Government is paving the way for a reform in the way the country addresses the health of the nation: but will it find the support of everyone? By MATTHEW VELLA
In a nutshell, the government wants you to go to private GPs before offloading the cost of your health on the state.
Take a look at the big picture. You are the taxpayer and if you want the health budget to slowly take on a more sustainable burden, it pays that more people “become healthier” (too simplistic a concept), or get treated in non-hospital scenarios, such as at their GPs.
Not just anyone can afford private insurance. But the government wants to see more people making use of GPs before taking their ailments to health centres and the general hospital. This primary gateway is key to the reform: you register with your family doctor, who becomes custodian of your medical files. Any time you happen to be getting care in a health centre, hospital or with another GP, a communication system will allow them to access your files. The result, hopefully, will be better treatment and follow-up.
But it is not going to be that simple. As it stands, the Maltese health system is already plagued by its own, idiosyncratic problems.
Private insurance is one: the common public perception is that “complex” interventions are only possible or safer in state hospitals. So private insurance companies offer a cash rebate per diem for insured persons who opt to make use of the state hospitals. This means the State bears the brunt of the financial burden of health care.
As things stand, our health system treats patients only when something goes wrong, rather than using health promotion and disease prevention to reduce chances of people actually ending up in hospital.
Without a patient registration system – a centralised system of patient medical histories – hospital specialists find it difficult to discharge patients from their outpatient clinics. Without GPs liasing with each other, nobody ever knows the patient well enough to provide appropriate follow-up.
Add to this situation the fact that GPs employed at health centres and polyclinics are an unhappy bunch: a study on job satisfaction among state GPs revealed poor levels of satisfaction, with doctors saying they are “unappreciated and neglected, citing poor pay and career progression as reasons for their disgruntlement.” The survey, published in the Malta Medical Journal, showed 41% of GPs felt “unappreciated, neglected and disrespected”, 39% experiencing job dissatisfaction, stress and depression, while 31% felt verbally and physically used, misused and abused.
This has led to a high turnover in state GPs and problems with recruitment and retention because health centres are not rewarding place to work in. And to compensate for their low salaries, nearly all GPs at the health centres carry out their own private work.
And in spite the relative success of the Maltese national health system, ranked highly by the WHO for its universal accessibility, it comes under criticism for failing to reduce its waiting lists on surgical operations; while the government has so far been unsuccessful in offering satisfactory salaries that keep government doctors inside the public service, rather than ‘moonlighting’ as private specialists.
The reform So what does the government want to do? In creating this Personal Primary Health Care System, the family doctor will become the primary gateway for patients’ health needs. This means a patient would need to be first referred by his GP, with whom he will be formally registered, for further treatment at a hospital.
This alone will not prevent patients from accessing health centres or other private doctors. However, if they are discharged from hospital, any medical information pertaining to the patient will be instantly communicated to the patient’s registered GP.
GPs will therefore be able to book patients directly for laboratory and radiological examinations at Mater Dei hospital, and also for day care procedures. The centralisation of patients’ medical histories will also allow GPs to have a two-way communication with other doctors and hospital patients.
As is normally the case, registered clients will continue to pay GPs for the standard consultation, whether in cash or through insurance coverage. A means testing system will cover those not in a position to pay doctors’ fees directly: government will pay doctors in advance, based on the number of exempt individuals registered with the GP.
The polyclinics, proposed to be absorbed in four regional centres in Malta and Gozo, would tend to minor but urgent conditions that might not be easily treated by the family doctor. The government’s policy document is unclear on how this will work – it says patients can still walk into the polyclinic, but that they will be “encouraged” to be referred there by their GP – who must provide 24-hour coverage for their registered patients.
This is in itself sounds like a contradiction: as one health centre GP said: “If you’re going to have walk-in health centres free, why should patients pay their GPs to be referred to the polyclinic? I think we have to see exactly what is going to be ‘free’ exactly in our health care system.”
The state-employed doctors, who like Martin Balzan (pictured) at the outset of the reform say that the consultation process is “flawed”, will be clinical points of reference for services that ultimately must be provided at Mater Dei – such as treatment of diabetes, cardiovascular diseases, paediatrics, obstetrics and gynaecology, physiotherapy, speech therapy and occupational therapy. In turn, the polyclinics will be equipped with minor day surgery theatres to serve as secondary care centres.
The end result, it is predicted, is to see Mater Dei become what is termed “a tertiary acute hospital”, catering to serious health matters rather than ailments that could easily be handled by a family doctor in the first place. The outcome would also cut down on aggregate health costs.
No more free health? Ultimately, the reform gives more power to GPs as gateways to the general medical service. The government plans to give tax and other fiscal incentives for capital investment and specialist training, hoping to see the creation of private group practices with several doctors and nurses catering for the community’s needs. Group practices in particular will get assistance to engage nurses and paramedics, and purchase premises and equipment.
They will become the keepers of thousands of euros in reimbursements paid to them by government for services rendered to some 80,000 ‘yellow card’ users who are eligible for free medicines for chronic illnesses.
They will also be first point of contact for nationwide programmes such as vaccinations and health promotion, fitness tests, occupational health screens and sickness verifications – again they will be remunerated for these services.
No wonder therefore, that Labour sees the reform as the first embodiment of the payments touted for the health system that had been discussed in Cabinet sub-committees.
“The concept of patients paying for health services still exists in this case, but in a more subtle and contradictory way,” said Michael Farrugia, Labour spokesperson for social policy and a medical doctor himself.
“The areas in which payment was expected, as revealed by Labour in the last election, have been removed, but the rationale is there… Additionally, patients will be encouraged to not make use of health centres, except in cases of emergency, because they have to be referred there by their GP. This is a payment on a health service. It is unacceptable that Lawrence Gonzi has broken his promise on this subject,” Farrugia said.
The left-wing think tank Zminijietna echoed Labour’s criticism, calling the reform a “gradual dismantling of the public health care system… the ultimate aim is to have primary health care service in private hands.”
Unhappy docs But while government doctors will be retained to provide services in the regional primary centres, they will not be able to enrol in the Personal Primary Health Care system, so as “not to create unfair and inequitable market conditions that would jeopardise the new system from the start.”
This means government doctors can either leave the public service to join the new system; or practice privately outside the scheme, while retaining their jobs in the national service.
This alone has incurred the wrath of State-employed GPs, who called the consultation process “flawed”.
Martin Balzan, secretary-general of the Medical Association of Malta, said it was “completely unacceptable” to exclude government-employed doctors from the process of registration. “It seems that the government is abrogating its responsibility to introduce an efficient public health service, where there is a personalized care.”
He also added that having regional hubs “manned by doctors who know nothing about the patient is of very dubious validity as they will not be able to filter patients for accident and emergency.”
“It is also completely unacceptable to expect private doctors to provide a 24-hour service, seven days a week to patients, if they are to be effective gatekeepers in the proposed system,” Balzan said – effectively referring to a great stumbling block in the proposed reform.
If doctors want to register their patients and receive the fiscal and financial support to set up their GP practices, it means they have to be on call to issue referrals as the case may be to health centres and hospitals – 24/7. Can doctors – with their estimated 2,000 patients each – handle this new chore?
“The concept is right,” Dr Mario Grixti, formerly the president of the College of Family Doctors says. “You can’t have a doctor you’re registered with, who’s not available for you. But we’re going to have talk about the financial investment required to set up such a system.”
Still, while the scheme is a step in the right direction, Grixti finds issue with the in-or-out mentality adopted for doctors working in health centres. He says doctors employed with the state should still be allowed to be part of the scheme, a sort of ‘part-time’ allowance for polyclinic GPs. mvella@mediatoday.com.mt
The national health system – a brief history
1815 Under British rule, all hospitals are brought under a single authority responsible for the management of all charitable institutions and orphanages.
1936 The medical branches of the Charitable Institutions Department are amalgamated with the Public Health Department with a doctor at the helm, and all hospitals come under the umbrella of the Department of Health.
1950s Influenced by the creation of the British NHS, the Labour government attempts to set up a free NHS.
1955 A pilot scheme in Gozo with a full-time salaried state district medical service is set up but is opposed by the doctors’ union. The District Medical Service remains unchanged.
1956 The National Insurance Scheme, funded by government, employers and employees provides welfare benefits, sickness benefits and pensions, but as the health bill grows it will be general taxation that will finance the burgeoning cost of health.
1977 The ten-year doctors’ dispute starts, and polyclinics are opened to provide emergency primary care service for free, later leading to Malta’s present-day primary health care system. The dispute starts when government introduces requirement for newly-qualified doctors to serve in hospitals for two years after graduation before being licensed, in a bid to stop junior doctors taking posts or continue studies abroad; and the control of the medical council is passed to the Minister of Health, rather than the President of the Republic. A partial strike ensues: dissenting doctors are barred from the statutory service; a professional boycott is declared on members who did not join the strike. The daughter of strikebreaker Dr Edwin Grech is killed in a letter bomb attack in the midst of the strike.
The government also made it obligatory for all doctors to obtain the minister’s authorisation before practicising in a private hospital, which is dependent on the practitioner being willing to undertake work in the public health service. The health service is mostly run by foreign doctors soon after the strike, recruited from central and eastern European countries, north Africa and Asia.
1980 In the ensuing nationalisation of the medical sector, the government issues new conditions governing the licensing of private hospitals, which directly affects the Little Sisters of Mary (aka the Blue Sisters), who ran the eponymous hospital in Sliema. Private hospitals were required to allocate 50% of their beds for government use. Private clinics as opposed to private hospitals were not supposed to keep patients overnight but were only meant to perform diagnostic and minor treatment procedures. In December 1980, six of the nuns were given a stark ultimatum by the police: either to leave the island immediately, or face court proceedings. The Blue Sisters were flown out of Malta, and the hospital itself closed down altogether in 1981. Today it is the Zammit Clapp Hospital.
1987 Doctors who had left the island after the strike to work abroad, now return with specialist experience. After the change in government, barred doctors are reinstated and medical regulation restored to the President of Malta.
1994 Work starts on the San Raffaele research hospital, that will later be converted into a fully equipped general hospital under the 1996 Labour government. Construction will only be completed in 2007.
1990s Creation of two new private hospital groups – St Philip’s Hospital and St James Hospital.
2008 Inauguration of Mater Dei Hospital, and start of new salary packages for medical specialists who relinquish their private practice to be fully employed with the State.
Any comments?
If you wish your comments to be published in our Letters pages please click button below. Please write a contact number and a postal address where you may be contacted.
Search:
MALTATODAY
BUSINESSTODAY
Download MaltaToday Sunday issue front page in pdf file format
All the interviews from Reporter on MaltaToday's YouTube channel.
