There is no doubt that in Malta the population is still privileged to have its family doctors provide a service in their homes, no matter what reason they give. It is enough to call one’s doctor in the morning and ask him to visit without giving details of necessity, other than perhaps if it is an emergency. The doctor usually either comes immediately or during a convenient time of the day, which patients often get used to. Patients call their doctors’ home for reasons ranging from running a fever to being tied down to staying at home because the company doctor will not find them there or because they are waiting for the washing-machine-man. This is fine by today’s standards and doctors comply (even because it is a market force). Even rain is a good enough reason for many.

Changes in practice may bring in changes in attitudes and practices which allow doctors a better schedule but which inevitably brings about the removal of privileges, especially when we do not realise they are abusive. It is not that doctors don’t get wet; but some people can do their best to open the door faster than usual when it is. Then you have to work your way through those plastic/canvas sheets which protect their doors from the splashing of cars, which inevitably shower you every so often.

When should house calls be done? We do not have clear guidelines here and in the UK they are at the discretion of the doctor. But we would do well, if we were to introduce a system as the one we are contemplating, which documents when doctors should make domiciliary calls, and educate people when they should not. That you are waiting for your company doctor may indeed sound legitimate to you, but it is not for your personal doctor. In many countries with national health services, laws have had to be enacted to guide professionals and patients alike. Unfortunately such has not occurred with our health care system and it is not the first time that doctors have had to worry about charges which certainly should not have been issued simply because they did not do a house call when it was uncalled for and when they offered alternatives.

Certainly it is not an emergency in and of itself which defines that a house call should be done. For example, health centre doctors were supposed to see patients after 5pm only for emergencies. Even if a sore throat is not an emergency, a woman once told me, “to me it is an emergency if my child has a sore throat”. What she needed was reassurance. A colleague in a health centre got charged because he failed to do a house call for a child who was running a temperature. Even though a fever can be an emergency and one has to exclude dangerous causes, it is not necessarily a cause for a domiciliary visit. This is the whole point.

There is only one condition which, legally (and when I say legally I am not referring to our law, but to what can be translated into negligence by a doctor should he or she fail to effect that call), requires a domiciliary visit (in lay terms, a ‘house call’): intransportability – when a patient cannot be transported to the clinic. This is usually linked to three practices and does not necessarily involve an emergency:

1. A list of patients who cannot make use of normal means of transport (including public transport);

2. An obligation on the part of the family to provide transport (in Italy this is law!);

3. An obligation on the part of departments of health to educate people on the correct use of these services.

It should be noted that ‘rain’ and ‘company doctor’ do not enter into the list. But to clarify what we mean by ‘intransportability’, many countries have a definite list to guide both patients and doctors.

This includes:

• People on the above-mentioned list;

• People who cannot be transported;

• Severe cardiac insufficiency;

• Severe respiratory insufficiency;

• Severe arteriopathy (circulatory insufficiency which renders a person incapable of walking);

• Severe encephalopathy (brain damage);

• Paralysis;

• Terminal illness;

• Severe disability

• Elderly people with fractures;

• Stroke patients;

• Psychotic patients;

• Temporary disabilities;

• And, for protective reasons (including protection to self or others).

Of course a competitive system like ours makes such a list almost useless. I say almost because should a doctor refuse, he or she is still liable to attend to a patient under tort law (which defines negligence). A doctor would be guilty of omission should he fail to provide a house call under these circumstances, without providing an alternative.

What is the alternative? Sometimes, if it is not an emergency, some advice on the phone suffices. At other times he may offer that he or she see the patient at the clinic. Note that this is legitimate. If the doctor feels satisfied that the patient can make use of transport, he is legally not obliged to visit him or her at home providing he has still offered to see the patient at the clinic. Alternatively one can make an arrangement for a day and time convenient for both. In emergencies one has to note as well that it is the patient’s inability to be transported which defines the situation. Thus, even if a fever is an emergency, the doctor is obliged to go only if the patient cannot come to the doctor. In reality this applies in our system only for health centres, and even here unfortunately the system has tended to err on the doctor’s side as described above. It is because things are not written down clearly.

Doctors have to make an urgent call within a reasonable period of time. It should be noted that the services of a doctor however are to be defined within the scope of the whole system. He is part of an integrated system. Doctors can send transport for patients if they are unable to attend to people. Many countries also have exact codes to follow in case of complaints. The doctor has to clearly have breached one of the above duties and only then is he investigated. A controller therefore decides whether a breach has occurred and then decides whether to issue a warning to the doctor or to proceed to further procedures. In private practice locally a patient only has recourse to the medical council to which one should complain in writing. The medical council then decides whether there is cause to proceed to investigate and may ask the doctor to explain himself.

Although the medical council has a right to fine a doctor or even to remove one’s licence, it is a more prolonged procedure. On the other hand experience has shown that when things escalate quickly with the professionals finding themselves having to repeatedly defend themselves in situations where they acted within their rights, the system tends to be abused by trigger happy individuals who do not even bother to complain through the proper channels but who phone their member of parliament. The honourable member in turn makes a report to the department, which in turn now feels under the undue pressure of the parliamentarian.

Believe me, it is not that easy to tell a parliamentarian that the doctor was not at fault, especially because the complainant usually is a constituent whom the parliamentarian wishes to please. I have seen a letter giving a ‘mild warning’ to a doctor under such a circumstance explaining that “even a fever can be an emergency”. This very statement shows that the people who wrote it had no idea of why a house call should be made in the first place and that the parent who made the call had an obligation to take his child to the health centre. Moreover the doctor had indeed offered advice and asked the parent to call again after an hour, something the parent did not do; instead the following morning he called his MP.

These things only happen when and where there are no clear guidelines. It is hoped that with the document of primary care, this attention to detail will be given, especially since it makes mention of some form of controller of the system.

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.