The following was published in The Sunday Times of Malta on the 27 February, 2000.

Funding the health care services

The money for the provision of such services should essentially be derived from three sources concurrently:

1. Private Medical Insurance: There is no doubt, that medical insurance provided by private companies is here to stay, as is the case in all developed countries around the world. This source of funding offers a very significant contribution. Even in Malta this is picking up at a fast pace. The government should aim at encouraging everyone to purchase a policy and eventually it should be mandatory for all in the same way that every working person has had to pay the National Insurance contributions.

2. The government: The government will remain another indispensable source of funding particularly for the lower strata of society. Instead of the state providing unlimited access to limited resources across the board, the strategy should be one whereby patients are refunded a portion of their medical bills, in inverse proportion to their means (i.e. a higher rate will apply the lower the means). The state should also assist the providers of the services (vide infra).

3. The patient him/herself: A small percentage of the bills should always be footed by the individual receiving the care. This will curb the misuse and abuse of the services available and reduce wastage of medical supplies (e.g. medicinals). People must be constantly reminded of the costs involved in the provision of these specialised services and that nothing can ever come for free!

Doctors

Whilst General Practitioners (GPs) may be allowed to work solo, they should be encouraged to organise themselves into autonomous group practices of, say, 5 doctors per practice. Patients should be at liberty (a) to choose the practice that they would like to enroll with, ensuring a more personalised service, and (b) to change to another practice if they so wish for whatever reason. This will motivate GPs to provide the best possible level of care if their practice is to survive, thrive and flourish. It would further encourage doctors to keep abreast with medical advances through continued medical education. Group practices will provide the setup so that each doctor can devote adequate and uninterrupted time for such educational programs (and at more earthly hours) than has been the case up to now without disrupting the continuity of care. Another advantage is the eradication of the odious distinction between 'government doctors' and 'private doctors'. The system will also alleviate the problem of 'shortage of doctors and nurses', a chronic malady that is singular to the government service. Indeed, Malta has a surplus of doctors (and probably also of nurses)!

Polyclinics / Health Centers

Once group practices are formed within each town and village, government health centers, or polyclinics as they are better known, may be converted into small district 'hospitals' with facilities for patients recovering from surgery, those needing gradual mobilisation or physiotherapy and those suffering from conditions that necessitate 'in-patient' management that can be provided adequately by the patient's own general practitioner (in contrast to those requiring specialised treatment and nursing care, in which cases the patient would be referred to a major hospital). In addition, patients with chronic or terminal illness could be cared for within their own community, closer to home and to their relatives. Beds in the state hospital, currently largely occupied by such cases, will be relieved and be made available to patients with new / acute conditions. Some services that are already being provided from health centers e.g. consultant clinics, gynae clinics, diabetes clinics, radiology etc could be retained with some changes since some fall well within the competence of most GPs.

The State

The role of the state will be that of (a) providing financial aid for the procurement, the up-keep and maintenance of premises and equipment needed and the purchase of medical supplies; (b) financing (at least in part) the salaries of recruited medical, paramedical and ancillary staff; (c) the re-imbursement of a proportion of the medical bills of the patients, as a percentage determined on an individual basis, according to pre-established criteria; (d) providing tax incentives to those practices which offer the best, the widest range and the most cost-effective services.

Some queries

After the opening of San Raffaele Hospital, I wonder what will become of St. Luke's Hospital. With the number of beds in the new hospital falling short by at least 350 compared to St. Luke's, what will happen in the event of a major disaster or in the wake of an ever-increasing demand upon a widening range of surgical procedures (as has been happening since the introduction of knee replacement surgery, coronary by-pass surgery, transplantation, etc)? Reducing the number of available beds will automatically reduce the space allocated to each consultant. There will be no room to spare for the younger specialists on their return from their training abroad (this too has happened already (despite the 1000 plus beds at St. Luke's!) with specialists having to leave the island to take up consultancy posts abroad!). Waiting lists are bound to get longer in terms of both the numbers of patients and the duration of their waiting time for treatment.

Conclusion

I believe that reforms should be implemented radically and rapidly. There is no more time left for further procrastination; the current primary health care is on the brink of collapse and the public is already suffering the consequences. Debates in health care reform have been going on for decades though, sadly, I cannot recall a single occasion where a joint discussion between government, doctors, the public and insurance-companies ever took place. Whereas advice from foreign experts may be considered as commendable or desirable, do we always have to rely on foreigners in whatever we need to do on this tiny rock of land? Are we not capable of sorting out our problems on our own? Where is the "fiducja fil-poplu taghna" that politicians brag on about endlessly?

I think it's high time for some action. I am sure that much can be achieved if there is proper planning, a concerted effort and goodwill; and, locally, we do have a few brains and I am sure we also have adequate resources to implement the changes within a short time frame.