Strengthening primary care services is a laudable aim. In fact the title of the consultation document launched this week by the Ministry for Social Policy (Health, Elderly and Community Care) – Implementation of a Primary Health Care System in Malta – sounded wonderful.
The document starts off on a positive note – studies had indicated that “investment in primary care resulted in improved health outcomes, higher patient satisfaction, reduced aggregate health care spending and increased equity and accessibility.”
Based on this statement, I expected that government was going to embark on a series of reforms and investment in public health centres, on the basis that every euro spent was a worthwhile investment and would save a lot of money in the long term.
As I started to read the document, I expected to be presented with targets for the employment of more doctors and nurses to support the existing overstretched cohort of primary healthcare professionals. I expected to read about investments in IT systems that would automate time-consuming repetitive tasks such as filling in repeat prescriptions, and plans to empower nurses and health technicians to assume jobs such as taking blood pressure readings.
However, it seems to me that what is being proposed is more along the lines of passing the buck to the private sector. All 413,609 of us must now register with a private family doctor who will be our first port of call when we are unwell.
It was rather amusing to read how the authors of the consultation document justified the ridiculous doctor-to-patient ratio that will result if each member of the population registers with one of the 149 full-time family doctors on the island. According to them, it does not matter that each doctor will end up with approximately 2,776 patients, because doctors in Malta work longer hours than their European counterparts. Hence, they can see more patients and can somehow cope with close to 3,000 people on their books.
The fact that family doctors in Malta are already working an average of 44 hours per week, with a large number of them working 60 or 70 hours weekly, is an indication that general practitioners are already overloaded. Is it reasonable to expect them to take on a larger workload? The consultation document states that “patients requiring emergency care will generally make their first contact with their registered primary care provider, who should make arrangements to provide 24-hour coverage for registered persons.” So these 149 GPs will be on call 24 hours a day, 7 days a week... is that realistic?
Frankly, I am astounded that the 149 family doctors are not up in arms about these proposals. If I were a family doctor, working 45 hours or more, I would be very worried about having to take responsibility 24/7 for any medical emergencies that my 2,776 patients may have.
If one considers that the initial premise was that the scope of the reform was to ensure a closer doctor-patient relationship, then it is clear that this is a ridiculous situation. If you were a doctor, would you manage to have a “close” relationship with thousands of patients?
What is even more astounding is the fact that the authorities are not proposing to put in place a limit on the number of patients that can be registered with each doctor. So hypothetically we could end up with general practitioners working all hours trying to form “personal relationships” with 5,000 or more patients.
So as a potential patient I am concerned. If my family doctor has thousands of patients, he will not even be able to remember my name, let alone build a relationship with me.
Another thing that I find worrying is the fact that in Malta so far there is no compulsory Continuous Medical Education (CME) for family doctors. In the UK, for example, family doctors are obliged to take a number of courses annually in order to keep up-to-date with developments in medicine and also to learn the social, managerial and personal skills required in order to provide a competent service in the community.
The reality is that if GPs in Malta are working 45 to 70 hours weekly they probably do not have the time and the energy to attend regular training courses and medical conferences unless they are obliged to do so. This is a matter of concern for all patients – if I have to go through a family doctor for all my medical emergencies, I want him to be up to speed on all things medical!
There are some excellent family doctors in Malta – professionals who are providing a sterling service and who are loved by their patients. However let’s face it - there are also some charlatans around - doctors who are just antibiotic and sick leave certificate dispensing machines. How can we ensure that our family is registered with the former and not the latter?
If government is determined to proceed with this plan, then it is vital that an excellent system is put in place to monitor the quality of care provided by general practitioners. If all Maltese citizens are obliged to register with a family doctor and have to use his or her services regularly, then issues such as quality of service and price cannot be left uncontrolled. There are too many patients, and too few doctors, so the principles of supply and demand dictate that the cost of primary healthcare is going to rise.
This is not because doctors are greedy. If they are expected to take on more patients and extend the range of services they offer, as well as be on call after normal working hours, then they are fully entitled to make more money. Who would not want to be paid for being on call at night?
Therefore it is clear that this consultation document is just that - a starting point for a lot of discussion; because it is evident that a lot needs to be said and done before this plan becomes even remotely practicable.
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