First of all may I congratulate the new Minister of Health for his ascent to this important seat. He does not have an easy job but is advantaged by the fact that as Parliamentary Secretary he had started work on the document for Primary Care and the Hospital bed issue. I say it is not an easy job because of the pressure already being generated by the document. Dr Cassar met with private doctors and I must say we did not give him an easy time. Yet he and his team showed that they do care about changes and seem to have accepted that there are things which GPs cannot be burdened with at such an early stage.

It is also a moment, it seems, when government is facing problems with backbenchers. Of course parliamentarians who are GPs may find that such a system limits their access to patients, which is their main source to meet people. This is no shame, for it is the parties themselves who chase doctors to contest elections on this issue alone. I do not think it is fair on Dr Jean Pierre Farrugia to put the burden on him for the changes which will occur following the consultation process. Dr Farrugia has shown courage to voice his opinions. But we now need to back the new Minister to come out with a good solution. We can only do this together. Dr Cassar has probably learned that it pays more to consult with the stakeholders as early as possible. Perhaps his biggest error was that the bodies representing doctors were not involved in the formulation of what has been referred to as the ‘skeleton’ of the white paper. But one has to raise one’s hat to the efforts being made now to amend the process.

Registration is a Pandora’s box. It is easy to say let us bring in registration. As soon as you open the box you find a lot of issues. Issues which in and of themselves, can shoot down the very concept of registration of patients if not tackled well. Doctors are self-employed. To provide a 24/7 service they will need to network. This networking will bring in extra efforts and headaches. They legitimately ask whether they will be remunerated for it. Moreover I may have my own schedule with which my patients are happy and into which they fit quite comfortably. This has resulted because many GPs, over the years, have filled in various niches. To try to homogenise a system overnight would be mere folly. It would compromise the livelihood of many as they would be obliged to change the way they work. Many have a family and many others have other doctor-related jobs. So if I do these jobs in a particular time of the day, it would be detrimental to me if I had to pass this time to another doctor or to be burdened with the headache of passing a mobile to someone else to cover for me. Moreover if people learn to complain because the doctor did not go at the instant he or she was called, it would create more tension. It may be the end of house calls as we know them today, for many countries, when faced with a binding system, had to compromise on the privileges offered to their patients.

What is necessary therefore, when all is said and done, is that the system does away, for the time being, with a 24/7 coverage, once the health centres will remain in place. The (now) Minister has conceded to this verbally. One has to guarantee three main things: That doctors who work part-time, will continue to work as they are, that doctors who are about to retire can opt out of the system in these last few years of service they have left without the threat that their patients are made to register with someone else, and finally, the key issue, that doctors on the specialist register only are allowed to have patients registered with them, as otherwise this exercise of specialisation would have been a laugh. So what we need is a system whereby people can register without the government rocking the boat too much and without therefore changing the status quo overnight. If patients are allowed to register optionally, they will then see and chose any advantage there is to gain by registration. Those who do not register may then see the advantage of being registered with a doctor.

On the other hand there are issues, as have been discussed, whereby patients feel they ought to have more than one doctor. A woman may be quite comfortable with one doctor for her general health and that of her children, but prefers another one for her gynaecological consultations (as many women GPs do a lot of women’s health clinics as things turned out). Personally I have patients who own shops, for example, in my area of practice, and therefore come to my clinic, but who live in an area too far for me to reach comfortably for house calls. They are happy with that arrangement; even though I make it clear they are welcome to come to my practice but will not make house calls. I have their files and they would presumably want me to continue being their doctor. These patients should have the option of being registered with one or more doctors.

Then there is the politician-doctor. Why should it not be possible for someone to register with one or more doctors, thus allowing this breed of politician to exist? Are we telling them that when parties used their catchments to the advantage of votes it was fine, and now we are doing away with them? As long as the new system tackles the issue of any undercutting of fees, why should not people be able to feel free to attend to these politician/doctors to make their acquaintance because they are constituents whilst still being free to see other doctors; conversely these same other doctors not losing patients to a politician who is strong in the area? This is a reality which is true but which many have been shy to discuss for such a long time.

At the end of the day, it is the patient who is paying for the visit, and therefore it is the patient who has to decide how many doctors he or she is going to allow access to his or her hospital records. This system would also allow doctors to know what other doctors have put down in the records and thus avoid health hazards. Conversely we may have to consider whether a doctor should have a right to request that he/she be the only GP. It would probably be to his or her detriment, but if the patients are happy, then why not?

A new system must be flexible enough so as to allow a gradual change without an impact on the livelihood of people and the service that patients now receive. It seems that in principle these changes have been accepted, with the exception of registering with one or more doctors. I augur that more dialogue is done lest the system be either shelved or imposed.

What, at the end of the day, are we trying to achieve? It is ludicrous to say that this system will alter the bed-problem, or the waiting lists in hospital. To hope so would be a waste of time and indeed a disappointment for the government. Even though this reason has been invoked on the media once too often, it seems that Dr Cassar has conceded this not to be the case. What this system will bring about is a better health plan for patients. Now patients may not be in a position to understand this – the benefit, that is, of one doctor being overall responsible for your care. This responsibility cannot be a medico-legal laden one, or else it would not be in the doctors’ interest to shoulder the weight, especially because there is only more work and no extra profit to be gained. Rather, it should be seen as a better management plan. But to tell patients that they cannot appreciate this would be paternalistic. Therefore it makes sense to bring it in slowly and as an option. In this way it is each individual who sees the advantage and effects the change in his or her own interest on their own.

Why would I want patients to register with me against their wish; why would I want someone else’s patients to register with me because their doctor did not opt into the system, or because that doctor feels he or she is on the way out and does not want to go through the trouble at this stage of his life?

Having the option to register with one or more doctors makes more sense than meets the eye. It is not only about convenience and about the fact that it is the patient who is paying for the doctor. It means also that when one’s doctor is getting old and beginning the process of retiring, patients can continue as they do now, and shop around a little until they find another doctor who will take over in time. People do not usually change their doctor abruptly. They continue to respect the doctor whom they have known for a lifetime. They appreciate that he cannot do house calls all the times of the day. They want a smooth transition. Having the right to give other doctors access to their records whilst they still can have recourse at times to their present doctor not only makes life easier, it removes much of the embarrassment and indeed secrecy which patients feel pressured with. They do not want to offend their family doctor.

There is the fact that some specialists also do primary care. Being allowed to register with more than one doctor can cater for this as well. A GP will also have access to the records of a paediatrician or an ENT specialist, or the obstetric files. They do not really need to register with specialists to allow them access to records. But registering may bring peace of mind to all, which, after all, is what life is all about. The last thing we want is that MAM will have to refuse the proposal because other specialists feel that they will lose their private practice.

Admittedly one has to draw a line somewhere, and just as with family doctors one can only allow access to those who are on the specialist register and not to the SHO who dabbles a little in the evening, so it is with other specialities. One would have to define which specialities are to be allowed access to primary care registering. At the end of the day, it is only for the hospital visit that patients will be obliged to get a referral from their private GPs. They will not need such a referral to see any specialist privately; but they should be able to get a referral from a private consultant who wishes to admit a patient. This reform is only about primary care. But when talking about the hospital burden, it would be well to look at the management issues in hospital. Some wards need to be bigger than others. It is pitiful to see some consultants having to go through five or six different wards because empty beds in the ENT department are made use of by surgical patients. It is probably also not safe. Wards are separate not merely for the convenience of the specialists. They are separate because they have different kinds of risks. Simply making use of a bed in another ward may not be a good thing. It may solve your immediate bed problem. But if the team in that ward is a specialised one, bringing in a surgical case into a ward where surgical cases are not the rule of the day, disturbs routines of the specialised team, with obvious consequences. So does putting older people in a paediatric ward. To solve the bed problem, you need to have extra beds which are accessed easily by the team. You just need those spare beds. Perhaps is it time to re-think St Luke’s for some specialities. Or perhaps it is time to think about rooms which are used for the ward during part of the year, and for something else throughout the rest. Certainly in a state-of-the-art hospital, to find we still have people in corridors during the winter months is not on. And that is what the grass roots are saying. After all, we in primary care listen to the grass roots the major part of the day.

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.