Health Minister Joe Cassar has inherited a very tangled web at Mater Dei. He has been in charge of health for two years, but it is only now that he has been promoted that we can truly say that the health buck stops with him. Unfortunately he does not have much time to settle down in his new role as minister. He has to hit the ground running because it is clear that resources at the hospital are stretched to breaking point and unless something is done immediately it is inevitable that patients are going to suffer.
News about a woman giving birth on a stretcher and a cardiac arrest patient having to be resuscitated in the middle of a corridor send a clear message that the time for political rhetoric is over. Action must be taken without delay on several fronts. There are multiple, interconnected problems which must be addressed simultaneously in order to come to grips with the situation.
The immediate concern is the current bed shortage. When Mater Dei opened we all thought that the days of hospital beds lining corridors were over. However it is clear that this is far from being the case. Patients are laid on beds and stretchers in long queues that resemble traffic jams in Marsa at peak times, with patients spending hours and days in full view of passers-by.
The situation got so bad last week that medical personnel went on record complaining about the situation and asked for immediate remedies. The first salvo came from consultants working in the Department of Medicine. They sent a missive to the hospital authorities complaining that the bed shortages were endangering patients and that they could not assume responsibility for any resulting mishaps.
A few days later it was the turn of Casualty doctors and nurses to make their voices heard – “We feel this situation is far from acceptable, shameful and downright appalling. It needs to be remedied today.”
The bed shortage is a serious problem. Mater Dei has 850 beds and up to a few days ago 108 of them were taken up by social cases or patients who just needed a place to convalesce and get rehabilitated. The problem has been alleviated slightly by transferring 48 such patients to St Vincent de Paule, but that clearly does not solve the problem since 60 rehabilitation patients are still occupying beds in Mater Dei. I suppose at this stage we should be thanking our lucky stars that the AH1N1 pandemic was not as bad as originally envisaged, or the situation would really have become untenable!
It is clear that the minister must immediately roll out two plans for this problem. The first must be a short-term plan which tackles the growing number of social cases and patients needing long-term care. Ideas could include a quick makeover of an old St Luke’s ward, or conversion of government buildings into care facilities for such patients. It might also be possible to rent beds and rooms in privately-run old peoples’ homes or private hospitals – however the likelihood is that this would be a very expensive option. Alternatively the minister could consider getting several large townhouses and converting them into contained care facilities for old people.
A different tack would be to immediately roll out schemes to help families who choose to keep their older relatives at home. The support could be financial, as in subsidies and stipends for the carers, or service-based, as in regular nurse visits. I believe something of the sort is already in place, so promoting the options available and extending their coverage would probably improve their take-up.
The long-term plan, on the other hand, must involve a study of the changing demographics on the island. As we live longer the number of old and frail people in Malta is going to grow year by year, so we need to have custom-built facilities to cater with the needs of this sector of the population.
The bed problem is more important than most people think. If all the beds in the hospital are taken up, then surgeons and physicians cannot proceed with their planned procedures because there would be no bed for their patients to recuperate in once the operation is over. You cannot remove someone’s gall bladder and send them home immediately – so if there is no bed for the patient, the gall bladder stays put!
In order to enable the hospital to function properly the administration must not only clear enough beds to accommodate new cases seen by the casualty doctors. It must also clear enough beds for all the patients who have surgeries planned. There is no way that medical staff can make inroads in the waiting lists if they do not have beds available for their patients!
It is vital that an administrative task force is empowered to look into why patients stay in hospital longer than is absolutely necessary. For example it is essential to streamline procedures related to the investigation and management of patients. If a patient needs three tests during an admission these should be scheduled on day one so that the patient can be treated immediately, as opposed to taking up a bed for days on end just waiting for tests to be administered.
Similarly, it is very important to harmonise the management strategy for various conditions. If evidence shows that five days inpatient post-op is what is needed to recover from a particular procedure, audits must be put in place to ensure that consultants do not routinely keep such patients for longer than that.
Let’s face it – what is needed is management!
Once the bed situation is under control, the next most urgent issue is staff. John Dalli famously referred to Mater Dei as a part-time hospital, due to the fact that medical procedures, operations and outpatient appointments run up to around 2.30pm. This gives the impression that doctors and nurses work short hours and have it easy, but as any doctor who works 60 to 70 hours a week will tell you, the reality is very different.
In order to continue scheduling appointments and procedures after 2pm, the hospital must employ many more doctors and nurses. More consultants must be appointed and asked to take on patients in the afternoons. There must be a full complement of medical staff in the morning, to see to patients in the wards and to all the procedures scheduled – and then another full complement from 2.30pm onwards.
Scheduling operations and medical procedures in the afternoons will help to slowly make inroads into the waiting lists. However the likelihood is that then the medical staff will run into another problem – the availability of consumables for these procedures.
Take knee and hip replacements, for example. There are currently around 2,700 patients awaiting knee replacement surgeries and 700 on the list for hip replacements. However orthopaedic surgeons need the replacement parts. Making available the beds, the operating theatres and the staff will still not solve the problem if the government does not also make available the budget to buy the required prostheses to finally operate these thousands of people.
If Minister Cassar sorts out the beds and the consumables, he could approach doctors and nurses to perform procedures after hours and on the weekends. For example an agreement could be reached for an orthopaedic surgeon and his team to be paid x amount of euros for every hip replacement performed at Mater Dei on Sunday. The same would apply for angiograms and cataracts and all the other operations that have waiting lists running into the thousands.
It is only with such creative thinking that the critical situation we are currently in can be sorted out.
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