It is the state’s responsibility to provide a system of health care which is fair and of high quality for all. The foundation of any system rests on two mutual needs: first, a degree of mutual trust between profession and patient; and secondly, adequate funding in the face of demand. Both are very difficult to maintain, but if they are not maintained the system will run into a crisis and the people will suffer.
In a democratic state, one of the fundamental rights is the right to welfare, where people receive health care as a right. Within most health care systems in Europe, there is no right to health care on demand. In Malta, walk-in medical services are common practice and seem to be maintained. The principal rights are a right to be registered with a GP, and the right to be medically examined. There is no formal right to receive any treatment. This lies within the discretion or clinical judgment, of the doctor.
Two pillars of a primary care system are comprehensiveness and continuity of care – the reform is held to protect all citizens. But there may be problems with this concept. Unless you are registered with a GP you are not technically entitled to medical examination. The draft document is stating that doctors working with the government are to be excluded from this system. In other words, it is saying that all those patients who use the services of these doctors cannot be allowed to register with them. What sort of choice is this? Or, is this an exercise on the part of the government to decrease the load from its shoulders and shift it on to the private sector without regard to the needs of the patients?
Our public health system is that of a free service at the point of delivery (but not free, as it is paid from our taxes). Is this concept going to be kept? According to what is being proposed, although there is a choice, this is not going to remain so: patients have to pay the GP of their choice for services rendered. In my opinion, the main social principle should remain that no-one should be deterred from seeking health services by a lack of resources. The introduction of means -testing is a tricky business. Many middle class citizens who pay their taxes are finding it difficult to cope with present expenses. If these suffer from a chronic medical condition which needs continuous and comprehensive care, these have to pay for the services they seek out from their GP. On the other hand, we know what is happening with the “pink form”. The abuse here is rampant. A discriminate burden is going to be placed on these families. These are real situations which should be considered.
Patient Registration According to the document all citizens can register with a GP of their choice, but not with a health centre. In principle, I believe patients should be allowed to have a first preference for either a private or a public health centre doctor. They should be able to register with both their own GP and with a health centre: there are instances where people feel the need to consult a doctor they have full trust in. On occasions for repeat prescriptions, any doctor can do it provided the necessary monitoring of the treatment is maintained. This is why it is important that all doctors eligible to work as GPs should be taken on board and allowed to participate in the scheme, even on part-time basis.
In Gozo, for example, the system cannot work since there is only one private GP on full-time basis and another two on part-time basis: all the others work with the government. So, although patient registration should be the basis of a future primary care system, it should not be a means of discrimination between citizens due to administrative reasons.
The patient list
As main result of patient registration, each person can be registered with only one practice, which will provide both primary care and referral to the more expensive secondary sector. So patients cannot refer themselves for hospital treatment unless in an emergency. Is this going to lead to a capitation-based payment on all those patients who cannot pay the GP? This is the principal basis for a GP’s income with the size of their patient list. Is this list going to be unlimited, or will each GP be allowed a maximum number of patients according to their part-time or full-time basis?
24-hr responsibility A GP cannot deliver care to the patients 24 hours a day for 365 days per year. This is humanly possible only if group practices are formed. Again, this is a new concept for Malta, as group practices in existence are few, yet they have proved to be successful. A legal framework has to be worked out for such practices. Such practices should also be encouraged. Health centres seem to be doing most of the work outside office hours and weekends. With this dual system, there is going to be an imbalance: unless the dichotomy between the public and the private sector is removed there will be problems and duplication of work.
The government already has a problem with a shortage of doctors to run the present health centres on a 24 hr basis. If the policy is to expand the services provided by these centres, from where is the personnel going to come, knowing that a number of doctors will opt to move to the private sector to be incorporated in the scheme? In my opinion, the public health centres should be improved and not rendered into first-aid posts. There is also a need of a greater inter-disciplinary and multi-disciplinary teamwork.
The White Paper doesn’t mention how the system will include mechanisms for supporting infrastructure development, including investment into IT, encouraging teamwork, and regard for the requirements of care in a developing technological world. It only mentions that tax incentives/breaks will be considered. Are we going to end up with a set of GPs who will be isolated in single-handed practices, who work out of poor premises in terms of design and equipment, who have large lists and who have difficulty in achieving a break from the eternal 24-hour on-call?
Consequently, the introduction of IT will create other demands. Are all the doctors capable to manage their IT systems? Are we prepared to receive the necessary IT training to use the computer system? Is this information going to be owned by the patient on an intelligent card carried with him or by the doctor/clinic on their computer? Although modern technology can lead to improvement in patient care and clinical out-comes it may not be expressed in patient satisfaction. The doctor-patient relationship remains the most important element in primary care. This is called the art of medicine, which cannot be replaced by modern technology.
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The reform in the primary care system should not be an exclusive exercise in health economics, but should take into consideration the social, political and medical dimensions. The services we are supposed to provide in the primary care should be personalised, professional, and evidence-based – which is not possible if the practice will not be IT-oriented.
I believe this is going to be a long process where a change in mentality is needed. From our part it will take courage to change and start doing things differently than before with more responsibility and continuity. Our patients need to be educated not only to look after their health by practicing healthy lifestyles but also to make use of the system in a more rational way.
But, we need to start. My impression so far is that during the last 20 years, no progress was made because every side had its own agenda. Are we going to reach a consensus? Is this going to be another proposal to be shelved like the ones before it?
Mario Saliba is a GP at the Gozo Health Centre, a member of the Malta College of Family Doctors
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