The Medical Association of Malta (MAM) is "very worried" about the status of the Medical Council, newly-elected association president Patrick Sammut told The Malta Independent on Sunday, noting that it is a serious point of concern for the medical profession.

"This is the body that regulates the profession and ensures that everyone abides by ethics. But it is currently unable to take disciplinary action against a member of the medical profession/dental profession, which could amount to issuing a simple warning or reprimand if a professional is found in breach, a temporary suspension pending investigation or a removal from the register in case of serious misconduct." He explained that its work in this regard had stalled following a court judgement.

In June 2023, the court had thrown out an investigation by the council into doctor and PN MP Stephen Spiteri over allegations of signing medical certificates without examining patients, finding that the process was unfair and breached his rights. The court noted that in so far as the Medical Council has the function to investigate, prosecute, present evidence, judge and impose penalties on the applicant, it amounts to a breach of his fundamental right to a fair hearing as enshrined in the Constitution and the European Convention. The judge had noted that the Medical Council does not satisfy the criterion of objective impartiality.

In March of this year, the Times of Malta reported that Ian Baldacchino, a member of the medical council, stepped down citing his frustration with the council's inability to carry out its investigative function. It said that after the court case the council's work has stalled, and reports Baldacchino as saying that little progress was made as the council's proposals to address issues fell on deaf ears.

Sammut said: "We need a strong medical council to regulate the profession, protect the patient and protect the professional." He noted that there have been cases of forged signatures of medical professionals, in reference to the disability benefits scandal.

"The main issue is that one cannot investigate, then prosecute and also be the judge. But we need to move on and cannot leave the situation as is. We need to start moving because at this point in time, both the public and the profession, are unprotected. We are very unhappy about this," he said. "I believe the government has prepared some kind of draft, but we need to get moving and it needs to be issued for feedback so that we can move forward."

Working conditions

Asked what some of the other immediate issues affecting doctors are, Sammut highlighted working conditions as a main point, saying that the association is always looking to improve conditions of work for doctors. By conditions of work, he said he is not only referring to salaries. "Improving working conditions for doctors is what will help retain doctors in the public service," he said, highlighting both working hours but also the working environment as possible issues to tackle.

"We are trying to work towards a better work-life balance, possibly by including new, flexible ways of working. It's about the quality of life for doctors. The job is obviously tough, but there are ways we can improve things."

Describing the profession, he said that graduating from university is just the start. "We all have to go through specialisation. The shortest specialisation route, if everything had to go according to plan without any breaks, is five years. That's the shortest right now, which is the specialisation in family medicine. But most specialisations will take around eight years, so the commitment is immense." This time, he said, could be lengthened if there aren't enough open posts in a specialisation.

In the majority of cases, all this is happening during the same period that a doctor is trying to build a family, he said. "Apart from studying, it involves sitting for exams, getting experience abroad, etc. You can understand how hard it is, and that's if everything flows easily."

He said that career progression, working conditions and trying to find that work-life balance are issues "we can work on with proper manpower planning". In some areas more doctors are needed, he said, but adds that "we should also look as deploying them more efficiently as well".

"Looking after your employees in any workplace, in this case doctors, is the best way to have a better output. We need to look at ways to better look after doctors, such as by giving them a better quality environment of work so that they could avoid burnout, remain interested, etc."

When asked what would be needed to improve the work environment for doctors, he suggested improving access to rest areas, highlighting the working hours junior doctors, in particular, often face. "A duty is 24 hours, some would need to stay and continue working, possibly staying 30 hours."

Primary health care

Regarding primary health care, he noted that there aren't enough primary care doctors. "There is a chronic reduction in workforce in this sector. They are overworked, to the extent that they sometimes have issues taking leave. There are situations where a primary care doctor is seeing a patient only for someone to knock on the door saying that they are taking too long. There needs to be a barrier where someone cannot just do that. There are also situations where a doctor is going to the bathroom and is stopped by patients. And people are surprised that many specialist GPs leave for private practice, where they have control over their clinic, appointments and waiting area." He said that public primary care is also more a walk-in clinic, which also "impacts continuity of care".

He said that in private practice, most GPs have adopted an appointment system, which has benefitted both doctors and patients, adding that patients would no longer have to walk into a full clinic and risk catching an illness. "This is something I would discuss with my colleagues in primary care in the lead up to the next collective agreement discussions; starting to move towards at least a parallel system of consultations by appointment and walk-in patients, but not remain exclusively walk-in."

He said that collective agreement negotiations will start sometime next year.

Mater Dei

He was asked about the capability of Mater Dei to cater for the rising population numbers. "Aside from immigration, people are also living to an older age," he said. "At an older age people run into problems, so demands on the health services increase. Mater Dei hospital is the only secondary and tertiary hospital. Many beds are taken up by older patients, quite a few of whom have a chronic illness. The government has tried to shift them by increasing services at St Vincent de Paul for instance and increasing community services. But I don't think this issue will go away."

Asked whether, looking 20 years down the line, the country would need a second Mater Dei hospital, Sammut said that in general the demands are increasing. "We either expand what we have or need to build new spaces. Currently, what is being looked at is what can be moved to other areas, but that might create some issues. For instance, there was discussion about relocating the Outpatients Department to St Luke's. While the idea of moving Outpatients and using that space for additional beds is sound in principle, it is likely to create some logistical challenges. The advantage we have right now is that if a problem crops up in the ward, you can call the consultant to come down. If the Outpatients is moved to St Luke's, we would waste an hour going and coming. So there are some logistical problems which the administration and politicians would have to work out."

Former MAM president Martin Balzan was highly critical of the Vitals hospitals deal, and said that because of it Malta lost 11 years of investment in health infrastructure. Asked if he agrees with his predecessor, and what could be done to recuperate the lost time, Sammut said, in terms of medical personnel, that investment in people and the professions "never stopped" and so are "on track". But he highlighted the need to attract more nurses "because there is still a shortage."

As for the hospitals' deal in general, he said that "the Vitals saga was a black mark in the history of our public service. I'm not a lawyer or a politician, but due diligence wasn't carried out properly in my opinion. We lost time and money that could have been used to improve services. Unfortunately, you cannot touch on this issue without sounding political and I don't want to sound political, but it was a mess."

Asked if patient care, given the nursing shortage he mentioned and the increase in population, has remained at the level it used to be, he said it has, but adds that there is room for improvement. "We work in a team, and very often what happens is that a doctor makes the diagnosis and prescribes how the patient is to be looked after. It is then the nurses that carry out treatment and they are the ones who spend most time with the patient. Often patients speak to them first. We should do everything we can to attract more nurses."

Medical consultants who work in the public service and do private work after hours had earlier this year filed a judicial protest against the health minister, complaining of pay discrimination in favour of consultants who work exclusively for the public service, stemming from a collective agreement. News reports read that both are expected to do the same work during working hours.

For the benefit of the patient

Asked about this issue, Sammut said: "When the agreement was signed it had its use as it introduced contracts and sessions, and now you can map out what a consultant or a resident specialist is doing at any point in time and so it is easier to contact them. It was a bit of a revolution which benefitted the patient. But the issue is that the way the contracts are drafted, it makes no difference between the two options, A and B. It's the same contract, but if anything with the changes in the last two collective agreements, it is to the detriment to those who have the option to do private work outside of their public service working hours."

Aside from the pay discrepancy, he said that there are other issues - for instance those working solely in the public sector can opt out of Saturday or evening shifts, whereas those on the alternative contract do not have that option.

Doctors first need to agree among themselves how to move forward on this issue, he said, but his personal opinion is that this contract division has not served the profession well. "If you look at what is happening, the government has contracted businesses in healthcare to take over some of the work, so why shouldn't doctors in their free time be able to work privately without being impacted. Just imagine if all doctors suddenly decided to work only in the public service."

It has to be said that while working in public healthcare hours, doctors have to be giving their all, he said. "You are being paid by the government and that is public service time. As long as you are giving equal work you should be given equal pay. What you do after hours is your life. We are in a funny situation where a doctor could become a real estate agent after hours and its fine, but if you practise your profession after hours you get a significant pay cut. We are talking about €20,000 a year difference."

"In my opinion there should just be one contract, and a doctor's free time is their free time."

Euthanasia

The Medical Association of Malta issued its thoughts on the government's proposal for the introduction of assisted voluntary euthanasia. It had mentioned there being deficiencies in palliative care. Asked what is needed in terms of palliative care improvements, he clarified that MAM did not take a stand for or against euthanasia, but that palliative care first needs to be improved. "We need to heavily invest at all levels in palliative care, and ensure that doctors and nurses working with terminal patients have access to everything they need," he said, mentioning staff, medication and equipment, "so that wherever possible terminally ill patients can be supported in their homes."

"Our point is this, how can you be sure that someone didn't arrive at the decision to go through voluntary assisted euthanasia because at some point in the process they didn't receive the best palliative care? They might have spent three or four days in pain longer than they should have, maybe there wasn't enough psychological support, perhaps they did not want to be on a bed in hospital but would rather have been back home, but there wasn't the support structure available. Maybe if we satisfy those criteria the patient might be speaking differently."

"It's like trying to run before learning to walk."

"I am not totally against the topic having been brought up for discussion, and it is a first draft asking for input to see how stakeholders reacted, which is not a bad thing. This is our reaction, lets invest in palliative care as much as we can, and once the professionals working in palliative care are satisfied, then maybe we could start discussing this. At the end of the day doctors will be the biggest decision makers if this were to come in, so I'm sure people want to listen to what we have to say."

While in the public consultation documentation a medical professional can refuse to participate at any stage of the process leading to assisted voluntary euthanasia, it states that the medical professional must refer the patient to other professionals. Asked about this, he gave his personal opinion, saying that it is a blurred line. "If someone doesn't want to do it for moral reasons, where is the morality in shifting it onto someone else? The moral reason would be as to whether it is right or wrong altogether, not about who is doing it. So there is a whole argument there."