Focus Diagnosis of a health service - The Times - 6/5/2006

Diagnosis of a health service
Cynthia Busuttil
link to article

Rehabilitation is imperative for a number of patients who have had surgery.

It is not rare to hear people complain about St Luke's Hospital, expressing the hope that the opening of Mater Dei Hospital will be the solution to all the existing problems.

The general secretary of the Medical Association of Malta, Martin Balzan, said the new hospital will give the country a splendid opportunity to improve healthcare but he stressed the importance of long-term planning.

"We have to stop thinking in terms of two to three years, and instead start looking ahead a decade or more. We have to establish what the needs will be and plan how to finance the system."

The president of the Malta Union of Midwives and Nurses, Rudolph Cini agrees. "Politicians often don't look further than their term of office. If things remain as they are now, Mater Dei will become a second St Luke's with the current problems being shifted to a newer and nicer building."

Mr Cini warned that without drastic changes the new hospital would not work well. "We have spent Lm200 million to build the hospital, but we seem unprepared to spend a few million liri more to create a good structure for Mater Dei to work well," he said.

Health Director General Ray Busuttil said Mater Dei will not operate as it should without the proper support services, adding that the government has already taken initiatives to tackle a number of issues. St Luke's Hospital's 900 beds include 150 for rehabilitation and between 70 and 100 for people who need long-term care, often referred to as social cases.

"The government is planning to build a new unit within St Vincent de Paul to offer rehabilitation services," Dr Busuttil said. He explained that apart from the 150 rehabilitation beds in hospital, there are another 12 to 15 at Boffa Hospital and 60 at Zammit Clapp Hospital. These will be increased to 280 in the new unit.

Mr Cini said the concept used at Zammit Clapp Hospital, where contact is maintained with the patients after they are discharged, should be extended to Mater Dei.

Dr Busuttil underlined the importance of rehabilitation, saying the earlier one intervenes and the more aggressive the intervention, the greater the chances of sending patients home in a functioning capacity. Zammit Clapp currently takes elderly people who have either suffered a stroke or underwent orthopaedic surgery.

For the new hospital to operate as it should, one of the most important things to do is to create a system of health services within the community. Mr Cini said these were currently lacking, leading to overcrowding because patients are having to remain in hospital for a longer period of time.

Health centres are not doing anything to solve the problem because rather than offering community care they are serving as mini casualty units, Mr Cini said. But with good community health services, a patient could be discharged earlier because there would be a support system.

Mr Cini highlighted the importance of having a family health nurse, who would not only help patients with their rehabilitation, thus reducing the length of hospital stays, but also be able to educate people.

Dr Busuttil said that despite services offered within the community for the elderly - including meals on wheels and home help - some senior citizens needed to go into a home. But, he said: "The government's policy will always remain trying to keep the elderly in the community."

However, since this is not always possible there is need for more residential homes. The lack of beds in homes is leading to a number of cases blocking beds in hospitals, which is affecting the whole system. Dr Balzan said social cases were accumulating at the shocking rate of 270 a year, and causing overload.

"This can only be dealt with through thorough all-around planning. People who could be semi-independent must have access to services in the community. Even local councils should become involved because at the end of the day the local community must have an interest in looking after the elderly."

Rehabilitation beds following surgery for elderly who do not have anyone to take care of them is important, but often this merely postpones the problem.

There is need for more places in homes for the elderly. "Unless this is done the whole system will collapse. The problem of social cases has been with us for the past 20 years and it is getting worse every year. It needs to be dealt with," Dr Balzan said.

Dr Busuttil said apart from the extensions at St Vincent de Paul, which will provide an additional 100 beds, a home in Mellieha, with another 100 beds, was also being built.

Undoubtedly, our aging population and constant advances in medical treatment are posing an ever-increasing burden on the medical system. The problem is most obvious in the winter months, when patients in corridors become an almost everyday occurrence.

"Demand for hospital services is on the increase, and it will probably continue this way," Dr Balzan said.

Discharging people earlier could help reduce the waiting lists for non-urgent procedures. Unless there are beds available, surgeries that need a number of in-patient rehabilitation services might be postponed until there are beds available.

Five of Mater Dei Hospital's operating theatres are expected to be dedicated to day surgery, and earlier this year Health Minister Louis Deguara said there was always the possibility that more theatres would be able to handle day surgery. Dr Busuttil said increasing day surgery was the trend in medicine around the world, but he stressed the need to develop home care and support services for the patients.

Health centres will need to offer a level of support, and the authorities are currently drafting a new contract with the Malta Memorial District Nursing Association (MMDNA). Nurses will also be trained to deal with immediate post-operative care.

There is also the hope to progressively increase the number of doctors in health centres. Dr Busuttil said vocational training in general practice will start in July in the hope of recruiting 12 doctors trained in family medicines.

Speaking about long waiting lists, Dr Balzan said the rate by which cases were accumulating was much higher than the rate at which operations are being carried out. The answer to this problem might sound easy - invest more - but there is more to it than that.

"To cut the waiting lists you need more surgeons spending more time doing interventions. But you also need more operating theatres, and more medicines and equipment, plus all the supporting staff," he said. The inevitable conclusion, however, is that more operations will only be possible if more money is spent on health.

But increasing staff in surgery will not solve the problem, and Dr Balzan stressed the need to give importance to the role of physicians, adding that the whole wheel needs to turn.

Dr Busuttil accepted that waiting lists are long, especially in the case of joint replacement and cataracts. "With an increasing elderly population, the incidence of cataracts and arthritis requiring joint replacement will increase," he said, adding that the problem was a case of not having enough facilities to step up the treatment.

"Another limiting factor which has hampered us over the past months was the need to stop elective surgery for a couple of months in winter to be able to admit medical patients to surgical beds because of overcrowding. We would like to review the waiting lists to make sure they truly reflect the patient load awaiting surgery."

The burning question is, can waiting lists be reduced by pumping more money into the system, creating the necessary number of theatres and employing staff? Dr Busuttil stressed the importance of striking a balance between priorities.

"Out of the about Lm80 million the health sector gets annually, between 20 and 25 per cent goes to medicines and 60 to 65 per cent is spent on salaries. Those are already taking up to 90 per cent of our budget, without taking into consideration the infrastructure.

"We need to be extremely careful with money. The government does not have an infinite supply of money, and we have to strike a balance between what we pay in taxes and what we get in return."

Dr Busuttil said the health authorities were introducing systems to make sure they were making the best use of the money available, addressing waste and seeking more cost-efficient ways of how to use the money.

Dr Balzan stressed the importance of having more consultants committed to public health service, those whose main source of income does not come from private practice. The package offered to doctors definitely needs to be improved. Dr Balzan stressed that there is no other way of addressing the issue.

"We have an excellent hospital being built, but the bottom line is that increased turnover of activities will mean that running the hospital will cost the government more money, especially in those areas where the waiting lists are accumulating faster than surgeries are taking place," he said.

Moreover, according to Mr Cini, the nurse to patient ratio is not yet at the desirable level. Ideally, there should be a nurse for every four patients in medical and surgical wards. But at the moment there is an average of one nurse for eight patients, which decreases further during the night.

Not enough carers leads to complications for the patients, and Mr Cini said studies have shown that increasing the ratio to one nurse for every six patients raises the risk of complications for the patient by 14 per cent.

The local ratio is higher than that, and Mr Cini said reaching the desired staffing levels would mean a need for 300 new qualified nurses.

Although increasing the number of nurses would mean a financial investment, the authorities would still save money in the long run.

Mr Cini said having adequate staffing levels would lower the morbidity and mortality rates, and lead to patients staying in hospital for a shorter period.

However, Dr Busuttil said he does not believe there should be a standard nurse to patient ratio, but rather this should fluctuate according to the type of patient. The ratio in a surgical ward on a day when you have many post-operative patients must be higher than days when people are in the recovery stage.

He admits that this is not the case at the moment, when the nurse to patient ratio is constant irrespective of the activity in the ward. For the ideal system to work nurses needed to be flexible, so that more would be working on certain days.

Dr Balzan strongly believes that the current mix of public and private services should remain. He pointed out that the government cannot carry the full burden of the health system and, secondly, it was always good for the patient to have a choice, both between public and private healthcare and between private hospitals themselves.

"The element of choice is part of the vision for the future," he said.

"We need people who are motivated and dedicated to the public health system, while on the other hand we need to preserve private healthcare," he said.

Mr Cini highlighted the importance of public and private healthcare working hand-in-hand. "The health authorities should be able to look into the option of using the private sector to help cut waiting lists in the case of interventions that could be carried out privately."

Dr Busuttil sees no reason why there cannot be more collaboration between the two sectors, something that already happens to a certain degree. Such collaboration can take place both at primary level with GPs having more access to resources available in the community and at hospital level through the sharing of services.

Despite complaints about the health system, Dr Balzan believes it is still highly efficient, also thanks to the dedication of doctors and other health professionals.

Dr Busuttil agrees: "Without being complacent, I think we do have one of the better health systems available in most of the world. We get a lot of services which for the size of our country nobody would imagine we would get."

He would like to see the health system continue to deliver high quality services in a sustainable manner. But it is not just a question of expanding; he stressed the need to maintain high standards.

"If for the sake of expanding the service you are going to lower the standard, I would rather not expand," he said.

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