Photo credit: Rasmus Kooskora via Martin Balzan

The Emergency Department is still under too much pressure,  Martin Balzan, outgoing president of the Medical Association of Malta, told The Malta Independent on Sunday. People still have to wait four or five hours he said.

"The emergency department is where the symptoms of the Vitals and Stewards issue are felt the most," Balzan said.

"We don't have enough beds. We don't have enough medical infrastructure in general, because we lost 12 years. To add on to this, there are issues at the Paola health centre."

The Paola centre would, once operational, take some of the outpatients, he explained. "But there is still a lack of infrastructure, there has been little to no investment. Mater Dei is the same as it was since the Sir Anthony Mamo Oncology Centre, which was started under Joe Cassar, was built, and since two emergency wards were built, which were also started under Joe Cassar and completed under Konrad Mizzi. The last two investments were started by the PN and completed by the PL government early in its tenure. The population has jumped to over 550,000, life expectancy jumped to 83, so supply, especially of infrastructure, does not meet demand." 

The bottleneck, he said, is because there isn't enough infrastructure. "If there aren't enough beds at Meter Dei Hospital, patients have to wait in the emergency department until a bed is found."

"For certain procedures there are waiting lists. People complain about them, but wait quietly at home. When people are seriously ill, especially if in need of emergency surgery, it is not good to keep them waiting for hours."

Balzan was being interviewed by The Malta Independent on Sunday, after he announced he will be retiring from his leadership role within the Medical Association of Malta (MAM), as he will not be contesting the upcoming internal elections. Balzan has played an active role within the association for 28 years, having first joined a sub-committee in 1997. He has been alternating between the posts of General Secretary and President, since 2001. 

Balzan has been vocal about the Vitals and Steward deal over the years. Asked how long he believes it will take to solve the issues, he reiterated that the country lost around 12 years in terms of investment, "so I think we need another 12 years to catch up." For the development of infrastructure there would be a design phase, the issuing of tenders, construction, a commissioning process etc. he said. "But whoever has to plan cannot do so based on the needs of today, but must do so on the needs of 10-15 years' time." 

Outsourcing

Asked about the outsourcing of services introduced by the government, he said that no emergency medical cases were sent to private hospitals. "Emergency surgery by and large is done at Mater Dei Hospital, because when it is an emergency you are dealing with limited information and despite that, you need to act quickly. You need to have a proper ITU, with resuscitation equipment and all the equipment needed in one place. A patient could look ok one moment, but the next moment not." 

"It is not in the interest of the private sector to take those patients as it is very expensive." What is happening, he said, is that people who have been seen and are ready to be discharged are being sent to nursing homes, and a few to private hospitals. Patients with minor surgical issues and minor issues like fractures, are being sent to the private sector, he said. "If the patient with a fracture is old, however, they are being kept at Mater Dei Hospital." People who go directly to private hospitals and pay out of pocket or with insurance are seen by those hospitals, he said. 

Speaking about another issue, he said that there was a tendency for walk-in cases at health centres to be left to junior doctors rather than more senior doctors. 

"This was not ideal. The minister agreed with us on the need to get more experienced doctors in health centres, as experienced doctors are more confident in recognising serious cases that require a patient to be sent to Mater Dei, or whether a case just requires the outpatient's visit. It is also safer for the patients. The doctors who work in the health centre, especially in the walk-in part, now get financial incentives."

Asked what he believes the main challenges for the MAM will be in the coming years, he highlighted three points. "We need to consolidate, there are areas in medical care which are slightly overmanned and some which are undermanned because they are less popular."

"The main challenge will be keeping pressure on the government to implement (medical-related) infrastructure for patients" he said, explaining that "this includes beds, operating theatres, equipment... the whole chain in general."

"For doctors themselves, the biggest challenge will be to realise just how important work-life balance is."

'Wards... which aren't really wards'

Regarding Mater Dei itself, compared to what the hospital originally had, he said, the hospital now has wards, "which are not really wards."  He gave the example of the canteen that was refurbished. "A patient who is 90 and needs a bathroom cannot walk 60 metres to reach it." There is a standard at Mater Dei and all wards should be of the highest standard, he said. 

Regarding the announcement last December, where the Ministry of Health said that a €80 million tender for new acute mental health wards and an extension of the Emergency Department at Mater Dei Hospital was to be published, he said that MAM was upset that the minister told them about it just 15 minutes before it was announced publicly. "He informed us 15 minutes before. That's not consultation. It isn't right, and we don't think this was done by experts." He said that the plan includes the opening of psychiatry wards. "We have nothing against psychiatry, actually psychiatry patients deserve better than what they have now, but that is not solving Mater Dei's problems. Let's say we are wrong and he is right, let's have a proper discussion about it."

Relationship with ministers

The two ministers that MAM had the best relationship with, he said, were Joe Cassar and Chris Fearne. "Both were very sharp, understood politics, understood doctors' mentality, and were always open to discussion." He said that this does not mean there weren't confrontations. "With Fearne it was mainly with the government because of the Steward Health Care and Vitals Global Healthcare deal."

The relationship with other health ministers was good, but not as good as with those two, he said. 

As for what he believes his legacy would be, he mentioned two points he was proud of having accomplished.

When he first joined the union in 1997, doctors were leaving the country, he said. "GPs were going into private practice, but very few were becoming GPs. The majority of the rest of the doctors were leaving and not coming back. The volume of work was increasing, and the number of doctors locally was decreasing."

Over the past 24 years, "we managed to reverse the brain drain. Looking at data, we are one of the countries with the most doctors per capita," he said.

Secondly, he mentioned the establishment of structured training programmes for specialisations. Prior to that, he said, doctors would have to do things themselves. "Now it is structured, there is a curriculum for everything. Entering the EU it became obligatory," he added. "The 'quality' issue coincided with the accession to the EU." 

As for how the turnaround in terms of the number of doctors was brought about, he mentioned three things. The first was salaries, the second was the aforementioned structured training and the third was career progression. "We had a pyramid structure, with a few at the top and many assistants." He said that this resulted in some who were angry due to having too much work, some who were angry with the quality of training, and others angry because they were good but were unable to advance.

"A stool must have three legs to be stable, and I used to tell the governments that all three are needed, and that if one is missing, then doctors will leave. This also coincided with the opening of Mater Dei Hospital."

"The government was investing Lm 250 million in a new hospital and we didn't have enough doctors. We used to tell the Gonzi administration that they were buying a Ferrari, but didn't save money for fuel. We were also aligned to enter the EU in 2004. The PN government wanted to open Mater Dei, which was a flagship project, and to take Malta into the EU. These were catalysts as to why the government was listening more than it normally would," he said.

"At that time we would admit 60 new medical students every two years. The fixed maximum number of entrants was not based on the country's needs. Nowadays its around 120 students admitted every year." It takes time for a medical student to become a specialist, he said. There had been progress under Alfred Sant's administration "as he was keen to have a manpower plan... But by the time it came to implement this plan, the government had collapsed and we needed to start again with the Nationalist administration," Bazan added.

Leadership

Regarding his time in MAM leadership, he said he never promised members anything that he knew was not achievable and would dampen expectations. "But when we got certain pay rises some doctors wanted to se the documents as they couldn't believe it."

Commenting about the medical field today, he said that it is doing well. "Most of the European countries have a workforce crisis. We had gone through it. In European circles they ask us what we had done to overcome it. It takes time, but if you don't plan ahead then it never starts. The problem is that the issue normally lasts longer than a legislature, and politicians see things one legislature at a time." 

Balzan announced that he will not be contesting the upcoming MAM elections. The MAM election results are planned to be announced on 12 April, after which he will no longer be President, but would be Honorary President. Asked if he will miss being the head of the MAM, he said he is moving into retirement mode, "in that I want to live a tranquil life," he quipped. "This was my choice." 

Last January a group of some 200 doctors had petitioned the union to hold an extraordinary general meeting, reportedly demanding a vote of no-confidence in the union leadership. Balzan said that they wanted an election. "We have 1,200 members, and our statute says that you need 10% for a motion. I had planned to leave at the start of this tenure three years ago. The difference is going to be that the election will happen around 4-5 months before it was meant to. I was due to stay until October." 

"I had already decided that this was my last term at the start of it. I'm soon going to be 63 years old. I think 28 years is more than enough. If anyone in the council asks for advice I will provide it." He also said that he received 82% of the votes for him to be made honorary president. 

He said that in 28 years "you cannot please everybody all of the time, there are too many diverse opinions. I think that internal opposition in an organisation is healthy. What we do not like is political interference from any party, we don't like political interference in our internal affairs, and I will stop there." he would not say more about that statement.

Balzan had also served a two-year-term as the Vice President on the Standing committee of European doctors (CPME) after being elected. The CPME and five other EU medical associations "set up a committee to draft a singular policy on the health workforce, because that is the number one issue in Europe, not having enough doctors. I chaired this committee and we developed an official policy for all the EU organisations on the health workforce." Malta, he said, compared to most other countries has enough doctors, and they are good quality doctors.

While there, he said, he helped develop four other policies for European doctors for the CPME. One was on climate change, another on air quality, one on doctors' wellbeing and work-life balance, and another regarding quality of basic medical education.