Besides being a relief that after the first sabotage, another document on the reform of primary care has been issued by the Ministry for Health, one’s first reaction to the document was ‘this could actually work!’. There are of course ‘buts’ and ‘ifs’ and other queries, not least the immediate reaction by the Medical Association of Malta (MAM) which addresses the fact that current health centre doctors cannot have patients registered with them as this would create a possible unfairness – presumably they would have to make a choice whether to go privately (and many already have private patients, which is why they would want to have the possibility of having patients register with them) or to remain solely in the health centre. They are at a disadvantage because presumably they would not have as many patients as private doctors.

The document however does guarantee that health centres will continue to remain open as they currently are and therefore patients who are used to going there and get a free service will be able to continue to do so. This is good for a start; one has to have a clear vision for the future however and if the quality of the service offered at health centres runs far below that in private, people will automatically be coerced into going privately. Surely even politically one must assume that the remaining two and a half years of the legislature will give a clear indication of where this is going to make it a politically sensitive election issue. And indeed, one must ask in which direction one intends this system to go. For if it is merely to have patients registered with private doctors and to encourage, as the document does, group practices, one must surely ask, “but in a foreseen future, do we intend these group practices to be private and therefore a place where one pays for one’s own care? Why are we maintaining a dual system of health centres while at the same time investing in group practices from tax money only to have fee-for-service? This question remains unanswered.

Clearly the government is not making an act of altruism by having doctors more organised. As the document implies it intends a better health care system for the people and therefore the funds can be justified with the same reasoning we subsidise Church schools – that they provide a service which takes a burden off the state. But in health care you cannot introduce the much hated polza on who gets to go to the health centre and who gets to go to the new group practices. The point is that the government has, or should have, clear indications where it wants all this to go. Clearly it is not about patient registration alone, for the very fact that the same people who utilise health centres can continue to do so means that a doctor with whom someone is registered but who is never actually seen by him or her, would still be asked to issue a death certificate. And if to get a referral I need to go to the GP with whom I am registered then I would either have to pay, or the insurance which is being suggested would have to pay.

But would this insurance pay for any test which the doctor does – glucose, cholesterol, an ECG? Indeed the document encourages investment in these by proposing tax relief. But again the question of who pays comes into it. If I want to do an ECG I can either pay for it or I can go to the health centre.

So we need to see this both from what is going to be gained by the patient and also by what is going to be gained by the doctor; not only because the army is run by the sergeants (presuming doctors all have that grade) but because a system cannot work unless proper incentives are given on both sides. It is understandable that anxieties can be felt at these early stages, but they have to be allayed by the time the government takes into consideration the input from the public. And if ever there was a document which affects the lives of people and the livelihood of those providing the service, it was this one.

I mentioned in a previous article how the parliamentary secretary spoke of the nostalgic days when the family doctor was part of the family. The document seems to be encouraging group practices which have proved not to have replaced the value-laden nostalgia in countries where they exist. It is right however for the government to insist that doctors provide 24/7 cover for their patients if they want to practice, but to preserve the family doctor concept one must allow for networking rather than group practices. Rather than providing practice nurses, one can provide network nurses. Alternatively we can maintain the current system and have the health centres provide out-of-hour services and cover for doctors who are absent for some reason. But do they not already do this? So clearly networking of doctors would work much better than group practices, at least in the short term.

The document encourages full time doctors. This is rightly so. But the reality is quite different. Many doctors have to work part-time to make ends meet. We have seen that many have maintained a government employment. But what about the hundreds of doctors who do company work – how will they juggle the time they run around the island with providing a 24-hour service. At the moment patients are accommodated, but if one provides networks or group-practices and imposes with them a necessity tied to them in order to obtain the benefits being offered, then patients may put on more demands and doctors may find they would have to give up jobs to cater for patient satisfaction. Of course the group can incorporate such work into its balance sheet, but how will doctors within the group be paid if one puts in much more than others.

What one hopes for is that such a system will not disadvantage those who have invested a lot and benefit only those who have nothing to lose. After all it is the former who have kept family practice alive all these years. There are people like myself who have a modest practice but who also work in other areas, say, academia (important as well for the field). One must see how these can be encouraged to convert to full-time as the document says. Take our department of family medicine, for example, which has full-timers and part-timers. It would be ridiculous either way to have doctors working within such a department without seeing patients as well. The point is that the very WONCA documents quoted by the report all advocate that family doctors in many countries do other work as well which is not only legitimate but necessary.

What is more worrying is that the document quotes a study by a friend and colleague that shows that at present there are 149 full-time equivalents (FTEs) catering for a population of 413,609. “This gives a doctor/patient ration of 2,776 patients which although it seems excessive, it should be noted that Maltese family doctors tend to work significantly longer hours than their peers abroad”. But is not such a system intent on changing this sate of affairs? There are also studies done locally which allude to burn-out of doctors. Now it is correct to assume that a system can only hold a fixed number of doctors, and indeed a government can impose this. But it is not in a very strong position to impose this unless one removes the right to work privately, for the government is not funding the system. Moreover there are nearly 400 doctors on the specialist register, not all of whom are FTEs but who all provide patient care. One would assume that therefore there can be half the Maltese population who have private doctors who are not FTEs. Certainly one cannot put these out of a job; certainly one cannot leave these patients without a doctor. What doctor-of-your-choice would it be?

These of course are only observations and much of what is pointed out here can be solved. But rather than solving it in time what is necessary is an exercise in listening and in reassurance. There is a deadline to receive suggestions but, as the saying goes, justice must not only be done, it must be seen to be done. And since Heraclitus pointed out that ‘Justice is Conflict’, a maxim which still holds true today, we have to have places where both the public and the family doctors can go and air out their concerns and make sure that their suggestions are not only ‘noted-and-point-taken-thank-you-very-much’, but are actually acceded to and studied carefully. To date people like me are annoyed that our voice has not been heard, were it not for the kind space of the media. And an unofficial report asked for by the minister seems not to have been heeded by whoever drew up the document. I am given to understand that an association of family doctors (one of many) was participant recently to draw up the new document. If this is so, no association has invited me to discuss what is going on. And what about doctors who are not part of that association?

When I presided for three years the council of the Malta College of Family Doctors, I had started a National Development Day, the aim of which was to discuss the future of health care then. These days were unfortunately not subsequently developed to their full potential and the future is now here. It would be wise to set these up urgently as it is the College’s and the Associations responsibility to all doctors who will run the system successfully, if successful it is to be. But not only, as doctors’ associations, they should also be running talks, seminars and debates for patients. We care about our patients and public debate cannot be left to the state alone – it would smack too much of ‘us’ and ‘them’, something which we clearly want to avoid. We are all in this together. We all need reassurance and knowledge.

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.