A hospital too far - Malta Independent on Sunday - 12/8/2004


Web posted on August 8, 2004 at 9:30:00 AM CET
A hospital too far

Raphael Vassallo

It seems that in my article last week I trod on one or two rather nasty corns. At least, that’s the impression I get reading the reply sent by Mr Edgar Gambin, Communications Co-ordinator of the Ministry of Health.

Right: I debated long and hard whether to answer this letter point for point. In the end I decided not to... partly because I feel it would be unfair to do so on the same day of publication, but partly also because the terrain of newsprint journalism in Malta seems to have lost interest in exploring issues of late. Instead, it appears content to inhabit that cosy little quagmire of mudslinging, personal attacks and petty bickering... always very good fun to read, but at the same time utterly inept when it comes to actually addressing any of the questions relevant to a particular case.

In this case, the relevant questions are the following. Does Malta really need a new hospital? If so, is Mater Dei the kind of hospital we need? Exactly what kind of hospital will Mater Dei be, anyhow? And how did expenses spiral so totally out of control?

The best place to start would be to examine the nature and function of our public healthcare system: where it came from, what it should have been, and why it departed so drastically from its original purpose. (Note: To this end I spoke to a number of sources both in and out of the medical profession. For obvious reasons, their identities cannot be divulged.)

The National Health Service

Originally, Malta’s healthcare system was modelled on Britain’s National Health Service (NHS), introduced by Clement Atlee’s Labour government in 1948. The original system was designed to provide free “cradle to grave” medical healthcare for all at the expense of the taxpayer... although according to its originator, Health Minister Nye Bevan, the idea was never to replace private healthcare, but rather to work in tandem with private clinics so that no level of society would be denied medical treatment simply because they couldn’t afford it.

In practice, the system functions on two basic levels. Primary healthcare is concerned with the administering of medical treatment at community level: patients would either contact their general practitioner, or visit the nearest public health centre to receive what treatment they need within the community itself. Secondary/tertiary healthcare, by way of contrast, involves treatment administered in hospitals.

From the outset, the idea behind primary healthcare was also to act as a “gatekeeper” to prevent unnecessary cases finding their way into secondary/tertiary healthcare... thus ensuring that a) hospital treatment is received only by those who really need it, and b) the system is not overloaded to breaking point.

The evolution of public health in Malta

So much for its origins. In practice, Malta’s version of the NHS has changed beyond recognition in the 40 years since independence... and not always for reasons related to medical science.

Our initial departure from the NHS model can in fact be traced directly to the political unrest of the mid-1970s. Shortly after the 1976 election, Prime Minister Dom Mintoff declared in Parliament that he intended to reform Malta’s medicare system. At the risk of oversimplification, his idea was roughly to wrest control of the system from the Medical Association of Malta (MAM)... an initiative which set Mintoff’s government on a direct collision course with the union, and which resulted, among many far-reaching consequences, in the untimely demise of the District Medical Officer system.

Much has since been said and written about the infamous “lock-out” of 1977 and the subsequent 10-year strike. For one thing, the dispute resulted in the indirect nationalisation of private hospitals – a move which the government tried to justify under the battlecry of “socialism”... but which ironically failed to take into account Nye Bevan’s own warnings, uttered more than 30 years earlier, about the sustainability of free health.

It also ushered in numerous alterations to the modus operandi of the public health department: sick-leave forms were suddenly issued by the police (a practice which, incredibly, survived all the way up to 1987); and more to the point, patients were encouraged to seek treatment directly at St Luke’s’ Hospital, thereby by-passing primary healthcare altogether.

St Luke’s as primary healthcare

Meanwhile, there were other, less politically-motivated changes which took place over the years, gradually eroding the efficacy of primary healthcare in Malta.

For instance: in the NHS model, it is standard practice for a doctor to have a number of patients (usually around 1,500) assigned to his or her care. In this way, a patient visiting a health centre will ideally always be treated by the same doctor; in cases when this is not possible, the new doctor will nonetheless have access to a file on that particular patient’s history.

In Malta, this particular practice seems to have fallen by the wayside over the years. Patients visiting a polyclinic will, generally speaking, be seen by whichever doctor is on duty at that particular time... thereby curtailing the polyclinic’s ability to provide effective follow-up medical treatment. As a result, doctors are often reluctant to take full responsibility for a patient whose history is unknown, and it has become more or less customary for doctors working in healthcare centres to refer patients to St Luke’s hospital “just in case”.

This is not the only reason for the status quo. Another long-term effect of the 1970s government/MAM fall-out (and, more to the point, of the rather sketchy way things were patched up in the late 1980s) is that today, St Luke’s is effectively managed by its own consultants – unlike most free hospitals abroad, which tend to be managed by a board of directors consisting mainly of non-medical professionals. In the past, this unique set-up of ours allowed certain consultants to indulge in a number of questionable practices, such as referring their own private patients to the State hospital. I am told that the situation today is much improved, largely thanks to sporadic bouts of criticism appearing in the press. However, things remain far from perfect, and it seems that St Luke’s’ consultants continue to wield far more power over each individual patient than would be permitted in hospitals abroad.

The upshot of all this is that Malta’s primary healthcare no longer fulfils its role as gatekeeper... a state of affairs which has resulted in serious overcrowding at St Luke’s, with all the tension and frustration this inevitably entails. Patients find they must wait for hours before receiving any attention, while doctors and nurses are required to work under increasingly hostile and difficult conditions. Sometimes things get positively nasty: very recently, two doctors on duty at St Luke’s were physically assaulted by an irate patient who refused to accept their verdict that “there was nothing wrong with her” – but one of several similar cases reported in recent months and years.

Enter Mater Dei

This is the point where some serious questions need to be asked. Faced with this scenario, what is the ideal way forward? Is it, as this government has repeatedly insisted since the early 1990s, to build a brand new hospital? Or would a simple revision of current practices and administration procedures have yielded better results, at significantly less cost?

Another question that must be asked is: what is the exact purpose of Mater Dei, anyhow? Was the intention, as the Foundation for Medical Services’ website suggests, to build a small “centre for excellence” to complement the existing St Luke’s Hospital? Or should we take Mr Edgar Gambin’s word for it, as expressed in his letter today, that Mater Dei is intended to be a “new hospital to substitute the present one”?

It’s a tricky question. After all, the project started life as a joint venture between the Government of Malta and the San Raffaele institute in Italy, to build a small, specialised 100-bed institute centred more on research and education. It was only after the original plain failed that the project suddenly assumed its new and somewhat improvised direction as potential substitute for St Luke’s. Today, two administrations of government and approximately Lm180 million later, different sources seem to have different ideas about its ultimate purpose. In fact, the answer seems to depend more on political expediency rather than anything resembling a properly thought-out strategy. Seen from this angle, the decision to build Mater Dei begins to resemble the decision to invade Iraq in 2003: its retrospective justification varies according to the changing circumstances.

In any case, it is a question that has so far eluded a clear answer: will Mater Dei replace St Luke’s, or will it not? Perhaps the Health Ministry’s communications coordinator ought to consider supplying a final answer once and for all.

Designed to

“maximise expense”

For what they are worth, my sources seem to concur that, in the interest of the free healthcare system, Mater Dei should not replace St Luke’s. Quite apart from being a gargantuan waste of money and resources, Mater Dei will not solve the fundamental underlying problems facing healthcare in Malta. In fact, most were of the opinion that this new hospital will only make matters worse, and will eventually contribute in no small way to the total capitulation of our “free health for all” system in its present form.

This brings us to the expenses – which had famously “terrified” former Prime Minister Eddie Fenech Adami, and which are today the subject of an investigation by his successor, Lawrence Gonzi.

I won’t go into the controversy concerning the original Skanska contract, or the endless bickering regarding the purchase and supply of medical equipment, etc... for that would require a considerably longer article all unto itself. The issue as far as this article is concerned is another: namely, that the finished project (provided it is ever finished) will be a hospital inferior to its predecessor on a number of counts. Not least, in terms of design.

In the 1930s-built St Luke’s Hospital there was an attention to detail which would appear to be lacking in its latter-day replacement. In some cases, entire wards were designed specifically to meet particular medical requirements... such as the infectious diseases ward, which is situated below ground level so that the temperature is always a few degrees cooler, thus helping to prevent the spread of disease without the need for expensive temperature control.

By way of contrast, the design of the hospital taking shape at Tal-Qroqq has been described as “maximising expense” wherever possible. The narrow, slit-shaped windows will limit natural light to the barest minimum all year round... with the result that, unlike St Luke’s, artificial lighting will have to be used 24 hours a day. The same is true of temperature and humidity, which for the same reasons must be regulated by air-conditioning all year round.

According to an estimate by FMS, Mater Dei Hospital will require 19 Mega Volt Amps, roughly the equivalent of 19 megawatts, to run. Most of this expense is directly attributable to air-conditioning requirements. Besides, because of its sheer size, the day-to-day management of Mater Dei will require more manpower than Malta actually possesses at the moment. All these factors point towards unfeasibly large operational costs (Note: needless to add, the figure of Lm1 million a day came from one of the above-mentioned sources. As such, Mr Gambin ought to know that his request for me to reveal this source is by its very nature unethical.)

To medical insurance, and beyond

However, the bottom line remains that the building of a new hospital does not in any way address the problem at its roots – i.e., the failure of the public healthcare system to distinguish between primary and secondary healthcare. This means that, unless the entire system is managed differently, Mater Dei will simply carry on where its predecessor left off... i.e., well-equipped with state-of-the-art facilities, yes, but also overcrowded, understaffed, and managed with the same set-up that has proved so damaging in the case of St Luke’s.

At present, there are no indications that the government intends to change the system. Earlier this year, former Finance Minister John Dalli was widely quoted as having questioned the necessity of 24-hour polyclinics in various localities. In other words, the government seems to be questioning the need for polyclinics, which is all that is left of the original “gatekeeper” system... but not the need for an enormous hospital which arguably poses the single largest threat to the successful continuous implementation of free health for all in this country.

How serious is this threat, you might be asking? According to the same sources, unless the management of public healthcare is brought back in line with its original function, the entire system will sooner or later buckle up under mounting financial pressures. Admittedly, not all these pressures have been brought about by Mater Dei alone: recent advances in medical science have resulted in higher life expectancy all round, as well as paving the way to new and previously unavailable technologies. These factors translate into the kind of running expenses that Nye Bevan would never have dreamed of in 1948. But in other parts of Europe, these same factors also prompted governments to invest more in primary and less in secondary healthcare. In Malta, unaccountably, things have worked the other way around.

Some (though not all) of my sources also imply that the present government is actively toying with the idea of phasing out the NHS model altogether in order to adopt a model similar to that used in the USA... where medical service is covered by private insurance packages. This might explain the zeal with which certain quarters have defended the new hospital project... for private insurance schemes would certainly relieve the government of a sizeable percentage of its recurring expenditure on health.

Whether they will be beneficial to Maltese citizens – especially those whose need for State-provided medical care is more genuine than others’ – is, of course, another question altogether.

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