Bitter Pill to Swallow - Interview Dr. Louis Deguara - 1/9/2007

link to The Times -

A better pill to swallow
The considerable capital expenditure involved in the construction of Mater Dei Hospital has overshadowed the underlying trends of recurrent expenditure on health care. Vanessa Macdonald spoke to Health Minister Louis Deguara about where costs would increase and where they would decrease - and why. But cost is not the only issue. What will change and will it change for the better?

by Vanessa Macdonald
Louis Deguara

Cost of medicines

The fact that there are more elderly people than before, the fact that the cost of medicines and treatment is increasing, and the fact that prescribing protocols are moving towards higher and preventive doses make a heady combination. They largely explain why the cost of medicine rose from Lm5.8 million in 1995 to Lm19.7 million in 2004, more than three times as much.

An 80-year-old costs Lm800 on average to treat, compared to just over Lm425 for a 70-year-old and Lm225 for a 60-year-old.

And there are far more people living well into their 80s. In 1948, life expectancy was just 55.7 years for men and 57.7 for women. This rose 73.8 and 79.5 respectively (by 2003) but will rise to 77.8 and 84 by the year 2030.

Protocols are also continually changing, Dr Deguara said.

"Take statins, which reduce blood cholesterol. Whereas before we used 20g doses, the recommendation is now four times that. And some countries are considering giving statins from the age of 30 onwards as a preventive measure.

"Of course, you have to remember the commercial aspect driving drug companies. There is a vaccine for the Human Papilloma Virus, a major cause of cervical cancer in women, which is now being suggested for men! The problem is that these adverts drive up patients' expectations and they begin to demand more," he said.

Surgical waiting lists

Mater Dei has 23 theatres, twice as many as St Luke's - although the additional ones will not be equipped and opened at once.

"We simply do not have the staff for them yet," Dr Deguara said.

However, he is confident that the waiting lists will start to come down rapidly.

"The population is finite and the waiting list will not continue to accumulate at the same rate so the day will come when we have no waiting list. For example, we anticipate that we will have no waiting list for cardiac patients needing triple bypasses within five years at most - much faster than we run out of ophthalmic or orthopaedic patients. This is because there is higher throughput, more staff, more beds in the cardiac intensive care unit for post-operative care.

"Although 1,105 cataract operations were carried out in 2005, 1,643 were added to the list! However, there will be a theatre dedicated to ophthalmic surgery at Mater Dei so those waiting lists will also start to decline," he said.

"Another problem is that St Luke's theatres stop working at around 2 p.m. We are now discussing afternoon sessions with the medical profession. If we extend theatre time by four hours, we would be able to cut a third off the waiting list.

"But increasing theatre use means increasing not only consultant time but nurses, anaesthetists, cleaners and so on. Unions complain that we are not talking to them enough - but before we reach an agreement with the doctors, we cannot discuss issues with the nurses. Things will fall into place once we know how the doctors will work."

In the meantime, though, many more operations will be possible day cases and Mater Dei will have 104 beds dedicated to these - but if the throughput increases, so will the cost.

"In the past we used to do an arthroscopy or cruciate ligament operation and leave the patient immobilised in hospital for eight to 10 days. Now, the operation is done as a day case.

"Instead of having a bed blocked by one patient for 10 days, you are now able to treat 10 patients for a day each," he said.

Some procedures have also become far more commonplace. In 1998, there were around 100 angiograms and angioplasty performed in a year. That number has now risen to 3,100 last year.

"The cost of disposables used therefore goes up. The catheter costs Lm70 and the stent costs between Lm500 and Lm700. So higher turnover means higher costs," he said.

Foreign revenue

Once the government has caught up with the backlog of patients, it will actually find it has spare capacity - which it can then offer to foreign health services. Not only will this generate revenue - but the revenue could subsidise care of locals, he explained.

"If we treat an EU citizen here because the waiting list in their home country is too long, we are paid what it would cost to carry out that operation in the home country - and not here.

"And we often cost half the price so by operating on an EU national, I can cover the cost of treating a Maltese patient," Dr Deguara said.

He believes that there is also great potential for patients from North Africa and Saudi Arabia.

"When we start to offer these services, we will complement - and not compete with - what is already being done successfully in the private sector. For example, a French company is bringing high profile patients here for cosmetic surgery, a sector more suited to the private sector," he said.

Bed occupancy

The hospital is a very expensive place to stay, costing an average of Lm85 per patient per day. So it clearly needs to ensure that only patients needing that level of care stay on. The average bed stay (4.2 days) is already one of the shortest in European countries.

"This is not because we are sending people home too early! If we did, there would be a very high re-admission rate - which there is not," Dr Deguara was quick to point out.

However, a long-standing problem has been the large number of social cases who lingered at St Luke's long after they were ready for discharge. He said that for the next two to four years, St Luke's would be kept for respite and rehabilitation until the new facility is built at St Vincent de Paul.

Free prescriptions

Dr Deguara thinks the whole system needs to be looked at again, especially with regards to the system of yellow cards for chronic sufferers, which is not means tested and not capped.

"We are moving towards a system which does not respect our values of solidarity. People who can afford medicines are getting them free merely because their condition is classified as chronic.

"The pink card system, for those low-income families, is capped and overall seems quite stable. Of course, you have to have suitable means testing and better verification of what is being earned."

What about normal prescriptions? Was the government rash to remove the 50c charge introduced by the Labour government?

"We were prepared to back this measure as long as it was not across the board and vulnerable groups would be exempted. But the revenue figures in the budget indicated clearly that the fee was not going to be levied on each prescription but on each item on the prescription. We would have ended up with people paying the fee on a packet of cotton wool!

"Then in the exuberance after we won the election, we did away with it. The principle of it was not wrong; it was the way it was done that we objected to."

Yet, Dr Deguara is against the idea of having patients pay for prescriptions, saying it did not generate revenue as it was expensive to administer - and it also did not necessarily cut abuse, giving an example from overseas of people who kept claiming expensive and unneeded medicines and bartered them for toiletries.

"When the 50c charge was introduced in Malta, the number of prescriptions issued went down but the overall number of items went up! So it was just as bad," he said.

"Some countries have different formulas for co-payments. In Israel, emergency services are free to all but other things like quality of life operations, such as cataracts and knee replacements, are pegged according to your income. I am not suggesting this but simply indicating that there are different ways of making the system sustainable," he said.

Cost of human resources

The government left it to the 13th hour to negotiate with the associations and unions representing the hospital staff - which could mean the government's back is against the wall. But he is still confident that negotiations will be concluded successfully.

"As we move closer to the final stages of migration, the professionals working at St Luke's are very eager - at any cost - to go to Mater Dei so I am also putting them under pressure. They want to work in a better environment. The staff are not only interested in money; an increasing number want to offer a better service. Even the unions and associations are being put under pressure by their own members.

"And you have to bear in mind that what the consultants are after is not necessarily what the registrars or junior doctors are after. Junior doctors are more after career progression - which Mater Dei will provide. Consultants, on the other hand, are more interested in working conditions and pay. "We have to guarantee that if we offer working conditions with better remuneration - which is where discussions are going - we get our money's worth. No one will be paid peanuts any more but we expect a quantum leap. A state-of-the-art hospital does not make a state-of-the-art health system."

Outpatient department efficiency

The IT systems at Mater Dei will make lost files and missing test results a thing of the past - but will the appointment system improve?

The high rate of "no-shows" - at 41 per cent the second highest in Europe - is being tackled by phoning patients up the day before their appointment to remind them and check if they are coming.

"If we do not know how many people are going to turn up, we get everyone at the same time so that if only half turn up, the clinic works efficiently," Dr Deguara said.

However, the solution does not only lie with the patients but with the consultants.

"I offered to let consultants have flexible clinic times but if they want to come in an hour later, at 9 a.m., they should not bring the patients in at 8 a.m. and they should still see the same number of patients," he said.

Another bone of contention for most elderly patients is that they are all brought in at the same time but Dr Deguara was not very optimistic of changing this for the moment.

"We asked consultants how long their appointment lasted on average as there is a big difference between, for example, an ophthalmic consultation and a neurological one. We also asked them to at least tell me how many people they wanted to see in each clinic. But most never replied.

"Still, when appointment times were staggered through the morning, the elderly still turned up at 7 a.m. because their relatives dropped them off at the hospital on their way to work!" He was pragmatic about the fact that consultants inserted their private patients onto waiting lists, saying that in certain circumstances this was acceptable.

"Some consultants used to see these private patients outside the normal hours, so they would not disrupt the regular list. It did not cost us any more and the private patients would anyway have ended up on the waiting list," he shrugged.

Preventive care

Although the pre-Budget document speaks reverently about health promotion and various programmes now in action, the focus of spending has clearly been on Mater Dei Hospital.

Isn't it short-sighted to spend so much money on treating people in hospital rather on trying to prevent their getting ill in the first place?

Dr Deguara was very blunt about this, quoting Dr Gro Harlem Brundtland, director general of the World Health Organisation, who once said that the unfortunate thing was that people voted based on what was available that day... and that politicians need votes.

"People do not worry about what will happen in 20 years' time. It is very difficult to get people to change their lifestyles; I only stopped smoking because I had a heart attack. This is why we believe that the best thing to do is to invest in the younger age groups, which is why we are undertaking anti-smoking campaigns, pro-exercise campaigns and healthy breakfasts. But these children don't vote. Those who vote now do not care about what we are doing to help their grandchildren in 20 years' time. Can you imagine telling a woman who needs a hip replacement now that the Lm500 for it is being spent on ensuring that her grandchildren would not need one?"

Dr Deguara said that the government had to prioritise its spending, unable to tackle everything at one go.

The next phase will, however, take a wider look at services peripheral to hospital care, such as community care. But Dr Deguara warned that although this would enable people to avoid spending time in hospital, it would not be cheap.

"Imagine delivering services - like changing a patient's dressing - to 20 people in their homes instead of having one person treating them all on the ward," he said.

He also said that the government needed to take a critical look at health centres.

"They were a stop-gap measure when there was the doctors' strike. We kept building and expanding them without an ultimate vision of what they should deliver.

"How can I reduce the number of people who go to casualty - 100,000 a year - if I do not have a specialist at the health centres who could deal with cases? Do you think that a fourth of the population has an emergency every year? Something is wrong. Many people go to casualty because it is easier and because if they go to the health centre, they are often still referred on to casualty," he said.

He was also frank about the fact that the primary health care system was failing to filter out cases that did not require specialist care.

"Unfortunately, many people are sent to the hospital because of defensive medicine, because doctors do not want to shoulder the responsibility as they may feel that they are not trained or competent enough to diagnose correctly. Who at the health centre is capable of interpreting an ECG?"

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