Stephen Calleja (TMIS, 27 September) quoted parliamentary Secretary Joe Cassar celebrating a mild decrease in the waiting lists at Mater Dei by making a common path through which patients are filtered and passed on to teams. This is indeed a commendable exercise and shows how positive and creative thinking can indeed solve many of the country’s problems, health care not least among which. However, the parliamentary secretary also acknowledged much of what has been written down in this column, that a better General Practice system will indeed reduce the burden on hospital lists.

Dr Cassar says that, “One common issue that unfortunately leads to an increase in waiting time is because patients do not follow up their cases with their own general practitioner, particularly when their condition worsens.

“People should realise that their first stop when they have health problems is their family doctor, who in turn has the duty to refer them for further medical treatment if he or she deems so.

“Unfortunately, there are quite a number of people who do not even have a family doctor. When people go to health clinics or the hospital for treatment, they are asked to name their family doctor but there are many who do not have one,” he added.

These comments are indeed food for thought and must be evaluated. The importance of Dr Cassar’s comments weigh probably more than he realises and indeed are a certificate to private family doctors who have been striving for a more formal recognition. It is not the first time that Dr Cassar has expressed deep interest in family practitioners and it is indeed a pity that the task force produced a report which seems to have been shelved. It should be used as a first step. But I will not dwell away from the main argument here.

The fact that a parliamentary secretary has formally acknowledged the important role of the GP, namely a complaint that patients do not follow up on their condition with their family doctors, which lead to increased waiting lists, shows that our health system cannot do without the family doctor. The family doctor has a direct competition from health centres, but notwithstanding the goodwill of the dedicated doctors there, our health centres have failed to provide, over the years, an adequate health system which is sustainable and comprehensive and which is totally free. Nobody up till now has presumed that family doctors played a vital role – although those of us in the field know it to be so. Nobody has admitted that family doctors were seen as nothing more than an add-on to the system and complementary or alternative rather than a vital artery in the countries’ system. The Prime Minister has indeed acknowledged their important role before the general elections, but the parliamentary secretary has now made the important link of this under-rated health care professional to the main health burdens on the hospital. The main question will obviously be: why not take full advantage and empower further the family doctor to act as gatekeeper and bring in a registration system making one person, the family doctor, the ‘contact point’ for his or her patients.

Dr Cassar has also complained that the waiting lists increase because patients do not follow up on their conditions with their own general practitioner (this can only be their private family doctor, as there is no such thing as someone’s ‘own’ general practitioner in a health centre). And this cannot be far from the truth. It shows not only that patients do have their responsibilities, but on the other hand it shows that we have failed to guide our patients in the pathways they should follow – for the simple reason that we cannot really claim that they should follow these paths.

What this means is that if someone (and this refers not only to these last few years but ever since the health centres, formerly polyclinics, were introduced under a labour administration) wants to have all of his health requests taken care of under the state primary and secondary care, there will come a point when this cannot be done – such as administrating one’s overall care, long-term certification, minor procedures, and at the end, palliative care and death certification. Patients tend to suffer from different ailments and they end up under different consultants for different conditions and cannot even have one Schedule V card which entitles them for free medicine as by its nature a Schedule V card will indicate the consultant responsible for the patient, and often this is not only one. How much easier it would be if the point of reference was the primary care physician who would be in a position to manage and administrate for the patient’s health and have the holistic picture of all under his or her care. The Schedule V card can then indicate the various specialists taking the secondary care responsibility for the patient.

Moreover hospital physicians may refer patients back to their general practitioners when the same patients were sent to hospital by their GP; but protocol will not allow them to do so when they were referred by the health centre. They therefore are referred back to the health centre. Now this has two implications. First, consultants often refer patients to health centres (for blood tests, for example) even if they were sent to hospital by a private GP, which complicates the web a little further. But even more importantly, Dr Cassar raises the point that “when people go to health clinics or hospital and are asked to name their family doctor...”, implies that even the health centres assume that patients should have their family doctors. This is clearly seen when someone dies. A health centre doctor who is called in cannot issue a death certificate and must refer the case to the family’s GP. When they do not have one, they simply find one who is willing to take on the risk of issuing a death certificate – something which technically and perhaps ethically (were it not for compassionate reasons) should not be done.

But there is an important point here: namely, patients are not obliged to have their own GP. Of course it would be prudent and advantageous for them to have one. But we have been moving along with the assumption that our system is only a dual system because we permit doctors to play a role. At most private doctors were seen to relieve the burden from health centres, just as private school relieve the burden of teaching from state schools, which would otherwise cost much more, and which is the sole reason why it is justified to subsidize private schools. It took several teachers’ strikes and several public protests in this regard to bring about a shift, which, incidentally, is due for a revision. So why the government cannot morally subsidise private practice, which not only has removed much burden from the state system, but which is now formally acknowledged to be the missing link holding the key to a more harmonised health care system and less waiting periods, is a matter for serious reflection.

There are several issues which must be acknowledged to achieve this goal. These have been mentioned often in this column but they are worth repeating:

1.Health care must remain free;

2.We must somehow subsidize private family doctors;

3.In this way patients can register with a doctor;

4.One can then easily harmonise digital files;

5.Moreover one can enhance the role of primary care physicians by allowing GPs with Special Interests, which although not specialists, would relieve much burden from the secondary care system – such as referrals for mere approval of drug items;

6.Patients would be referred back to the community much faster and will resolve the much disputed discharge letter as the doctors will have access to hospital records as well, which after all are the property of the patient, according to international protocols of both data protection directives and physicians’ collegiate documents.

This will in no way limit the private practice of specialities either, as there is always a market for those who would prefer a more personalised and continuous care with a specialist. The patient’s doctor who can easily recommend specialists to them will also enhance this. We will have a system were everyone with an identity card, which will act as a social security number, will be on someone’s list. If someone has an accident, the primary care physician can be informed more easily. This will require a seventh point: doctors will have to be networked to cover for each other when they are on holiday, sick, or on Sundays and feast. Group practices have not proved to be very popular for various reasons beyond the scope here. (Some doctors have larger practices; others have investments in equipment that others do not; some have a clinic whilst others avail themselves of free space in a pharmacy. All this proves too complicated for those who have spent years of investment.)

Doctors will have to be helped, and this is where subsidy can come in handy, for secretarial services to direct calls to appropriate doctor, to mention an example. And all this does not mean that the system will not need considerable thought – such as how to avoid abuse; clear protocols on house calls, etc. But that what governance is all about, after all. A government should help facilitate a system it wants to implement. Clear goals and targets must be set however. We need a clear direction before we start driving as otherwise we will change our destination with the first road block or traffic jam, as recent experience has shown.

The parliamentary secretary started on the right track in the beginning by organising a task force on primary care. Time is now passing by and one augurs that one has learned from the process, picks up the pieces, forms clear goals and moves forward to give our patients the health care system (not only a hospital) that they deserve. For a country with a population of 400,000 this should not be a big deal. It is our sometimes attitudes towards each other, bumping together in such a small area, that limits us. But clear health care objectives, mixed with positive political objectives may be used as good catalysts.

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.