At present the Primary Care system in Malta is run by two systems: The polyclinic (health centre) system, which is free at the point of delivery, and the private family doctor service (against payment).
The former is undermanned to the extent that some health centres have to close in the evenings and at night. The service provided by the medical professionals at these health centres is episodic in that it provides no continuity of care since frequently the doctor has to refer patients to secondary care (i.e. to Accident and Emergency or to consultants in hospital). The setup at health centres cannot guarantee that he/she will follow-up a particular patient.
However health centre doctors have access to several facilities which are still being denied to private family doctors. Family doctors working only in private practice cannot order several blood tests such as specific tests for diabetes (the “national” disease), for thyroid malfunction or to screen for cancer of the prostate. Unlike their colleagues working at health centres, they are unable to view results of X-rays, CT scans or blood tests results online. Thus, they too have to frequently refer patients to secondary care just to obtain these tests or the results thereof.
This “unnecessary” referral to secondary care is an added burden on government health expenditure. The government has just issued the “costs” of visits/appointments and procedures carried out at Mater Dei Hospital. An Accident and Emergency consultation costs e46.59, whilst an outpatient consultation costs e34.94. Add to this the loss of time (and the value of this loss of time) to the patient and to whoever accompanies him for the several times required to finally get the result. One must then multiply the resultant sum by the number of patients who need not have accessed secondary care in the first place.
The Reform in Primary Care announced recently addresses these issues.
So is the reform a cost-cutting exercise? Of course it is!
In all fairness however, this is not the only aim of the reform, which has long been overdue. For one thing it should reduce hospital waiting lists, which would leave more time for consultants to attend to other cases that really require hospital consultant care.
We welcome the commitment by government to reform this important sector. However, there are issues which will need to be discussed, elaborated and possibly amended. We make it clear that we are apolitical.
Government has been so clear in those aspects which relate to its part: Registration for everybody is compulsory. An 24/7/365 cover is envisaged. Group practices are to be set up; quality assurance will be mandatory. Clinical audits and practice accreditation will be required.
It is not at all clear how these responsibilities, all extra to the present family doctor’s set-ups, will be financed and managed by the doctors. We are not sure how clear government is either.
Nothing is free. In the consultation document there is no mention of where the substantial funds required to set up practices, employ staff and to improve facilities are to come from.
The systems in three countries have been quoted as examples, The Netherlands, Denmark and the UK. Will the Maltese government match the financial commitments made by the respective governments to make their systems work? Vague statements are not good enough.
Access to secondary care and to the social services will be only through doctors who agree to participate in the scheme. This is reasonable – to an extent. But what about the patients whose doctor/s do not choose to participate in this new system? Will they be denied what is theirs by right?
We are ready to participate in discussions with the Health Department, as we have been doing all along, for as long as it takes. But does this whole system have to be up and running before we can order more investigations and access results on our patients’ behalf? This would reap immediate benefits. On the other hand, the provision of these facilities, which after all benefit the patient, should not be like carrots dangled in front of private family doctors to entice them to participate. Once the technology is presently available these are the rights of the patients – whoever their doctor is.
Private family doctors will be the linchpins in running the system. If they do not accept it and what it entails, then it will not even take off. However, we are confident that reason will prevail and that no hurried “reforms” would be launched until all the above points, and others, are thrashed out.
Anthony P Azzopardi
President of the Association of Private Family Doctors