When attending a conference in Cardiff about a year ago, my luggage did not get through due to a short connection time. All my medication did not arrive, therefore and naturally I went to the nearest pharmacy to ask if they could give me a day’s supply of anticholesterol drugs and a couple of other medications. They said that they could not unless I got a prescription from a local doctor. The fact that I am a doctor too did not help. All was in vain. They could not give me anything without formal prescriptions.

This year I was holding a short ethics course for public health officials. One of them explained how she was attending meetings in Brussels where they are finding ways to improve across border health within the EU. One of the proposals is that prescriptions given to patients in their countries can also be used in other EU states. The problem is Malta! Our prescriptions are all hand-written on a prescription pad. We do not even have to make formally printed pads, and often prescription pads given to us by drug companies suffice. All that is necessary is your signature and rubber stamp. This is actually very practical and it is a legal document as far as most are concerned. The problem is when you go out of your village. Pharmacists tend to recognise GPs and when they cannot, they can always countercheck with the medical register. But when you go abroad it is quite another thing.

The issue of prescriptions, over-the-counter drugs, etc is very complicated in Malta. That pharmacies compete with each other may make the situation a little more difficult. Of course no pharmacy would wish not to satisfy a patient. This however may translate (and by no means am I accusing all pharmacies of doing this), that if the pharmacist knows the patient, a drug may be dispensed without a prescription. My experience with patients is that once I issue a prescription for something, the same prescription can be used again and again, and once the pharmacist gets used to the patient and knows his or her treatment, it would not be a problem to be given one’s medication.

Again, I cannot say that I am not satisfied with this state of affairs. Once things are under control, it is probably good that one is practical. But one should be aware of the risks. It is not the first time that a patient tells me he or she was given an antibiotic over-the-counter – which, means without a prescription.

What is practical is not always foul proof and it is probably time, if we want to be able to buy drugs within the EU, to review the way we issue prescriptions. Even if one had to use the prescription pads, an official document, which one uses for free medicinals, they are still hand-written, and probably abroad it would make more sense to have something typed out. Are we too far away from the computer generated prescription as is used abroad?

Not that abroad they do not have problems. But certainly we are verging on the unethical when people can buy antibiotics, anticholesterol drugs, and perhaps, even merely Aspirin 75 – a mild but effective drug for people at risk of arteriosclerosis. There is no strict line in Malta between what is an OTC (over the counter) drug and what is not. In theory, of course, there is. But in practice it seems not to be working.

A prescription system would have been tied to a revision of the primary health system. We have not heard of any advances on this lately and the cabinet has refused the report given by the task force. What is needed is a vision for health care. A system whereby people who have their minds at rest about their health cannot be considered such an insignificant thing, even to let politicians not see its advantages. Of course, it is the moral value which one should be looking at. But we have introduced too many things which do not have any moral value at all but were introduced merely for political reasons. One government introduces something and the next is too shy to remove it. Instead it introduces something else. Take, for example, the pink card. This card allows the holder to get any form of medication for free through the health system – from paracetamol to canesten cream. It is people below a certain income who were supposed to receive this card. But who, in fact gets it? We have members of the Armed Forces and the Police Force, and then Diabetics. Now I can understand that the government treats his soldiers and police force and gives them a much earned benefit. But why is it that I as a diabetic am entitled to this card, whilst, I again, as an asthmatic am not? Given that both are chronic conditions, the medication is given to everyone through the yellow card. The pink card is there for any other thing which normally people buy.

Now diabetics are not known to be poorer than asthmatics. In fact it is probably the asthmatic who needs to spend more on his condition. So why was this introduced? The most obvious answer is numbers! And the perfect lay reasoning is that a politician along the line may have thought that this translated into votes; and a future politician thought it best to let sleeping dogs lie. There is no official explanation (at least not a valid one that I know of) on why diabetics (that includes myself, mind you) should get this card and asthmatics or someone with arthritis should not. We in primary care, who look after people with these chronic diseases, have always wondered why. Not only, but as a diabetic, if my income is below a certain bracket, I am also entitled to a monetary benefit. Now many people ask for this monetary benefit. They are surprised when they are told that there is a specified list of conditions listed as requirements to the entitlement. There was a medical board to decide upon this. We just sat there and investigated anyone who brought proof (as if proof was needed, once you are receiving free medicines already) that he had a disorder. We would countercheck the list (before we learnt it by heart) and tell the poor soul whether he was entitled or not. So, being a schizophrenic means that you get a benefit but being a manic depressive means you don’t. If you are hypertensive or diabetic means you do; if you are (again) asthmatic, it means you don’t.

Now it is an open secret that some doctors, in their pity for patients, are known to put down one condition for another so that the patient is entitled to free drugs. Ironically if the consultant happens to score on a condition (which, remember, you do not in actual fact suffer from but which is being used as an excuse) that also happens to be on the list (like Schizophrenia), then you get these people coming for this extra monetary help as well. It is not enough that the doctor put his licence on the line to help them get free medication.

Moreover it is a known fact that those items dispensed by the government are not always up to the standard of those that you buy. It is fair that the government buy generic drugs, as these are cheaper. But some generics are the generics of the generics and not even worth the box they come in. A good example is the antihypertensive drug enalapril. The generic used here changes with every full moon, so no one need be offended. But ask as many GPs as you wish and they will tell you that it takes double the usual dose for some of these to have an effect. Which means that even if you are spending half the amount, you in fact are not, for it takes twice as much medication to do the job. Not to mention the salbutamol being dispensed instead of the non-generic ventolin (and I do not mind mentioning it by name). Not only does the former not contain the 200 puffs specified on the box, but its aerosol does not exactly drive a Jumbo-Jet either. How can it have 200 puffs, when the other inhaler we use in conjunction for asthma – the steroid – and the former ventolin were twice as big in volume. I do not think that the company which produces them has found a formula for space. The reality is that after 20 puffs, the ‘puff’ becomes a whiff, which turns the canister into a projectile into the bathroom bin. (I have become expert at this that my five-year-old daughter calls from the next room enquiring whether I made the basket).

Perhaps we need to contemplate some change here. Why is it that other countries afford to give their population the real thing and we do not. It is probably because we give out all those medications through the pink card, which other countries do not and which would balance the books if they were not being given. We do not have people in such a low income bracket that they cannot buy a box of panadols or a tube of canesten. The reality is that many patients would tell you, ‘Iktibli tnej. Hu pacenzja’. Thank God many a doctor tries to act as a gatekeeper. Free panadols has nothing to do with free health care.

Now, with the pharmacy of your choice, people still have to go to hospital for the more restricted items. If there was a way how to avoid this, it should have been through the pharmacy of your choice! But a pharmacist tells me that they are being more careful now. For example, with asthma, they are strict not to give more canesters (of the ‘former’ kind) than a quota established centrally, irrespective of the dose your GP or specialist feel you should be getting.

If by now you are confused as to where I am going on this article, well, you should be, for I am as confused as you are and I am a doctor. All we need to do is to dispense with all our pink, yellow, white and gold cards and make one nice platinum card which entitles the patient to get the medications for his or her chronic disease for free, from a pharmacist of his or her choice. The pharmacist will then get reimbursed. Of course the government will still have control over whether a generic or not is given. But really, between one generic and another there is really no difference and it will not cause the balance sheets to topple over the desk. All that is needed is a pilot study in a small area served by a health centre and they will see it is more efficient, effective, and give a certain leeway to choice and dosage to doctors, which, by the way, translates into better health... and which will translate into less morbidity and hospital costs. And of course will allow our colleagues from public health centres to be proud of our prescription system. This means of course we as EU citizens will still be able to buy medications with a prescription from our own GP. It may take some time to implement, especially if we are to introduce computer generated prescriptions, but the benefits pay off.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta, specialized in Philosophy of Medicine. He is also Ethics Advisor to the Medical Council of Malta and is former president of the Malta College of Family Doctors