Health Minister Interview on Malta Today - - 18/4/2006

link to Malta Today

Mind the drip!

With St Luke’s Hospital’s corridors crammed with extra beds and wards overcrowded with social cases, Health Minister Louis Deguara promises everything will be solved when Mater Dei will open its doors in July next year. Only that there will be less beds in the new hospital and more elderly to take care of

Passing through some of the wards at St Luke’s Hospital, the sight of ailing patients in beds placed in the middle of the corridors makes an utterly depressing scene.
People meant to recover are left exposed to all visitors carrying all kinds of infections and staff passing by, leaving them absolutely no privacy and at times forcing nurses to manoeuvre their trolleys around the beds to get from one point to another.
It is a whole rotten system of social cases admissions, long waiting lists and consultants’ unchecked powers that has been straining the public health service for ages, with the nurses’ union repeatedly voicing its concern over problems that seem to never get solved.
Health Minister Louis Deguara acknowledges the problem with a certain aloofness that makes you wonder whether the hospital actually falls under his remit.
It is with this same detachment that he speaks about the long delayed opening of the Mater Dei hospital, as if it were something totally beyond him and the rest of the government.
“We have 173 extra beds in hospital”, Dr Deguara says matter-of-factly. Extra meaning either thrown in corridors or placed in the middle of wards beyond capacity. “So we get the usual question about what will happen at Mater Dei; if it is going to have fewer beds than St Luke’s, what’s going to happen there? The truth is that Mater Dei will have almost as much beds as St Luke’s, but the way it will operate will be different.”
Putting aside for a moment the fact that it will have taken 15 long years for the hospital named after the Mother of God to open its doors, it will take more than just the minister’s declaration that things will be different for them to be really different. Probably a miracle.
“Experts tell us that the way our life is getting longer, we have to find 100 extra in-patient beds every year for the next 10 years,” he says about the rising need for extra beds in the years to come. “So in 10 years we need to have found 1,000 new permanent beds; it’s not something the government can do on its own. What we’re doing is we’re looking at the way wards have been divided at Mater Dei over the years in a critical way. The birth rate has gone down by around 50 per cent over the last 10 years, so it doesn’t make sense to keep all the 40 natal beds we planned originally in the nineties, we can use them for other purposes.”
In other words, so many years have passed since the original planning of the Mater Dei hospital that they have to be changed yet again.
Already three years ago, Deguara sent shockwaves when he told The Times that the health system was “unsustainable” and the situation was “alarming”, when Lawrence Gonzi was still social policy minister and John Dalli was making sure our country’s finances were “fis-sod” (solid). Since then, nothing much happened except that Gonzi has been promoted to a position in which he could decide the Mater Dei opening day on his fifty-fourth birthday and Dalli kicked out of Cabinet.
Now the situation must be more alarming than ever, but one does not really get that feeling when talking to the minister.
The original St Luke’s migration plan, a report commissioned to British experts and costing nothing less than Lm2.9 million, originally stipulated that the transfer to the new hospital would take three years to complete.
With all deadlines disrupted and the whole report shelved, Deguara claims he will manage to migrate to the new hospital in three months. “The idea today is to migrate in the relatively shortest period of time; it could take about three months.”
So now it’s three months? Are you sure you’ll make it?
“Do you give up on everything?”
I’m sceptical.
“I know Good Friday is approaching but you don’t have to be a St Thomas on everything.”
It will have to be worked out like clockwork to manage in three months, something which given the government’s delivery remains incredible.
“It will be clockwork, yes. We’re saying we’ll receive the first patients in July 2007. The equipment will be there, all you have to do is transport patients. It doesn’t make sense to operate two sites because we don’t have the manpower. Day surgery can be operated from day one, but certain operations will not be offered immediately, like bypass surgery where you might need the backup of the ITU. Maternity, on the other hand, can be migrated immediately.”
So by July 2007 you will receive the first patients, because even that is unclear.
“Yes, we’ll get the first patients. Now this depends upon Skanska honouring its set timeframes, but it looks like we’re on target.”
As Health Minister, how does it feel having taken you 15 years to finish a hospital?
“Bla sahha (exhausted).”
Come on, it’s no joke wasting 15 years like that.
“Again, that’s a sweeping statement. This started in the early nineties. We had two years under a Labour government in which nothing was done, another two years studying what we were going to do after that, another year to decide that this blessed plan was to house 350 beds was increased to 800 and there was this idea to house 1,000 beds, and we had problems with the contractors.”
And nobody was responsible for all this?
“The responsibility rests on the government of the day; it’s not a responsibility that an individual can carry. I can say I want to finish the hospital in one year but if the Finance Minister doesn’t give me the money it’s useless. There are lots of things involved. When it came for the medical equipment, for example, it took those who won the tender two years to manage things. This is not like ordering a sofa set, there are lots of complications.”
Once complete, the new hospital on its own is expected to cost Lm1.2 million a week to run. At the moment, the whole health system costs around Lm1 million weekly.
“What I’m interested in is not just the Lm1.2 million to run it, but from where we can get them and what value we are taking back,” the minister says. “Is it going to cost us Lm1.2 million and we keep getting the same service, or will we eliminate waiting lists? In that case it would be worth it, because then we will be able to offer services even to foreigners, and it could turn out into a revenue generating exercise.”
Of course to do all this he still has to reform the health service system, and this hasn’t happened yet. Last year, the medical association came out attacking his proposals describing them as “the work of a sick mind”.
“I take them with a pinch of salt, as long as we’re meeting around a table discussing issues,” he says. “I can assure you that nurses are for a change to Mater Dei, and even some doctors because you can’t put them all on the same footing; there are those who are seeing the new hospital as a new opportunity to improve everyone’s conditions. Others are seeing this move exclusively from a financial perspective – demanding new salaries etc. The truth is we have to keep everything in perspective; we can’t compare consultants’ wages to those offered in the UK for the simple reason that differences are enormous; the cost of living there is much higher; come on, the whole quality of life is different.”
The problem of waiting lists for operations at St Luke’s is exacerbated by unscrupulous consultants who leave their patients waiting for months, only to be seen privately in a matter of days. “It is highly irresponsible,” the minister says.
It’s happening all the time.
“It’s highly irresponsible and unacceptable. Every case I know of is investigated. I don’t accept that a case is urgent in private practice but not at St Luke’s, especially if they’re seen by the same consultant.”
And what do you do about these cases?
“We ask for the details to investigate them, and I’ll report them to the medical council. How could it be that after all these rumours there is not one case to come forward?”
People may be afraid to talk where their health is concerned. They are ultimately dependent on their doctors.
“They can change consultant. If I’m not satisfied with my private consultant I just change him. If he tells me I require an urgent operation and then at St Luke’s he tells me I can go for the operation in three months’ time, I would just change the consultant. This is not like changing your mobile phone operator. Lives are at stake and unless you put checks and balances the same abuses will keep going on. One of the anomalies is that waiting lists are in the hands of consultants.”
Precisely. Are you going to change that? “Yes, definitely, I give you my word.”
And who will be responsible for the waiting list?
“You’ll see. What’s in a name? Irrespective of the name we will give to the person in this position, there will be someone in charge of waiting lists at Mater Dei.”
About the social cases at St Luke’s, the minister says he will be opening a new facility at Mount Carmel to accommodate some of them.
“We had to decide whether to open new units or else use the hospitals we already have. We looked at different options, one of them is Mount Carmel, which up to some time ago housed around 700 people, now we have 400; so there is the physical space for 300 people. It will be a separate unit that has nothing to do with the mental hospital. It would be crazy if we throw away bed capacity for 300 people just like that. So we’ll be opening a completely refurbished unit with 34 beds, of the same level as San Vincenz.”
This will serve as a step-down facility, meaning that to go from St Luke’s to San Vincenz one has to pass through this unit, he says.
“It will be a temporary ward because people will not stay there permanently,” he says. “Every bed occupied by a social case at St Luke’s is making the waiting list longer, so I need to clear the number of social cases as quickly as possible. We’ll be taking up 34 beds at Mount Carmel, and we should finish another refurbishment project at Mount Carmel for another 34 beds. In this way we will have solved all the social cases at St Luke’s.
“One other thing,” he adds. “The policy we will adopt for social cases in this step-down facility is no questions asked, first in, first out, so that nobody comes with excuses not to go to Mt Carmel. It is not fair to use the stigma against Mt Carmel to be choosy. If you want to choose you can choose to remain at home. I’m making it clear from the outset so that people don’t start phoning me.”
Deguara’s trick at Mater Dei will be a reformed admission policy that will start working out the discharge date of patients upon their arrival at the hospital, through a team of consultants, social workers and nurses – a policy which nursing officers at St Luke’s say is already theoretically in place but which remains only on paper.
“One of the posts we will be creating is that of a bed manager,” Deguara said. “We will also have an admission ward, where one will be admitted immediately for further tests, as opposed to what happens today at St Luke’s where you have people awaiting tests and others waiting for the ward round to be discharged. So if the ward round happens twice a week you’ll end up occupying the bed for three days until the next ward round, for no reason whatsoever.
“What happens at the admission ward is that once a patient is suspected to be a social case, he will be assessed by a gerontologist or a social worker, so once you put your foot inside the hospital your discharge starts being prepared. Also, at Mater Dei you will have five-day surgery theatres, so that most of the people who are nowadays admitted to hospital say for appendix or hernia, you will be able to admit them in the operating theatres and release them in the evening.”
To the question of what will happen to St Luke’s Hospital, Deguara refuses to give a straight answer. “Then we’ll see, hux,” he says.
Do you have a plan what to do with it? “Of course I have, but its very premature to say.”
A lot of doctors and nurses do not believe you’ll close it. “I wouldn’t say a lot. A lot of doctors do not know of the progress registered at Mater Dei. Those who were interested may have seen it two years ago. There are some for whom it’s not in their interest to go to Mater Dei, they may be happy with the system as it is today because there may be advantages for them… I’m talking about all the staff. For example there is no system that checks at what time you come in and go out in a foolproof way. There will be one at Mater Dei.”
Why are you closing down Boffa? “How many hospitals are we going to keep? These are not discos.”
What do you mean? “Boffa hospital is primarily used for the oncology and spinal unit. Now the spinal unit will go to Mater Dei, so we don’t need it. At Boffa we don’t have enough beds, we only have 28 and we need 40 or 50. Structurally, we can’t increase bed space there, and the time has come to change all the equipment. Treatment of cancer is nowadays mostly on an outpatient basis, so we can’t depend on one radiology unit, we need two. That means we have to dig two other bunkers and install a substation. Boffa is a scheduled property, we can’t do any structural alterations. We have to enlarge and change equipment. A radiology bunker will cost us Lm0.5 million… it’s too small to accommodate any units there, that’s why we’re moving Boffa hospital. Then we’ll sell it.”
What, Boffa Hospital? “Of course.”
There are lots of rumours about who may buy it. “Let me tell you something; all rumours are silly. Not one single person was approached or approached us. Yes we’ve decided it is going to be sold, I would guess to the best bidder, obviously.”

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