Initially announced by Prime Minister Robert Golob in May when he said that dual practice would be made significantly harder if not prohibited, the reform Health Services Act was unveiled by the Health Ministry on 16 September as it entered a month-long consultation period after which it is expected to be finalised before being put forward to the government and parliament for adoption.

The minister says the main rationale behind the proposal is to ensure that public healthcare remains accessible, of high-quality, and free of additional charges for all citizens.

This is why they want to separate between providers within and outside the public network, which also includes private providers with a concession to provide publicly funded services.

When drawing a line between the public services and market activity, public providers will have to bear in mind that market activity merely supplements the public service and that it can only be provided outside office hours for patients.

Curbs but also incentives for doctors

To curb after-hours at private providers, the proposal seeks to re-introduce non competes. Doctors employed in public health institutions would still be allowed to work after hours for extra pay, provided there are no waiting time issues at their main workplace.

While they will be still allowed to work for concession holders to perform public health services, they will no longer be able to provide private, out-of-pocket services, either at private healthcare facilities or with concession holders.

To work for another provider, doctors would need to obtain consent from their employer for a maximum of six months. That consent would be issued if the maximum permissible waiting times at their employer have not been exceeded and if the plan of the public health insurance fund for the types of healthcare services provided by the employee in question has been realised.

Under the proposal, consent can be given without these conditions being fulfilled if the doctors perform work for the general benefit, such as participating in the round-the-clock provision of health services in another public institution, palliative care and work in the mountain rescue service, Red Cross or the public organ transplantation institute.

Doctors will also be incentivised to put in additional work to tackle wait times at their principal employer by means of tax-advantageous contracts. They will also be allowed to do up to an additional eight hours a week of scientific research work, teaching or professional work for their employer.

A bonus will be introduced to encourage health workers at family medicine clinics and at children and school clinics to accept patients without a named GP and thus improve the accessibility of healthcare services at the primary level.

Stiffer conditions for concession holders

There will also be new requirements for concession holders. Being part of the public network, the same financing and employment rules that apply to public providers will also apply to them.

Minister Prevolnik Rupel says this means staff working for concessionaires will need to have proper employment contracts, rather than having sole proprietor status, which is to create a level playing field for the public sector in tax terms.

Before being registered, all healthcare providers will have to obtain a permit from the Health Ministry. Only applicants meeting all the requirements to perform services in their own name and on their own account will get the clearance.

After a concession period expires, the concession is to be awarded anew based on a public call for bids, and the area for which the concession is awarded is also redefined.

The list of reasons for which a concession can be revoked is also being expanded, including when the concessionaire changes its legal status or turns away patients without justification.

Another key change in the proposal is the possibility for the government to set maximum prices for essential health services to meet people's needs in private healthcare.

Prime Minister Golob has argued that the changes will stop "trading in concessions" and instances where some doctors put in little or no work for their employer in the public sector while referring patients to private practices where they work after hours, a claim that has upset doctors as much as the proposed legislative proposal.

Doctors up in arms

Medical organisations, including the Medical Chamber and the country's largest trade union of doctors and dentists, Fides, have come out to argue that the changes put forward will merely encourage more health professionals to leave the public sector and thus further undermine public healthcare.

The Fides union, whose members have been formally on strike since 15 January although the impact of their action has been limited by a law expanding the list of services they have to provide while on strike, said it was "appalled".

"We note with great concern that the proposed changes will have a major negative impact on the accessibility of healthcare services, which will directly harm patients and healthcare workers," the trade union said, warning that "coercion and penalties for doctors" would prompt the best experts to quit the public system.

An association of private doctors and dentists also expressed its indignation at the proposal, which they say would make public health workers third-rate citizens, and demotivate providers and workers to stay and work in public healthcare.

"The increased motivation to work is not only higher pay, but also mostly enabling individuals to exercise their constitutional rights, such as the right to work, the right to rest and, ultimately, the right to strike," they say.

Criticism from opposition, civil initiative

The proposal has also elicited criticism from the opposition as well as a civil initiative campaigning for public healthcare, although for different reasons.

Appearing in a televised debate on 16 September, Democrat (SDS) leader Janez Janša and New Slovenia (NSi) leader Matej Tonin argued that the proposal, if passed, would speed up the collapse of public healthcare, with Tonin accusing the government of wagging "a holy war against doctors".

Both argued that patients should be put at the centre of healthcare and that people did not care where they got the service from as long as it was paid for from public funds.

Janša concedes that problematic practices raised by Golob do exist but does not think they are the main issue of healthcare. "The main problem of Slovenian healthcare is the organised chaos that suits certain people who of course encourage it," said Janša, pointing his finger at the government.

Meanwhile, the Voice of the People, a civil initiative behind the anti-government protests during the previous, Janša-led government, slammed the government's proposal for failing to fully separate public and private healthcare as promised by the ruling coalition.

They have drawn up their own bill where they propose doctors in public healthcare first eliminate the unacceptably long wait times in their department, and only then could they ask to work in a different public healthcare institution and work to shorten their wait times.

Only once no public hospital in Slovenia had exorbitantly long wait times in their speciality could doctors ask to work for a concession holder or private provider, they propose in the bill, tabled by renegade Left MP Miha Kordiš and independent MP Mojca Šetinc Pašek, once a member of the prime minister's party.

Meanwhile, the NSi has again tabled a bill where it proposes tackling wait times by paying private practitioners for services out of the public health insurance, an idea that this Christian democratic party has been championing for years.