Suddenly some are beginning to see the light. Every year we invite a professor of family medicine to our respective department in the faculty of Medicine and Surgery at Medical School. Every year she brings us experiences from her own country and how family medicine is so broad that it is practically the same in many countries. This year she focussed on ‘Patient Registration’. She mentioned it during her lectures and even during our social events. But when Parliamentary Secretary Joe Cassar asked for an interview (as I was informed, for I had not seen the interview), there on headlines, on The Times, was what was all along the crux of the problem. She categorically stated that Patient Registration moves on the assumption that patients do not pay. That is not only what they have in Canada but that is how it is in all countries that have patient registration. This is what has been being said in this column all along; whether people are heeding or not is another question.

We are moving under the (false) premise that patients will eventually somehow be educated to go to their family doctors with whom they are registered. We are however completely ignoring the political element to this, which at the end of the day translates into patients’ rights as well. Are we forgetting the ‘jew b’xej’ jew xej’’ (For free or nothing) scenario? Now, more than 25 years later our Church schools are still considered by many to be better than government schools and instead of choosing the school-of-your-choice, we are subjected to lots (and going in through windows of all sorts). But this is not the subject of this piece other than to point out that the same cry will, in less than two years, if we are not careful, be another cry, this time not in front of the door of the Floriana Curia, but in front of the doors of the Ministry of Health and metaphorically (hopefully not physically) in front of the clinic doors of private doctors.

The false assumption everyone concerned has been making was that what has been achieved in other countries where health care is paid for by the state or some form of insurance, can be done in the private sector here. I am not saying that we may not be pioneers, but certainly there is a great political risk and I sincerely hope it is not an exercise for the political gain of one or more people. These people are asking of patients the equivalent of asking the consumer to register with the Supermarket of their choice. You can switch from one to another if you are not satisfied, but you must be registered. Does it make sense to do this? Can we actually do it legally? And, more pertinently, does the EU allow you to do this? So why do the same questions not apply to private health care? I have serious doubts whether the law, let alone the EU, will allow the government to ask everyone to register with a private GP, without some form of contract with GPs.

So this begs the question of contracts. At the end of the day it is all nice (and indeed fair) to say that the system should cover 24/7 and put down rules which are by right, patient rights. But at the end of the day can you bind private GPs to increase their work load, to provide full cover (presumably at a penalty if they do not) and invest in IT and IT services, without giving them something in return? If one thinks for a moment that what the GP is getting in return is access to hospitalized files and perhaps a small computer, then one has to think twice. Apart from not answering who is going to provide for the IT services that go with it, this is in no way any compensation to the family doctor. It is in the patient’s favour, no doubt. But one still has to say what (besides coercion, which I fear is what is going to happen) is going to make the GP, who already is paid a pittance, accept the system.

Are GPs who have invested in a premises, and in equipment going to be treated the same as those who merely have a doctor’s bag and sit in a pharmacy. What if the doctor of your choice does not happen to be in the pharmacy of your choice - but that again is diverging? It is food for thought however how a pharmacy with several doctors can entice patients to it into the system from pharmacies which do not have the space.

But what is in it for the doctor? Should we honestly say that the government has a right to see that services provided by doctors should be of a certain quality and level, without it having a stake in covering the cost? Whilst the country can demand quality from doctors, it is quite another matter to demand that private doctors, who work in a market force of their own, organise themselves and oblige themselves to hook up to a system. It would not be private anymore insofar as now you are not your own boss. Whilst in theory this can all be said to be good, in practice you cannot ask people to start upgrading without providing the means and financial incentives to do so; which in turn means that fees may go up. But, then, it would not be the government’s fault would it? Alas, it would be the party in government that would pay the price dearly.

Doctors have also something else to lose which no one seems to have been considering: the Means Test. Those doctors working in the poorer socioeconomic areas of Malta would probably have half, if not more, of their patients who would qualify for the means test. Now if the government sets a price on the mean test, it would mean that instead of seven euros per visit, for example, the government would agree to five or four. So automatically these doctors’ incomes will go down. They will only be able to compensate by increasing the fee for other patients. For those in higher socioeconomic areas, it would not make much of a difference; in fact they may get more of these patients, which is a bonus. I should clarify that this is for political consideration.

Can doctors be coerced into the system? It would be foolish to think not. Supposing that when everything is said and done, the medical bodies decide it is not good for them. The government has the power to say, ‘right, I am still going ahead with it. Those doctors who want to have patients registered with them just fill out this form by such and such a date’. What would happen is that some doctors will feel afraid that they will lose patients. If they are not in the scheme, the government (unethically) is going to make my patients register with someone else who is in the scheme. Younger doctors may also take advantage of this. We would then all be coerced into the system.

Again, from a political aspect, let me point out that patient registration was not on the electoral manifesto. One could have surmised, from the nice words which were lavished on family doctors during the election, that something may have been in the offing. At least this is what some colleagues have been saying in our meetings. But why not mention something so important? One concludes that it was concocted by the hand-picked advisors which were supposed to give the Minister some advice on how to improve the health care system. Much advice was given.

But this, which sounded nice, as it carried with it a principle, a philosophy, was chosen. Indeed it not only resounds as it should, but the irony is that it is good. But it is good not when you impose it on the pivate sector without giving this sector something in return. It is good when you yourself fund primary health care. To me, at least, it seems that the government is telling us that notwithstanding it kept Health Centres going for the twenty plus years it has been in government (presuming therefore that it was happy with it; as were the patients - who said so on the vox pop given on NET TV); for some reason it now wants to destroy them and want the private sector to shoulder the weight. It is not giving the private sector any chance of increasing its lots, as competition will still be there. The sole reason, which resounds in every document produced so far, is that the waiting lists in hospital and the people going to Casualty, are, at least partially, going to be resolved by this new system.

While this may indeed be right, in my humble and poor opinion, you cannot solve a hospital management problem by creating a whole new system outside it. We all know why there are waiting lists and it has nothing to do with GPs. There are waiting lists because, as the Minister has oft said, and as has been mentioned in this column, we entered the third millennium with a state-of-the-art hospital, which is doctored from your morning yawn to the yawn you give at noon. After that it is rest, tea, and private clinics. And as for the Casualty, they simply do not have the courage to turn simple cases back; or to roster health centre doctors, in a health centre side-by-side to Casualty.

While therefore we are witnessing a lot of lip service toward the humble GP, who sun and rain can be seen knocking doors, asking, for a house call, a fifth of the price it would take to visit a specialist weeks down the road, he/she are being used as a scapegoat by showing them the carrot of registration which they have so long been arguing for. Only it is a carrot designed to meet the needs of a hospital and not of a nation, let alone patients. If it is to meet the needs of patient, it must come in (and if we have not noticed, the professor we invited to speak in its favour has pointed out) with funding. If the party in government, to which I have no shame of adhering to and hich I hope to represent, does not take this into the portfolio of the Minister-to-be, someone else will. Then, after several weeks of that electoral cry 'jew b'xej', jew xej'', we will say, 'that was our idea'.

The only way this system will work without coercing patients and doctors alike is to give the option of registering. Patients will realise the benefits on their own. But use of files is only a carrot. You do not need registering with a doctor to carry a credit-like card which contains your code which any doctor can zip through a machine to access your file. WE must at the end of the day remember that it is the patient who is paying, and once he or she is paying, they have a right to visit me in the morning and another doctor in the evening. Registration will make it more difficult to move around. If on the other hand the government pays or the system (perhaps with the help of an insurance) then we will not be pioneers and it will have the strength to dictate conditions.

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.