The secretary-general of the Medical Association of Malta, Dr Martin Balzan, talks of waiting lists still haunting Mater Dei and why government must go back to the drawing board on primary healthcare reform
Matthew Vella
Without any prompting, Martin Balzan is off, as he points out how waiting lists and lack of bed space are problems that still plague Maltese healthcare, even in its modern reincarnation with the ‘state-of-the-art’ hospital that is Mater Dei. “With its 850 beds, even when used in the most of efficient of manners, Mater Dei is not sufficient for the Maltese population. At least during the peak periods, because the load is always seasonal. The government is now building a new block for oncology, which will certainly reduce the pressure, but it will still take two or three years to complete,” he points out.
As we make way to the Medical Association’s (MAM) offices on the third floor of Mater Dei (at the end of that interminable corridor) Balzan stops and points out of the window: “Look at that,” he says, showing me the internal courtyard of the hospital. “Do you see those two corridors? One of them was built by Labour, and the other was built by the Nationalists.”
Concretely, the two corridors are symbolic of the malaise of our political culture: the second floor corridor does not run exactly over the first floor corridor (the one built by Labour), but a few metres to the side. And there are no corridors connecting the third and fourth floors. “We cannot go from one side to the other of the two blocks on the third and fourth floors, to the other: we have to catch the elevator to the second floor, pass through the corridor, and catch the other elevator back up,” Balzan says, smiling wryly.
But such architectural mayhem is not what really gets his dander up, as we get back to the problem of bed space in Mater Dei.
“We’re losing some 100 beds right now,” Balzan says. “They are people who have been discharged by their consultant, but have not yet been taken home by their relatives. It’s a complex problem. There are a good number of people who are dependants, single, or whose families don’t take care of them. They are not necessarily social cases, although a lot of them would be better off in a care home. And even when they are scheduled to be transferred to homes, it sometimes takes up to over 30 days to transfer them.
“So in a nutshell, the amount of people that the system is generating – the Maltese population – is not equal to the amount of services being provided. These people need homes for the elderly or services within the community. If these services, such as meals on wheels or home-nursing, are improved and kept in the community, they would be freeing up bed space at Mater Dei.”
On the flipside of this ‘clogged-up’ reality of public healthcare are the private hospitals, which, as Balzan notes, are essential to freeing up the waiting lists on those operations in which patients prefer to pay for themselves. “People like it that way,” Balzan succinctly notes, “and when Mintoff tried to close down the private hospitals, it wasn’t just the doctors who were up in arms, but the people. They want to have choice.”
I ask Balzan whether the MAM’s successful negotiation for increased salaries for public health doctors, just prior to the 2008 general election, had been fruitful in keeping more surgeons and consultants employed full-time at Mater Dei, rather than on the payroll of both the State and private hospitals. It seems, not much. Although some other advantages are evident from the renegotiation of the salaries.
“What I can say is that anyone who spent the last 20 years building up their clientele was in no way going to kill it off… but the younger generation are choosing more and more to work for the government, and even coming back from abroad. Although it’s not happening overnight: more doctors choose to work in public healthcare, and less graduates are leaving the country.”
Instead, Balzan turns to the problem of waiting lists, and says that if the salary renegotiation had little effect it’s because Mater Dei has 20 operating theatres, only half of which are being used for operations: hence, the waiting list problem.
“Doctors want to operate, but have neither time nor place to operate. The limit on the operations that can take place here is due of the lack of nurses and paramedics in the theatres. There is not enough theatre time: the government did not plan for the appropriate manpower.”
When I ask Balzan whether he agrees with the concerns of nurses’ union boss Paul Pace, who claims the health system requires 1,000 nurses by 2013, the MAM secretary puts up a brick wall. “I’m not going to get into it…”
But there is a shortage of nurses, and the government has just opened the nurses’ graduate course to more students. How many more nurses does the system require?
“I don’t concern myself with this issue.”
Don’t you need nurses to assist you in a hospital?
“My job at MAM is to see to the interests of doctors,” Balzan says, even though he reiterates that bottleneck of surgeries – year-long waiting lists for cataract operations among them – is down to the lack of nurses and paramedics to run the theatres.
Have you ever brought it up with the government?
“No, not really… that’s an issue between government and the people,” Balzan says, curiously eliciting the sensation that he doesn’t want to get dragged in the issue of nursing shortages. I seem to be missing something: isn’t it in the doctors’ interest to ensure there are more nurses to assist them?
“Rest assured that surgeons want to do more operations, but the administration of the health services is not our job. It’s up to the people to put pressure on government. In the meantime, the volume of operations has increased thanks to afternoon sessions, so the waiting lists have decreased.”
We come to the plans to create a reinforced frontline of private GPs, which government outlined in the primary healthcare reform document, which Martin Balzan has called ‘flawed’.
The plan is to get people “healthier” and treated in non-hospital scenarios, such as at their GPs, to reduce the burden on state-provided facilities. So the government wants to see more people making use of GPs before taking their ailments to health centres and the general hospital. Patients register with your family doctor, who becomes custodian of their medical files, which can be shared through a communication system with other doctors and hospitals to provide better treatment and follow-up.
“GPs are already giving a good service in the community, and to this end they serve the frontline’s purpose. What we need are more services in the community, such as nursing and support for bedridden people. I don’t think that cutting down the waiting lists at Mater Dei is dependant on the primary health reform. I think the document itself is a work-in-progress.”
But surely, the vision set out in the government’s primary healthcare reform document does address the need to stop treating Mater Dei as a glorified polyclinic, and to institute a frontline of primary healthcare within the community.
“The service given in the primary healthcare sector today is not bad. It is decent. The problems being faced here are down to fragmentation: people using more than one GP, using both health centres and GPs, never seeing the same doctor in the health centre... And what happens? If a doctor has any doubts about a patient which he doesn’t know, he is not going to take any responsibility – he refers them to Mater Dei, they go straight to emergency or outpatients.
“So, to get back to the document, if a GP knows their patient, and has the tools to order tests and has access to their medical history, he will be treating these minor conditions in their clinic – reducing the load here at Mater Dei, mainly at outpatients and to some extent in casualty.”
However, for the system to work – at least, going by the primary healthcare reform document – GPs will have to be available to their registered patients 24 hours, seven days a week, so that their patients do not avail themselves of any regional clinic or a general hospital when they could ‘easily’ be seen to by their family doctor.
“That’s one of the things which, as stated in the document, makes the reform unacceptable. As it is proposed, it is just not acceptable to have a private family doctor available 24/7. MAM has its own proposals to discuss with the government on how to go around this issue,” Balzan says.
He also takes issue with the reform’s intention to do away with public health doctors who moonlight as private GPs. If family doctors want to avail themselves of the benefits of a registered clientele, they cannot form part of the cadre of public health doctors. They will have to choose.
“That’s another thing we don’t agree with… it’s unacceptable. The government has a public healthcare service, which has no reason to be worse than that offered by the private sector. A state-employed doctor after all is not going to give a worse service than a private doctor. Today there are many doctors, especially female doctors, who don’t want to work in a private practice – their family commitments can be better served as employees of the state, with fixed hours. The question here is not having public healthcare doctors excluded from the reform – it’s the continuation of service, from private to public that must be improved, by providing an unbroken link of information.”
I chip in with the fact that many doctors in the public healthcare system, especially in polyclinics, have reported widespread dissatisfaction with their jobs. 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 places to work in. And to compensate for their low salaries, nearly all GPs at the health centres carry out their own private work.
“This demotivation stems from the lack of a personalised rapport between patient and doctor. The moment patients start going to the same doctor every time, they will get better service and doctors will enjoy this relationship even more. It gives them satisfaction. But the government does not need to exclude its own doctors from furthering this relationship in the private sector.”
So why don’t these doctors just choose to work in the private sector…? Balzan proposes that the government caters for three groups of doctors: the ones who work with either the public or private spheres, and those who want to work in both areas. “We need a system that caters for the three groups. What government needs is to protest the most vulnerable of patients, which will be seen to by the public health sphere. A big chunk of the public also makes use of their private GPs, because the service is not expensive.”
While Balzan insists on the happy medium in the role that public-private GPs play in the community, the government still hopes the patient registration system will prevent people from making use of polyclinics and hospitals unless they are referred there by their GPs – while at the same time, patients will still not be turned away from these centres, even if they have no referral tickets. So, where’s the catch?
“It’s not exactly clear. It’s a grey area. You can’t expect a doctor to give you 24/7 service, so he must be available at established office hours. The government should be looking at three different grades of care: there’s elective care, such as check-ups; the emergency situations; and the illnesses that can wait until the next day. We already know that the bulk of emergencies will fall on the public system because few private clinics cater for these cases… so the government cannot prevent state-employed doctors from the patient-registration system, or it will only be frustrating them even more,” Balzan says.
Balzan continues that, as stated in the reform document, while patients are expected to pay their GPs in order to be referred to a public hospital, there is no question that hospital doctors would refuse patients without referral tickets at the emergency department.
“The document basically is saying that patients must pay to be referred... it’s wrong, because patients are paying taxes for this service. If people paid for Mater Dei to be built, then it’s their right to go to Mater Dei.”
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“With its 850 beds, even when used in the most of efficient of manners, Mater Dei is not sufficient for the Maltese population. At least during the peak periods, because the load is always seasonal. The government is now building a new block for oncology, which will certainly reduce the pressure, but it will still take two or three years to complete,” he points out.
