Daphne writes on the Medical Brain Drain - 4/12/2006

link to The Independent

The Malta Independent Online
by Daphne Caruana Galizia

A bit of news made the inside pages recently and nobody seems to have noticed. It’s not the kind of thing that gets us worked up into a great frenzy, like the Eurovision Song Contest, Jesus on coins, or the need to defend Fr Anthony Mercieca of Gozo against all those nasty Americans who are abusing him. The news is this: Maltese doctors are leaving Malta, never to return. I can’t blame them, because I would do precisely the same in their position. Yet I can’t help wondering why nothing is being done to stem the flood, given that there are consequences for the rest of the population, and for the staffing levels of that mammoth general hospital called Mater Dei. We can afford to export priests and lawyers, but there is no way on earth that Malta can afford to carry on training doctors – free of charge to the students and at great expense to the national coffers – and then exporting them to the rest of Europe, while trying to work out how to make up for the shortfall.

It’s not because we’ve joined the European Union, either. Between 1994 and 2003, 166 hospital doctors left Malta. Only 24 of them have returned. The figure is not to be sniffed at, because it is a full 62 per cent of the number of hospital doctors registered by the Malta Medical Council for those years. They all graduated between 1992 and 2001, finishing their compulsory housemanship at the State hospital two years later. The Medical Association of Malta and a medical student researcher asked them to volunteer information on where they are, what they are doing, why they left and whether they plan on returning, and now has the data to hand. You might have thought that the Ministry of Health or the Ministry of Education would have taken this initiative, given all their organisational resources and the fact that this matter is of direct concern to them. You might also have thought that the Opposition could have bothered to take notice and to come up with a plan to inspire us with confidence. But the Opposition seems more than ever to be sound asleep, waiting for the soon-to-arrive day when it wins the election by default. No effort is required on its part, and so, no effort is forthcoming.

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The figures released so far also show that more than 50 per cent of all doctors who finished their housemanship between 1994 and 2003 have left Malta, and only 7.5 per cent have returned. Unlike the figure of 62 per cent, which relates only to those registered with the Malta Medical Council as hospital doctors, this figure of 50 per cent relates to hospital doctors and general practitioners. More than 16 years ago – I remember the year because it was one of the first news features I had written – we were promised a scheme called the “doctor of your choice”, which would allow us to choose a family doctor on the State system. Now it seems that the doctors who might have been our choice are somebody else’s choice in Britain, tending to the fevers of British children after their education has been paid for by Maltese taxpayers.

The sad thing about this situation is that, from what I can gather by speaking to a few people, many of these doctors don’t especially want to leave Malta. What they do want to leave is terrible working conditions, risible pay, a hospital hierarchy more fossilised than the English class system in the 19th century, and no room for career growth or for the expansion of professional horizons. It is impossible to be an ambitious doctor in Malta without ending up embittered and frustrated. The system encourages a lackadaisical attitude and a lacklustre approach to the advancement of one’s own knowledge in the medical field.

You can say that it’s all very well for doctors, and that the same can be said of most people in almost every field in Malta. However, the situation is particularly aggravating to doctors and the consequences are particularly grave for the rest of us who need them.

Some days ago, the heart surgeon Alexander Manche asked to be released from his “special status” and to be paid the salary other medics at his civil service grade are paid: Lm10,000 a year. Please, don’t all laugh at once. His former salary, which wasn’t extraordinary by any means for that kind of specialised work, had been causing a great deal of resentment among his colleagues, who were paid far less. Mr Manche had come from England, and was paid as a “foreign consultant”. Somebody with a different kind of personality would have waved two fingers at the lot of them, the government included, and gone where he was appreciated and remunerated suitably. Mr Manche is a quiet and decent kind of chap, so he didn’t. I imagine he worked out that the only appreciation he needs is that of the hundreds of patients whose life he has saved.

The publicised resentment among other consultants at Mr Manche’s higher salary was deeply unpleasant to observe, though it was entirely understandable that such resentment was felt. The unfortunate thing here is that, having given up trying to whip the government into releasing them from the civil service and raising their salaries to something more appropriate, they have instead chosen the socialist way of dragging down the higher-paid individuals so that they are all equally low-paid. That’s no solution at all, even if it does soothe their nerves.

As some kind of consolation, the specialists who are paid this ridiculously inadequate pre-tax and pre-national insurance salary are permitted to take on private work. All of them do so, which is why patients are so often presented with a choice between an appointment with the specialist at the State hospital in six months’ time, or at a private clinic or hospital the very next week. The specialists make their money from private work, and treat their hospital salary as so much pocket money. You can argue that they might as well quit the State hospital and work only privately. Some of them have done that, but there are varying reasons why the others don’t. These range from the altruistic need to give something back and the urge to help people who most need it, to the realisation that a general hospital is the best form of lifelong medical training, and to the rather less altruistic perception of the State hospital as a source of private clients.

There’s something else. When the government pays peanuts to hospital doctors in return for essential work that is worth far, far more, it becomes indebted to them. Doctors in this position have a lot of leverage. Their position is basically this: I will give you my services in return for a pittance as long as you give me these other things in return. So far, the most important of these other things is the exemption from the obligation to give tax receipts in return for payments they receive. The argument is that they do not charge VAT for their services, and so are not obliged to give a receipt. This is rubbish. Everybody is obliged to give a tax receipt, even if they are VAT exempt. Doctors are the only exception. Even animal doctors give VAT receipts. The underlying reason for this is that without tax receipts they can get away with not declaring all their income. The government has well and truly been held hostage on this one.

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There’s another important point to be made, and this is the fact that not all specialists and consultants can carry out private work. The nature of their specialisation may preclude this. Certain forms of heart surgery are conducted where there is a specialised cardiac care unit and even an intensive care unit in case things go badly wrong. This means St Luke’s Hospital. The scope for heart operations to be done privately is severely restricted, as most patients prefer to have the work done at St Luke’s. They may be wrong about the greater safety of the State hospital in an emergency situation, but that is the perception.

If doctors at the State hospital are paid as they should be, then I rather suspect that most of the complaints about terrible conditions would subside. Conditions for doctors at a general hospital are inevitably trying, anywhere in the world, because it’s the nature of the work involved and the ceaseless pressure of patients. They know this. As for the rest, there is nothing that some new offices and rest quarters, more respect and better management won’t cure.

It is the government’s business to find out why all these doctors are leaving and have no plans to return, and to then do something about it. Medical training, unlike a bachelor’s degree in the arts, costs an absolute fortune but is given free of charge, in addition to the subsistence stipend that students receive. If more than half of all doctors being trained at Malta’s medical school leave immediately after serving their housemanship, there are serious questions to be asked about whether the Maltese taxpayer should continue to fund the training of doctors who never work in Malta. These would be legitimate questions, given that our education system is perennially deprived of funds. A choice seems to be the moral way out of this dilemma: doctors either work in Malta (whether in private or public practice, it doesn’t matter) for an agreed number of years or, if they want to leave Malta, they must pay back what has been spent on their training. It’s not “the government” that’s paid for all that, after all: the government doesn’t earn any money. It takes it from people, and those people probably don’t want to have their taxes spent on training doctors who will be seeing to the needs of British patients in Britain.

There’s another question to be asked: how is this mass emigration of doctors affecting supply in the country where they are trained? The Medical Association of Malta has answered that one already. There’s a shortage of doctors in all fields, including the mainstream areas of specialisation.

The 24 doctors who left and then returned are in better positions at the hospital than those who never left at all. We don’t yet know whether this is because their stint overseas gave them more experience, or whether the offer of a good position is the reason they came back in the first place.

Meanwhile, the hospital doctors who graduated between 1994 and 2003, and who have stayed behind in Malta, are all engaged in the accident and emergency department at St Luke’s Hospital – what we know as “casualty”. Yes, all 99 of them are there. What happens if more of these decide they have had enough, and to up and leave for better prospects? That department is under enough pressure as it is, and still it manages to deliver truly excellent service. I have used it several times over the last 20 years or so, and the doctors there were thorough and reliable. They also have to put up with a great deal of bother from drunks, rough-necks, harridans, and people who believe they are entitled to jump the queue and get instant attention because they have a sudden backache at 2am.

As the Medical Association of Malta has pointed out, it doesn’t make much sense to spend Lm200 million on a new general hospital without investing in the medics who will staff it – and let’s not forget that these include nurses, too, who also have dreadful pay and conditions for a very difficult and demanding job.

The Medical Association has sounded the alarm about the fact that the brain drain situation is actually set to worsen. Before EU membership, the get-away figure stood at 62 per cent of new hospital doctors and 50 per cent of all new doctors including general practitioners. And that was in a situation where they had to struggle for work permits because Britain allowed them only a four-year “work window”. Now that we have freedom of movement right across Europe, the get-away rate is likely to have shot up. We still don’t know.

Traditionally, Maltese doctors have gone to Britain because our medical training follows the British system. Now the USA is facing manpower shortages and it’s possible that the brain drain from Malta could shift: to the US instead of Britain. We may find ourselves having to import doctors, just we had to do in the late 1970s and 1980s, when the government caused a massive brain drain in the medical field. We thought that brain drain was bad, but it’s happening again now. The difference is that we haven’t noticed because it’s not the result of a single government action, like Mintoff’s in the late 1970s, but of on-going corrosiveness.

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