link to the times article
Monday, 21st July 2008
Investment in the health system
Gordon Caruana Dingli, secretary general, the Medical, Association of Malta, Gżira
In November 2007 the Medical Association of Malta reached an agreement with the government after a long period of negotiation. This agreement addressed crucial issues which are important to improve the efficiency of the health service. Local postgraduate training was entrenched in the agreement to improve standards and to retain doctors and to stem the "brain drain".
The new agreement allowed for flexibility in the hours of work and the new contracts enabled extra hours to be worked outside the established working day of 7.45 a.m. to 2.30 p.m. (Monday to Saturday). The agreement also introduced improvements in the pay packet, commensurate with the hours worked. For the first time, a new form of contract that precluded private practice was introduced and this has been taken up by a substantial amount of consultants and it is envisaged that these will increase with time.
To the government's credit, a lot of work has been done to introduce post-graduate training. The general election and the change in administration may be the reason why other parts of the agreement have not yet been adhered to. MAM expects that the rest of the agreement will be respected soon and that this will lead to greater efficiency. In a recent interview, the minister mentioned waiting lists and partly attributed these to a "part-time" hospital and under-utilisation of operating theatres. Consultants are contracted to work "office hours" including Saturdays, but many of them work way beyond the contracted hours, either because of long operating lists, long out-patient clinics or when "on call". Many even carry out elective (that is, scheduled) regular afternoon and Saturday and Sunday operating lists.
There is also a large number of non-consultant-grade doctors who work long hours, way beyond "part-time", in fact, working long shifts through the nights, sometimes once every two or three days. Many of these doctors go unrecognised; many are very experienced and they handle complex cases 24 hours a day, seven days a week. Among them are a number of experienced expatriates who have provided sterling service for many years.
The waiting lists have increased because the population is increasing in number (including tourists and foreign residents) and age, with increasing expectations. The services offered are also continually being expanded. The number of operations performed continues to increase from year to year and compares very well with foreign institutions but has not managed to keep up with the increase in demand. A surgeon does not operate in isolation, and to make use of empty theatres there is a need for more support staff and services.
Waiting lists are not the only measurable quality indicator of a health system. Mater Dei Hospital cares for many other patients besides those needing surgery, like patients on the general and specialised wards and the intensive therapy units. Other quality indicators, such as the infant mortality rate, WHO classification, bed utilisation and patient satisfaction surveys, have shown sustained improvements that equal or surpass those achieved in other countries. All this has occurred in spite of the decline in the numbers of doctors, nurses and other employees.
MAM has claimed for a long time that it is not enough to invest in bricks and mortar. The health system can improve through increased efficiency with existing resources but major increases in throughput require substantial investment in primarily human resources.