The recent conflicting message and interpretations of the report of the task force formed by the Parliamentary Secretary for Health on reform in primary care merits some comments. It is fair to say that the report is a good effort to start discussions in this field. It would be disappointing of course if this report were taken as a fait accompli of what there is to say and propose. The committee was personally chosen and by no means represented all those who would have had something significant to add. This is also reflected in the references at the end, which besides some government and international reports, does justice only to those who were actually on the board.
In general the government should reject any health plan which contemplates the removal of a free health service. Rhetoric about nothing being free because we all at the end of the day pay taxes is based on epistemological arguments which do not translate into real-life perception. Governments look continuously at containing taxes, which in turn are there to provide, in a society like ours, social services. The greatest and noblest social service provided is health care, and primary among these is the reaching out into the community.
If improving our health care system means that at the end the poor man or single mother who cannot afford a GP, and who currently use health centres, find themselves having to fork out money, it would be retrogressive in the eyes of many, unjust for some, and probably political suicide on the part of the government. This does not mean of course that we should not find means to fund a free health service. Among these one can easily tax those vices which have a direct causal increase on health care; another is to direct National Insurance to the provision of health and pensions only, which is what it is supposed to be directed to. Instead it is all put into the general pot. If people know that health costs X amount of euros, and the government only collects X minus Y, then it may be more acceptable to the public to accept that increase in Y in the NI contributions. But if the same thing happens as with road tax, which is collected, but which never fixes the roads, then it becomes perceived as an unjust tax.
Once we have accepted the right to a free access of primary and secondary care, it is inevitable that any change which contemplates a fee-for-service without a safety net for those who cannot afford (or will not afford, be it as it may), then it is obvious that this right is to be seen as to be taken away. However one must be careful when planning free health services. We have clear examples of two extremes – that of the UK and that of Italy. In the former, the NHS has been providing group practices to the public. Doctors are paid well, but gone are the days of the ‘family doctor’ who visits you at home, at your whim, or because it is too cold outside. Doctors work in groups and on a schedule and one may wait weeks for an appointment. Patients do not have the luxury, as in Malta, to simply go to the GP to have their blood pressure checked and get some reassurance when something distresses them. On the other hand, in Italy, the family doctor has been reduced to the person who writes out prescriptions and certificates.
They have made a retrogressive step in that the GP cannot even manage your diabetes and, much like us, has to refer patients to other specialists for approval of drugs. This has therefore not helped the waiting lists – something which we want to resolve. If in any way, the work of the family doctor is undermined, then not only will they be unhappy, but waiting lists are bound to lengthen.
The balance is to find a system whereby GPs are given incentives to do sub-specialities while working in their group or solo practices. Solo practices can be networked together to allow the doctor to take the much earned time-off. But if we discourage procedures like minor surgery, infiltrations and mere injections for acute pain, then people will have to obtain this from secondary care or continue to receive it privately – if the system allows doctors to do so.
However if doctors are not paid extra for such services (house calls, for example, are paid for extra in the Italian system), it is inevitable that such services will not be offered. This is the reason why doctors working in health centres do not do any minor surgery other than perhaps, emergency sutures, and do not perform procedures, from ECGs to joint infiltrations – all legitimately within the family doctor service provision. Even giving an intramuscular injection may be risky for the doctor, as reports and litigation are bound to increase. One need only look at the number of doctors working in health centres who are reported by the public as compared to those working privately. The latter are practically nil, while in the former they verge on the ridiculous. In one instance, when I was president of the College of Family Doctors, we had a doctor who received a request for a house-call at night due to a child with fever. He could not leave the health centre and legitimately gave advice over the phone and told the parent to call again within the hour. The parent did not make the call but instead reported the doctor to his GP the next morning. The latter, being a parliamentarian, made it his duty that by that day the doctor was issued with a charge. It was with considerable defence that we managed to put it down to a reprimand (still unacceptable, to be sure).
In proposing new systems, doctors have to be careful not to shoot themselves in the foot. The report of the task force, at the end of the day, is saying nothing new. Basically it advocates for group practices and registration. It makes the extra (good) advice that doctors within the primary provision be on the specialist register, which guarantees patients that vocational training has been undertaken. It is ironic in fact that even in countries where the family doctor is not yet recognised as a specialist, they have obligatory vocational training, and we do not (at least in the private sector, which by far carries most of the burden, anyone can do General Practice, not specialising therefore in the recent topics which have turned general practice into an area of specialist care as well).
We should also however learn from countries like the UK. Pilot studies have led to systems which have considerably removed the burden from hospitals. In gynaecology for example we still do a lot of D&Cs (raxkament); this, I have been told in a recent meeting at the Royal College of Obstetricians and Gynaecologists, has been history in the UK for quite some time and they do hysteroscopies instead, whereby they insert a small endoscope into the uterus and there and then remove any polyps. They took it further. GPs with a special interest have been trained to do this procedure and pilot studies showed how much the pathway to care was decreased in time and how much the NHS saved in money. It was therefore subsequently encouraged throughout the UK, the limit being only the number of GPs ready to do it. Of course they worked hand in hand with gynaecologists for obvious reasons and the argument is not necessarily to introduce hysteroscopies here, but to encourage procedures in the community rather than increase costs and waiting time in the hospital.
If the aim is to decrease referrals, one must consider that a system as proposed may do just the opposite if these and similar considerations are not introduced. In fact one has to think about a system which will reward GPs for extra work and not conversely encourage defensive medicine. Defensive medicine is a way by which a doctor does not take undue responsibility. This may be due to blame being put on him if he does not refer early but tries to cure the patient (competently), and/or the issuing of orders which may demean the doctor’s capacity, such as happened in the past when one mistake led to the department requesting that all patients presenting with chest pain at the health centres were to be referred to hospital without even the hope or scope of taking a history to separate the true emergency from the manageable angina pectoris. Inevitably many hysterical cases were sent to hospital due to ‘policy’, which not only increased the waiting time in casualty and unnecessary observations, but, as far as one knows, has not been shown over the years to have saved lives. It was simply a distrust in GPs, which vocational training should hopefully put to rest.
One must also think about the MD course which this year has reached a record intake of 100 something students. This ridiculous situation, we were told, was due to our being in the EU. Not true. All countries in the EU have a numerus clausus. Why should we pay with our taxes for all those doctors? While studying is a right, neither are we obliged to pay for all that is not necessary. The reason we keep our numero aperto is that we try to lure people from the Middle East. This is good for our culture and they bring a lot with them. But if the reason is monetary, it is short sighted indeed. We can easily make up the difference by providing post graduate specialist courses for doctors at University. With a population of 400,000, and a minimum of 1,000 patients per doctor, all you need is 400 doctors, with a small influx to make up for those who retire. This means that every four or five years we produce this number repetitively. Then we complain we do not have doctors in our hospital because, of course, we do not pay them what they deserve as doctors.
Finally one cannot contemplate a change in primary care without touching the secondary care system. It would be absurd indeed to try to save people less than 100 euros a year on primary care visits, when even the poorest, in order not to wait for months, if not years, will spend it all in a half hour visit to a specialist. Even specialist private lists may go down if GPs only refer to hospital. If patients can go on their own, without a referral, to a specialist, we will be creating a system, as has happened in other countries, no less the United States, and (again) Italy, where it would be economically unfeasible for the same investment in years and energy to become a family doctor. I was told just last week by the president of the Italian Association of Family Doctors that by the time he retires, there will not be enough doctors who have taken up the speciality of family medicine. He is 58 years old! We would simply be back to square one.
Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.