Editorial | Sunday, 21 February 2010

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The great health conundrum

Last Monday, Health Minister Joe Cassar announced that he would consider ‘substantial changes’ to the primary healthcare reform bill he himself had proposed some weeks earlier.
This was a momentous decision, as it clearly delineated the narrow boundaries within which the present administration is being forced to operate. With at least one Nationalist backbencher threatening to vote against the reform, Gonzi was left with no option but to bow to pressure and reconsider his health minister’s proposals.
The political implications are clear for all to see. Less immediately clear, however, are the possible future consequences for a national public health service that most would agree is utterly unaffordable in its present form.
The discordant reality of Cassar’s aborted proposal is that it reflects one of two possibilities: either that the NHS must be buttressed by a stronger primary health gatekeeper, that filters patients out to avoid the twin problems of overcrowding and understaffing; or else, that the government is not willing to invest further in an expensive service, and therefore prefers to make patients pay for it through their GPs.
In either scenario, it is money that underpins the great health conundrum. Clearly, the existing system does not represent a judicious application of public funds: both because of patients’ dependence on a general hospital for minor treatments (a dependence ironically encouraged by the present government before the last election), and also on account of the plethora of services and expensive medicinals generously dispensed to taxpayers for free.
Cassar’s reform addresses this issue by encouraging patients to visit their GPs instead of availing of regional polyclinics of a general hospital. In a recent interview, he went through great pains to explain why the government had chosen this approach, rather than reinforcing the existing service with an IT infrastructure that would enable the exchanging of health records. But why should taxpayers, whose monies contributed to the construction of a €1 billion state-of-the-art hospital, suddenly be turned away from availing themselves of this same hospital’s services?
Cassar’s argument was that more patients should be seen by private GPs anyway, and that these would additionally serve as a precautionary buffer to reduce the prospect of future morbidity. This in itself is a rational argument – indeed, it was precisely how the earlier system of District Medical Officers was intended to function – but there is of course a price to pay. Private GPs do not offer their services for free, and if the reform bill went through as first proposed, it would have spelt the end to ‘free health for all’.
Patient registration was another major plank of the reform: one which will hopefully be retained, as it is by far the bill’s most attractive aspect. The idea is ultimately to network the system by means of electronic transferral of medical records, so that patients (regardless of which doctor they are seen by) will have their medical histories available for other doctors to examine, thus ensuring better continuity of care.
This is all well and good, but Cassar has so far failed to explain why this has never been attempted within the public sector in its present form. After all, the use of information technology to link polyclinic records does not depend on a system of referrals by GPs, and therefore does not justify the apparent ‘privatisation’ of the service. Why should private doctors suddenly supplant the polyclinics, which provide minor emergency treatment on a 24/7 basis? And how does this direction in healthcare tally with the prime minister’s irrevocable commitment to free health?
Cassar claims that the success of primary health reform lies in a durable doctor-patient relationship. But this argument is in itself debatable, and differing views consider the electronic exchange of medical histories a far superior end to that of having patients pay their GPs before walking into a public hospital of their accord.
This policy direction is not just a concern for low-income earners, who are dependant on the regional polyclinics and the general hospital for their everyday healthcare needs. After all, the reform envisages subsidising these very groups to turn to private GPs. It is also the middle-income earners, accustomed as they are to a hybrid system of public and private healthcare, who may not want to rely solely on private GPs, especially in the prevailing economic conditions.
Moreover, the proposed reform does not answer Malta’s healthcare needs by tackling its root problem: money. While the prime minister declares his undying commitment to free healthcare, and opposes any levying of fees on minor services, he appears to be backing a health reform that will de facto make patients pay for services they currently take for granted.
From this perspective it is perhaps no bad thing that government has chosen to reconsider the reform bill... even if for all the wrong reasons.

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The great health conundrum

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