Article in Malta business weekly - 5/10/2005

link to article in The Business weekly

Train and retain: a motto for public health?
by Blanche Gatt

Dr Martin Balzan, general secretary of the Medical Association of Malta, talks to Blanche Gatt about the danger of a brain drain in the public health service.

As the new hospital inches slowly towards completion, Maltese doctors, and in particular, Maltese specialists and consultants, are wondering whether they would be better off somewhere else. This, at least, is what the Medical Association of Malta (MAM) is warning government as they begin the preliminary negotiations for the next collective agreement.

“We have an excellent health service,” Dr Martin Balzan, general secretary of the MAM, said during an interview earlier this week. “And this statement is substantiated by objective surveys carried out by the EU and Who that show that in Malta over 80 per cent of the population say they are satisfied with the pubic health service, that we have one of the lowest rates of child mortality, and the highest rates of life expectancy in the world. Indeed, in terms of client satisfaction, the survey puts us in the top three in the EU, while in terms of the other measurements mentioned, we are in the top four or five in the EU and in the top 10 in the world.”

“And,” he continued, “when they look at the costs in relation to the services, that is, the fact that we spend some eight per cent of GDP on health, two per cent of which is the yearly outlay on the new hospital, when you see these costs vis à vis the high client satisfaction, it is clearly a very efficient service, despite what some say.”

I was somewhat surprised by the 80 per cent client satisfaction rate quoted by Dr Balzan, but he was quoting the Eurobarometer study, and is thus considered to be an objective survey.

The efficiency or otherwise of the health service, however, would be drastically affected if Dr Balzan’s warnings of an imminent “brain drain” were to come about. “It is actually already happening,” he said. “The thing is that now that we are in the EU, doctors have even more opportunity than previously to move abroad and stay abroad. Before, young doctors would go abroad for training…now we are seeing fully trained people starting to move. This is extremely worrying…we have to be able to train people and to keep them here.”

I asked exactly how many doctors have left Malta in the year since we joined the EU. “A recent parliamentary question on the subject revealed that in the past year we have lost about 50 doctors,” he replied. Considering, however, that some 60 new doctors graduate every year, it does not seem an excessive amount, I commented. And many of these will have been young doctors going abroad for specialist training. “Indeed, some 40 of those were doctors going for higher specialist training, while 10 were ready trained people,” he said. “So you might say, 10 is not so many… however in fact it is a significant number. It takes 10 years to train a specialist, those 40 going away for training won’t be back for a long time and may indeed never return. In the meantime, we have a situation where in the radiology department, for example, there were five Maltese consultants last year. Two left this year, which means that they lost 40 per cent of their complement! Another example is anaesthetists. We need around 45 to 50 anaesthetists and up to six months ago we had some 10 fully trained Maltese anaesthetists, 10 trainees and 25 foreigners. In the last six months we lost 10 foreigners and they are having great problems replacing them, and two of the Maltese anaesthetists are doing weekend sessions in the UK instead of leaving but it is only a matter of time before they decide to leave too. And they are losing all the trainees. The effect of this? Quite simply, that they have had to cut out the afternoon and weekend operating lists because they simply do not have the anaesthetists they need. And it’s a similar situation in orthopaedic, and so many other departments.”

The big danger, of course, is that these shortages mean waiting times and waiting lists get longer, and the public health service risks becoming seriously compromised to say nothing of what customer satisfaction would be.

Dr Balzan told me that some 30,000 operations a year are carried out at St Luke’s Hospital. There are around 240,000 outpatient visits every year, and some 110,000 emergency visits. Hospital admissions amount to around 30,000 a year. Looking at something like cardiac surgery, some 400 operations are performed every year, or an average of around two a day.

“The turnover of patients is so high, and productivity is so high,” said Dr Balzan, “and most of that work is done by consultants. And this is where the problem lies, current remuneration of top grade consultants is too low and this is a big problem.”

The issue of consultants’ salaries is well known to everyone by now. However, not all would agree that a pay increase would be justified. Consultants, after all, are free to do private practice, and many of them, though by no means all, only visit the public hospital for a few hours every morning. “Well, maybe it is true that so far they stay here because they are able to do private practice (after family reasons of course),” said Dr Balzan, “but private practice is a finite market, there is only so much they can do.”

“It is a great contradiction that the salaries of highly trained medical staff is so low,” he continued “In fact, if we break down the rate of pay they get, we see that for a major, three-hour operation, a surgeon actually gets just Lm10. Is this right?”

“What we are saying is that the public health service needs people who are committed to the service and will not leave,” he stated. “In order to achieve this they have to be paid well and not have to depend on private practice for a good salary.”

Undoubtedly, consultants should receive adequate salaries. However, while they continue to enjoy part-time conditions with the freedom to do private practice, it seems a bit like the proverbial gentleman who wanted to have his cake and eat it too. Would the consultants be prepared to sacrifice private practice in exchange for a better salary, I asked, or do they want the higher salaries under the same conditions they enjoy today?

“The idea that giving low salaries because of private practices is outdated now,” replied Dr Balzan. “This is not good enough now. What we need is for consultants to get a decent salary so that enough people are committed to the public health service. I am convinced that if government offered a contract similar to the one that one particular cardiac surgeon has, more than half the consultants would give up private practice.”

There are currently some 140 consultants, including all departments and health services, and another 60 specialists on government payrolls. “If government spent Lm200m on the new hospital,” said Dr Balzan, “plus the health budget which is now Lm35m, the reality is that in order to have more people totally committed to the service wouldn’t cost more than a couple of million liri.”

Dr Balzan’s message is very clear, unless consultants are motivated to stay in Malta by a decent salary, there is a very real danger they will leave, and the implications for the health service, as outlined above, are ominous indeed.

“What we don’t agree with at all however,” he added, “is that government should just pick and choose in the way it did with this one particular cardiac surgeon. It should be the same for everyone. In a public health service we are governed by a collective agreement, and you can’t act as is if you don’t have this and then do things outside the framework of the agreement. The position of MAM is that the consultant rate is covered by collective bargaining and what is good for one consultant should be good for all the rest.”

Dr Balzan, a consultant himself, relates a joke from his student days: “There are two students and they are arguing over who is the best professor. This one, that one, they couldn’t reach a conclusion and kept arguing and discussing. Until finally one of them said, of course, the best one is always the one you need at a particular moment in time.”

Lots of truth in that quip of course, but on the other hand, if the consultants are asking for competitive salaries as per international market levels, is it logical for them to be using the collective bargaining card at the same time instead of each negotiating his or her own salary individually as happens in a competitive market?

“In my opinion this issue should not be governed by market forces,” insisted Dr Balzan. “It should be a collective bargain based on reality, there has to be an agreement that solves the problem. All consultants should be on a par or else there will be chaos. And at the end of the day we need enough qualified doctors motivated to work in the service and dedicate themselves to the service. And private practice should always remain a right.”

This smacks even more of having your cake and eating it, I commented. “Not exactly,” replied Dr Balzan. “You could have Option A and Option B, for example, in which Option A would include a good package, but only public service, and Option B would be a different package but still allows private practice.”

“What we want is for government to put a good option or menu of options on the table.”

The next collective agreement has to be in place by July 2007, Dr Balzan said, and these issues, the brain drain that is already happening, the enhancement of local training so fewer doctors go abroad to train, and the establishment of a fair salary for consultants, will be central to the future of the public health service.

“The two most important things are that all salaries for consultants should be at par,” he said, “and that we have to put in place restructured training for young doctors. We should be aiming at training and retaining, we shouldn’t be giving our doctors away as a donation to other countries!”

Train and retain is the leitmotif of the MAM’s announcements in anticipation of the negotiations proper beginning with government. While clearly the issue of increasing salaries for people who do such crucial work is pivotal, especially in light of the fact that training others to replace them takes over a decade, it is also pertinent to remember that Malta is not London or New York. Whatever agreement is reached must be affordable to the nation and the tax-paying public who ultimately foots the bills. “We are investing huge amounts of capital in our health service to build the hospital,” concluded Dr Balzan, “but we should also remember that we also have human resources to man the facilities. Consultants and specialists should be kept motivated, and I am convinced a decent salary package would ensure that a large chunk of them are totally committed to the health service. Someone who has spent 15 years of his life training will deliver, there is no doubt about that.”


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