ANNUAL REPORT OF THE PUBLIC DEFENDER OF GEORGIA 2013 The medical referral procedure consists of the following stages: 1. Primary healthcare units (in the penitentiary institutions) decide on their own whether there is a need for specialized medical services and, if positive, submit a request for a patient’s referral; the request may be registered in the system either directly by an institution’s doctor or through an operator. 2. After the request is registered, it will be processed by the Ministry’s Medical Department using the National Recommendations on Clinical Practices (Guidelines) and the State Standards of Disease Management (Protocols). If the request is well-founded, it will be accepted and assigned a serial number, which becomes known to the relevant primary healthcare unit and the beneficiary (the patient). 3. After the request is accepted, according to the number in the row, the patient’s referral will be agreed with a medical service provider and the patient will then be referred to that provider. It should be noted that if the request is rejected, the rejection will be registered in the system and the primary healthcare unit will be informed about the reasons of rejection. In the period of 1 September 2014 – 1 January 2014, 306 requests were deemed unfounded and rejected. Patients will be put in electronic queue only if they have their medical services scheduled ahead of time. Patients who need urgent or emergency assistance will not be put on standby. There are two separate electronic queues – one in the western Georgia and the other in the eastern Georgia. Inpatient and outpatient referrals (queues) are also run separately. This is to eliminate obstacles linked with a geographical area or the type of services. Requests are processed by the principle of “first come – first served”. A patient in an electronic queue may not be artificially moved forward or backward. It should be noted that the functioning of the electronic database of medical referrals is not regulated by a separate order of the Minister of Corrections. The Order of the Minister of Corrections and Legal Assistance no. 38 dated 10 March 2011 approving the “Rules of transferring sick prisoners from pretrial detention facilities and institutions for sentenced prisoners to general hospitals, the Penitentiary Department’s Center for the Treatment of Tuberculosis and Rehabilitation or to the Institution for the Treatment of Remand and Sentenced Prisoners”, does not contain any specific rules about the database. These Rules are not perfect, on their turn. In particular, under Article 1 of the Rules, remand and sentenced prisoners may be transferred to the Center for the Treatment of Tuberculosis and Rehabilitation based on a prison director’s order; such orders are based on a recommendation sent from the Ministry’s Medical Department to the prison director, which on its turn is based on a request made by a prison doctor. As regards transfers from pretrial detention facilities and institutions for sentenced prisoners to general hospitals, Article 2 of the Rules says that such a transfer shall be based upon an order of the Penitentiary Department, which on its turn is based on a prison doctor’s request to the Penitentiary Department and the latter’s recommendation approving the request. When making a request for transfer, a prison doctor must furnish one copy of the request to the prison director. Both prison directors and the Chairperson of the Penitentiary Department may dismiss a request. To summarize, a prisoner’s access to medical services formally depends upon the decision of prison directors and the Chairperson of the Penitentiary Department. This contradicts the spirit with which the reform of the penitentiary system was carried out when the medical personnel were brought under the direction of the Ministry of Corrections Medical Department. The very aim of the reform was to increase the independence of penitentiary healthcare staff. The launching of an electronic medical referral database is certainly an interesting novelty and should be evaluated as a positive change towards better regulation of the referrals. However, a problem with the referral system, which continues to be a concern, is the lack of individual approach to ensure timely provision of required healthcare services. In other words, it is axiomatic that the one who needs medical assistance the most must be the first to receive such assistance. This principle must be taken into account in any endeavor of perfecting organizational aspects of the penitentiary medical referrals. The European Court of Human Rights has been constantly stating in its judgments that “the relevant domestic authorities shall ensure that diagnosis and care are prompt and accurate and that supervision by proficient medical personnel is regular and systematic and involve a comprehensive therapeutic strategy.”76 The electronic medical referral database is, in our view, an instrument to effectively manage medical referrals. Representatives of the Ministry of Corrections have stated that a major strength of the electronic database is that it ensures equal treatment of prisoners and a greater transparency of the referral procedure. 76 See, inter alia, Jashi v. Georgia, Judgment of 8 January 2013, par. 61. NPM Report 32