Interview - Minister Deguara - Doctors' working conditions - 13/3/2007

link to interview

Master of Ceremonies

Mater Dei will open on 1 July, Health Minister Louis Deguara assures everyone, but the only functioning part will most probably be an X-Ray department, a sterilisation unit and a decompression chamber.

Four months down the line, the beleaguered Mater Dei Hospital project should be opening its doors to the public on the day that also happens to be the Prime Minister’s birthday.
But with the migration from St Luke’s not even begun, agreement with doctors far from concluded and the IT tender up in smoke, everything points towards the much-awaited event turning out to be a mere door-opening ceremony on the eve of a general election.
Health Minister Louis Deguara is in fact unable to give a straight answer. So much depends on things beyond his control that almost all of his replies are in the conditional.
“What’s meant to happen on 1 July?” he replies to the question of whether it will be just a door-opening ceremony. “On 1 July Skanska should hand us a finished hospital, or else start paying penalties. That’s what is going to happen for sure. Once you have the finished hospital in hand you can start the transfer of services and patients. If Skanska gives us the hospital on 1 July, then you can’t open it on that day, so then it would be just a ceremony as you said.”
The minister goes on to add that the only finished units will be the sections that have nothing to do with in-patients – namely the hyperbaric unit, popularly known as the decompression chamber, the CSSD (Central Sterile Supplies Department) and the X-Ray department – meaning that the only people able to enter Mater Dei will be its staff.
The migration from St Luke’s to the new hospital is also another big question, with the goal posts shifting so frequently it almost makes you dizzy.
“Migration started a long time ago,” the minister now says, “because an integral part of the migration process is to take staff to the new hospital to see where they will be working. The greatest hassle is not the equipment especially if the staff are getting their training on new equipment at St Luke. For example if you’re shifting from a paper system to a paperless system in the X-Ray department, the equipment will basically remain the same. What’s going to change is the storage system and the processing, because you will no longer need filing or developing or drying of films. It will make life much easier for everyone.”
With the IT tender scrapped for good, the minister now announces that, after all, there is no need for a costly tailor-made system for the new hospital.
“There are other solutions,” he says. “There are other systems which we can adopt which will allow us to open the hospital without the complete IT system. Remember that the IT system had to be launched with the hospital’s opening but it would have taken until 2012 to be fully implemented. You have certain critical factors that we call LIST (laboratory investigations system), RIS (radiology investigation system) and the PACS (patient archiving communications system). If you have those three, the essential services of hospital can function, then you can add other services later on. These are systems which you can pick off the shelf, they are readily available. You can start building a system in this way.”
That sounds more like patchwork, but Dr Deguara isn’t bothered – he is now convinced it’s a better system, though only after insider information about the tender was allegedly leaked.
“Call it what you like. The original plan covered from A to Z, but you can stick to the essentials and then build upon them. One of the things we insisted upon when introducing the IT system presently in use at St Luke’s hospital was that the system was not an off-the-shelf system but one that was modelled according to our particular needs. That had drastically narrowed our choice of procurement. That system also ended up creating lots of problems for us, because for its maintenance, spare parts or whatever we were always bound to the company that delivered the system. With an off the shelf system one has a much wider choice and can negotiate a better price.”
If the IT system will end up costing less, the running costs of the new hospital will soar to Lm4.3 million a month, that is Lm1.2 million more than the monthly costs to run St Luke’s, or Lm14.4 million yearly.
“That’s because it’s a much larger hospital, and there are many more amenities that make it more expensive. The footprint is four times the size of St Luke’s, so automatically, it will cost you much more to clean it. But at the same time there are several other expenses that will be saved – for example it will have 13,000 sensors all spread out to control the air conditioning and lighting, and the building is built in a way to conserve energy. It will also cut down on most of the staff’s need to run around for results, samples or X-Ray developments.”
Whatever the cuts, an extra Lm1.2 million a month would still have to be forked out from public coffers, with no precise plan on how government will foot the bill. Deguara’s plan is as generic as unbranded drugs.
“We will continue to foot the bill and we’ve managed so far because we have been able to spur the economy. In spite of unexpected international hikes in oil prices. During January of this year alone government revenue has increased by one million liri. We have licked the budget deficit, applied to join the Eurozone, we have an education system that is not only free but that also pays students to learn, we have social services that have been described among the most generous in Europe and we enjoy a health system which is free at any point of entry.”
Yet he was the first to say years back that the health system is unsustainable.
“You are perfectly right. I said so and still maintain my conviction. But I invariably added to that statement that our health system is unsustainable unless we change our ways. We need to revisit our modes of financing the system, our work practices, to cut down on abuse and wastage as well as to revisit entitlement. The WHO Director General Dr Bruntland repeatedly stated that a health system that provided free treatment for all, all the time at any point of entry, was a perfect recipe for failure. At every meeting I attend for Commonwealth or EU health ministers, sustainability of health systems invariably comes up for discussion as a priority. We are aware of the challenges ahead. An ageing well informed and increasingly demanding population, new treatment modalities which are never any cheaper, newer medicines and lower birth rates. These are all factors escalating costs and challenges that we have to address while ensuring certain basic principles.
We hold the health system as a basic social service, centred around the person with particular attention to certain strata of society – the marginalised, the elderly…”
But what’s the financial plan? How will you make good for that extra Lm1.2m?
“You’re forking out an extra Lm14m, but you’ll also be saving if we increase efficiency and manage to attract foreign patients and develop medical tourism. We have certain advantages, such as the climate, the language, a state of the art hospital, so you will have patients who are sick of waiting abroad who would come over here. These things are not just in the air, we haven’t managed to do them before for the simple reason that foreign patients would expect hotel services within the hospital; services we so far haven’t been able to offer because the very structure of St Luke’s did not permit it. Mater Dei will overcome these problems.”
Another problem that risks postponing the shift to Mater Dei, at least in any meaningful way that would really solve waiting lists and long queues, lies in the fact that the minister hasn’t yet reached an agreement with doctors and nurses, and the financial package is not even his responsibility.
“The fact that we haven’t reached an agreement doesn’t mean that we aren’t discussing. A lot of the unions are looking at the migration to Mater Dei as an opportunity to increase their remuneration more than to change their work practices. There are ongoing intensive discussions with the doctors’ union, because to reach a sustainable health system you need a medical team leader. It would be a mistake to discuss with a union when you know that the conditions you’ll allow to that union can’t be given to other unions too. Besides, all unions have signed a collective agreement except the doctors’ union, so it was wise from the Management and Personnel Office to start discussions with the doctors. The discussions are being held with the Office of the Prime Minister, and not the Health Division, because they’re not about work conditions but about remuneration, and that’s not our remit. Once that is addressed and proposals have been put forward from both sides – and MAM has also described them as very positive discussions – the discussions will continue with the health ministry.
“One of the issues we discussed was that the new hospital cannot just operate in the morning. We can double the output and the capacity, and if we really want to go for medical tourism, then obviously we need to make this hospital work, not just till 2pm, but all day long. It doesn’t make sense to have 23 operating theatres working only in the mornings – you would have solved nothing. We also have to discuss the way doctors work. They do not work shifts. Should they remain working with the government and in private practice? Should we offer a package to those who want to dedicate their work to the government health service? Should we start offering the possibility to those not employed by the government to work on a session basis?
Again, Dr Deguara gives more questions than answers, when the answers should be crystal clear right now.
“The principles have been agreed upon. Now we have to see how applicable they are to be implemented in the new hospital. We can move to the new hospital with the present system, too. The problem with consultants remains that while nurses work on a shift basis, consultants do not. Now if you want to increase turnover of patients and cut down on waiting lists, reduce queues and attract medical tourism the hospital has to function for much longer periods especially in the evenings.”
But you’re speaking in the conditional, Dr Deguara. What are you going to implement at the new hospital?
“All this has been discussed with the Medical Association of Malta, which described the discussions as very positive. We didn’t discuss things we don’t want to implement.”
On the doctors’ brain drain, Dr Deguara dismisses this as almost a myth despite all the warning signs in the form of figures or young doctors leaving to work abroad.
“Let’s not keep spreading this rumour about the brain drain,” he says. “Look for a moment at who is leaving and ask yourself why. The main reason doctors are leaving Malta is not because of money or working conditions as some would have us believe, but primarily because of career progression and accredited specialisation. Most of the doctors we lose are at registrar level. If you are a registrar or a senior registrar aspiring for a consultant post but aware that no vacancies exist, and furthermore that all consultant posts are filled by colleagues aged an average of 45, then you start to realise that to achieve your aspirations would mean having to wait for at least another 20 years. So you’ll either wait all that time or else go abroad.
“So the brain drain is not affecting consultants, even though they can get a much better salary abroad, but we’re losing the senior registrars who wish to become consultants, and those wishing to train to become consultants. Given that we didn’t have specialist training committees, we couldn’t give recognised training. Nowadays, the training in certain areas such as obstetrics and gynaecology is recognised abroad too. We are not against them getting part of their training abroad, because notwithstanding all the training they get here the population remains 400,000, so exposure to certain disorders and diseases remains limited. But it is only understandable that if you’ve specialised in a branch and you’re offered a consultant’s post abroad, you wouldn’t want to return to Malta in a lower grade.”
Another worrying figure relates to the expenditure on medicines. Last year the figure soared to Lm24 million, around 12 per cent more than the previous year, yet government refuses to even consider means-testing.
“Across the EU the price of medicines goes up on average by 12 per cent every year. That is not just the drug bill but also includes prosthetics and disposables. That is where the escalation of costs is coming from. We’ve increased longevity and that also comes at a price. Whether we’ll introduce means-testing or not is not our competence as health ministry.”
But what is your opinion?
“It has never been discussed. Personally I believe that continuing with the present system where everybody is entitled to free treatment irrespective of means, especially where medicines are concerned, is making our system less equitable. My conviction is that the rich have to make good for the poor, the healthy for the sick, the strong for the weak.”
Does it make sense that a millionaire keeps getting, say, diabetes drugs for free?
“Whether it makes sense or not, that’s the system. As long as it’s sustainable nobody will change it. If there really are serious threats it would have to be revisited.”
You’re afraid of political repercussions, aren’t you?
“I don’t think so. If there is one thing distinguishing Lawrence Gonzi’s government, it is the difficult and unpopular decisions that had to be taken. I don’t think the controls we introduced on social services made us popular, but they were necessary. If we reasoned things as you’re suggesting we wouldn’t have done anything about it.”
What about doing that in health now?
“So far there has been no need to do it but we’re keeping an eye on the rising costs of medicines. Remember, however, that co-payment has never led to a reduction in service costs abroad. What has to change is the financing model of health services. If we’re seriously moving towards a health fund, the idea would be to spend as much as you collect. Before going into co-payment you have to quantify how much of the National Insurance goes to the health bill, and you need to give incentives. If, say, I pay 30 per cent of my NI towards health and I opt for a private insurance, there is no incentive to do that because private insurance would be over and above my NI contributions. So you need a system that identifies that 30 per cent contribution towards health, which would then be refunded, say, up to 20 per cent if you have private insurance. That would mean I’m not paying for all the service for free, because the hospital would then be able to charge the insurance company. These are systems we have to analyse.”
Fow how long will you keep analysing things?
“We’ve tackled the pensions problem, now the next step is health, whoever is in government.”
You’re suggesting this will only happen after the next election.
“It’s not a question of before or after the election because we have already tackled pensions.”
The pensions reform is criticised as half-baked, in fact.
“Do you find that prolonging your pensionable age to 65 years to be a popular policy?”
The fact that it’s unpopular doesn’t mean it’s the solution to the problem.
“That is part of the solution and we’ve taken the decision despite the forthcoming election. It’s one step of many that have to be taken. We have taken unpopular decisions because we believe in them. The same will happen with health, and they will be gradual solutions.”
Gradual may be a euphemism, but as a doctor with two decades’ experience in Parliament he might be right. Better introduce gradual doses than risk a fatal overdose.

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