places are difficult to get.
At the same time, we need to establish how many people would genuinely begin receiving the service if a place became available. The Social Insurance Board has done a very thorough job of identifying the real reasons behind the waiting list figures.
In fact, even before the Supreme Court ruling was issued, we launched a reform of special care services at the beginning of the year to take a genuine look at what practical tools are available within the existing resources and legal framework. In other words, we are examining what can be done to speed up access to services for those who actually need them.
We have also had cases where a person says, “I am currently working in Finland and do not yet want to move into a special care home.” Cases like that would then be removed from the waiting list, so that these figures do not give the public a misleading impression.
But there is still a large number of people who would like to move into a special care home tomorrow but for whom no place is currently available. That number is around 800. The Supreme Court has now said that the state must ensure that people have access to a place in special care services. The court found that the state does not have the right to allocate less funding for special care services in the budget than is required to fulfill obligations arising from the Constitution and other laws. How will the state, or the Ministry of Social Affairs, respond to this ruling?
I very much hope that, with the support of this Supreme Court ruling, our budget requests will be taken more seriously than they have been so far.
Requests to the government?
Exactly — requests both for next year’s state budget and for the longer-term four-year state budget strategy. Of course, it is not only up to the government; ultimately, the Riigikogu approves the budget.
After several difficult issues have been brought to public attention and advocacy organizations, representative groups and service providers have all helped explain the situation, I hope this Supreme Court ruling will provide yet another reason to increase the funding we have requested.
What we have done in the meantime is to refine our estimates of the amounts needed to create service places for those people who are in the most urgent need. We are primarily talking about people with more complex needs and those requiring a higher level of support, including people with mental health problems, so that their family members can receive some relief. We have calculated what we believe the minimum level of funding required would be.
This year, a legal provision also came into force stipulating that a person cannot continue choosing among available places indefinitely. There is now a time limit. They must make a decision, because around 100 people may be waiting behind them in line. These are the kinds of changes we have introduced.
Let’s talk about money. Four years ago, in 2022, the Ministry of Social Affairs submitted a request as part of the state budget strategy for roughly €350 million in additional funding for special care services over four years. That would have meant about €90 million more per year for special care homes. You have said that this funding would have made it possible to hire a sufficient number of employees at reasonable wages and ensure an adequate number of special care places. Now, four years later, we are probably talking about a much larger sum if we want to calculate what it would actually cost the state to comply with this Supreme Court ruling. Or am I mistaken?
We could talk about a larger figure, but given the state of our national budget and the overall economic situation in Estonia, there is little point in putting forward such large numbers.
What would that “large figure” be if budget deficits and financial constraints were not limiting factors? If we wanted simply to comply with the Supreme Court ruling and ensure that every person in need has a place, while also providing dignified pay for support workers and caregivers, what would the ideal level of funding be?
I am not going to put a figure on that ultimate ideal. But let’s do a very rough calculation: take the cost of the service and the number of people on the waiting list and multiply the cost of a service place by the number of people waiting.
If we look only at that figure, without increasing wages or improving any other component of the service, then the additional annual cost at current prices would be about €25 million.
Per year?
Yes. But those figures are based only on the current service prices and we already know that the current rates do not cover providers’ actual costs. Providers cannot hire additional staff with that level of funding, which is why there was little point in relying solely on that calculation.
Once we also take into account the price increases needed to ensure that service providers can continue operating and are not at risk of shutting down, the figures become even higher than simply multiplying the per-person funding rate by the number of service places.
Let’s talk about next year’s needs, for example. The current special care services budget is around €55 million — that covers all services, including both community support services and care home services. We would need roughly the same amount again in additional funding each year. At that point, we could say that our needs are being met.
If we multiply that €55 million by four years, the total comes to about €225 million. The funding request we have prepared for the budget negotiations, which would resolve the situation, is around €197 million.
So roughly €200 million over four years is the minimum amount needed over the next four years to ensure compliance with the Supreme Court ruling — that every person in need has access to a place in special care services?
Yes, but that amount does not only include the creation of all those places because creating new places and constructing facilities takes time. A very large share of that funding would go toward labor costs and salaries for professional staff.
When we have spoken with advocacy organizations, they have also emphasized that the most important thing is having people who are both willing and qualified to work with individuals with special needs.
In fact, nearly half of that amount would go toward raising staff salaries and investing in their education and training. It would also certainly be used to increase staffing levels. We can no longer have situations where one employee is responsible for 30 people. The cost of those measures alone over four years is in the region of €123 million.
In any case, is that roughly €200 million the figure you will be taking into the state budget strategy negotiations this fall?
I certainly hope so. We have worked out that figure together with ministry officials. We have also discussed it with the minister, who has had to respond to inquiries about what both she and the ministry plan to do to support and assist people with special needs.
Yes, that is the figure we intend to put forward.
I don’t know whether you meet with the secretaries general of other ministries every week, but I assume you’ve already had a chance to present this figure to Merike Saks of the Ministry of Finance. What was her reaction to a number like that?
I can let you in on a secret: this is actually the first time we are stating this figure publicly. I have not yet had the opportunity to discuss it with Merike.
Knowing her, and knowing what officials at the Ministry of Finance have said in the past when preparing these same state budget requests, a figure like this will naturally make them stop and think. And this is not the only funding request we will be putting forward. There are several other issues within the Ministry of Social Affairs’ portfolio as well.
But let’s return to the main point: in our view, this figure reflects basic needs. It includes support for the workforce so that there are people willing to work in this field at all and so that their pay is competitive enough to prevent them from leaving for jobs in hospitals or general care homes.
The current gross salary of around €1,500 for someone working with people with special needs is not, in our view, a dignified wage. So yes, these are large figures, but they are backed by reasoning and logic. They are not simply made up. If we wanted to, we could make the number even larger.
Four years ago, the Ministry of Social Affairs requested €350 million over four years. A year ago, you were again asking for a nine-figure sum. In the end, however, the government gave the ministry only about €4 million in additional funding per year. Year after year, you have asked the government for this money and year after year the Ministry of Finance has effectively shown you the door because the budget situation is difficult. So what is Plan B this time?
We are still focused on Plan A, which is what I have been talking about here. These are the calculations we will be presenting.
The €197 million is not needed all at once. If we are talking about next year, the figure is on the order of €21 million. That is the additional funding we would need in the 2027 budget and then the amount would gradually increase from there.
The Ministry of Finance’s latest forecast still predicts a very large budget deficit next year. I doubt the ministry even wants to hear about requests involving tens of millions of euros. That’s why I’m asking: given that backdrop, what is the so-called Plan B if your request is not approved?
Alongside our efforts to secure additional funding, we are also looking closely at who should receive assistance first and what kinds of services they need. Given the limited resources we currently have, we must establish priorities.
So far, we have talked a lot about round-the-clock services and the need for places in special care homes. In reality, however, we can provide special care services at three to four times lower cost if people have access to support services close to home. That includes day care services, as well as opportunities for young people to study and work. This is how we are trying to manage for the time being and make the best use of the funding already available.
Very often, we confuse special care services with general long-term care. We are not talking about people who simply want to lie in bed all day. In most cases, we are talking about adults between the ages of 18 and 64 — people who, for the most part, could live active lives, participate in society and earn an income.
In my view, we need to move away from the traditional care home mindset and focus on what can be done beforehand to help a person remain active and independent. Only later, if that person’s special needs become so complex that they are no longer able to function independently, should a place in a round-the-clock care service be created for them.
But ensuring that these people do not end up in special care homes — that they remain as independent and active as possible in their own homes and receive supportive services there — surely costs money as well?
It does. But this year, for example, the Social Insurance Board has created 200 additional places in support services precisely for that reason: don’t just sit on the waiting list waiting for your ability to cope to deteriorate further. Instead, please direct your loved ones to these support services right away.
Likewise, in my own experience as a service provider, I often saw people arriving at care homes too late, when they could have been helped much earlier.
We certainly need to look at the efficiency of the system as well. That is why we are working on this special care services reform, the aim of which is to examine how the current system can be improved so that next year I will not have to ask Ministry of Finance Secretary General Merike Saks for quite so much money.
In its ruling, the Supreme Court found that the state does not have the right to allocate less funding for special care services in the budget than is required to fulfill obligations arising from the Constitution, legislation and regulations governing the Social Insurance Board. One way to ensure that everyone in need receives a place is, of course, to create enough service places so that people can move into special care homes. But another way to comply with the ruling would be to change the laws — lowering eligibility thresholds and quality standards. To what extent is that possible and would it be sensible?
We certainly need to take a closer look at how care needs are assessed. That means examining which health indicators are used to determine whether a person can still manage at home or whether they now require a place in a care home.
In other words, make the criteria stricter so that not everyone whom we currently assess as needing assistance would necessarily qualify for it in the future?
You could put it that way, as making the criteria stricter, though we ourselves would describe it as reviewing the assessment system. Based on my own professional experience, I can also say that there are people who are referred to support services even though they actually need round-the-clock care. We need to look closely at the assessment process itself and review the options available there.
In the long term, if mental health problems in Estonia continue to increase, we will genuinely have to consider what the state’s capacity is to support people.
There also needs to be greater personal responsibility, as well as greater responsibility on the part of relatives and families, for maintaining mental well-being for as long as possible. If that is not the case, then yes, the eligibility threshold would ultimately have to be raised much more significantly than anything currently being considered in our plans.
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