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Interview with Dr Stephen Fava -Malta Business Weekly - 1/5/2003

What are the challenges facing the medical profession in Malta? Dr Stephan Fava, president of the Medical Association of Malta tells David Kelleher why certain developments have to take place sooner rather than later if the profession is to move forward

How would you describe the medical profession in Malta? In what areas have important developments been made?
Health care in Malta has always been very good. Maltese doctors have a good reputation both locally and overseas. In fact, many Maltese doctors have worked overseas for a number of years, some indefinitely, and they have made a good reputation for themselves, for the medical profession and obviously for the country in general. There are certain problems, just as there are problems in any other professions; these relate mostly to the public health sector.

In what areas have important developments been made? Are there certain areas that have major considerable improvements?
Medicine is evolving all the time, it is not static. Malta is not an exception and we have made advances in a number of areas. We have also expanded, in the sense that certain services that were not provided locally in the past, are nowadays being provided in Malta. Maltese patients today can avail themselves of nearly all services and procedures here in Malta. There are, however, certain conditions, such as rare diseases, that cannot be treated locally and patients have to sent overseas for treatment. This is because of the smallness of the country there will always be certain diseases that are so rare or procedures that are done so infrequently that one cannot maintain the necessary expertise locally. Even in other countries, these would be referred to larger hospitals with a catchment population of a several million.
Therefore certain procedures that are dealt with rarely in Malta will always have to be done overseas. But what can be done locally is being done locally. Only very few patients need to go overseas for treatment. This is beneficial for a number of reasons. First the patient benefits because he is closer to the family, friends and home. Secondly, the government and the country will also benefit because you save a lot of money in the hospital fees, travel and accommodation. From a psychological point of view, the patient is taken care of by medical professionals with whom he or she can relate better. There are no language barriers, for example.

Can you give some specific examples.
Well, patients are still sent abroad, for example, for some oncological treatments (rare cancer cases) that have to be treated overseas. On the other hand, treatments that used to be provided overseas and now done in Malta include angiography, heart surgery, dynamic endocrine testing and hip replacements. These used to be either carried out overseas or we used to bring over a specialist to carry out the procedure.

What are the main reasons for these developments?
Mainly due to the fact that there has been an increase in the number of specialists, especially those who have returned to Malta. Increased investment is also another factor and at the end of the day, it makes sense from a financial perspective. In the long run, it is worthwhile to invest locally and not have to pay to send people abroad. I need to emphasise that we still have manpower shortages, even though a number of Maltese specialists have returned to Malta. This is very evident in the public health sector.

You mention a shortage of staff in the public health sector. Every year, 50 doctors leave university. Do they all go abroad for specialisation? Are enough doctors leaving medical school?
The university produces enough doctors, however we do lose a large proportion of them from the public sector. As regards general practitioners they would have left the government service to take up positions in the private sector. With regard to hospital doctors, many opt to go overseas for training or to work. Some of them never come back. That is one of the major problems that the profession is experiencing. This usually leads to long waiting lists and a service to patients that sometimes may not reach optimum levels.

A good percentage go abroad, spending four to six years cut off from the island. Some of them return, but do we have a situation where doctors, for a financial reasons and to widen their horizons, prefer to go abroad rather than settle down as general practitioners?
I don’t believe that is the case, because what motivates doctors to specialise is normally one’s aptitude rather than financial considerations. It varies from year to year but aptitude is the main reason. One point, however, that you have raised is that those who go abroad remain overseas for up to six years. This means that there is a deficiency in the number of junior doctors in the public health service, apart from consultants in specialised areas. Most countries could train them themselves, in which case they would continue to work and provide a service in their own country. We have had training locally for quite some time, but it has to be better structured. It is something that needs to be tackled and it is being addressed. One of the requirements of the EU directives is to structured training. This will be advantageous to the country on three levels: First, local doctors would have the option to train locally without having to go overseas. Secondly, it will be advantageous for the health service because doctors will remain within the local health sector and, third, when you have a teaching and training hospital, the quality of service there tends to improve as well. Structured training needs to come into being as soon as possible.

What is being done to have Malta’s first fully-fledged training and teaching hospital?
First we need the legislative framework. There is new legislation, the Health Professions Act, that should be passed by Parliament soon. Among other things, it will establish the specialists’ register, structured training and vocational training for GPs. MAM has been in favour of having such structures locally long before Malta applied for EU membership. Unfortunately, although this draft law has been prepared and other interested parties, it has still not been passed in parliament. We need to get our act together as soon as possible and formalise our training structures and vocational training for GPs.
We have discussed the draft with government but we are still awaiting the fifth draft. We haven’t seen this draft yet but we strongly suggest that the final draft be published for all to see, not only MAM, and that agreement is reached on certain issues that are still pending. After consensus is reached, the law should be passed by Parliament as soon as is possible. We cannot waste more time.

What issues are still pending?
Mostly vis-à-vis structured training. We have to build the infrastructure for that to happen. There is agreement that there should be a committee called the Specialist Accreditation Committee comprising of the specialist societies for each speciality, the health division and the university. The specialist society will formulate a special training programme and will recommend to the SAC that a doctor should receive specialist accreditation. The major point of disagreement is on the appeals committee. There will be an appeals board for decisions taken by the SAC and the constitution of this board has still not been agreef. It is also very important, and there is agreement with the government, that the training supervisory body and the SAC should be autonomous and independent of the training institution , that is the hospital. You cannot have a supervisory board supervising itself or giving itself accreditation. I think this is fundamental. We had brought over an overseas expert, who was the President of the European Union of Medical Specialists and he emphasised that both had to be separate and independent of each other. The function of the training institution is to provide training along the lines of international standards and recommendations.
Another important issue in primary health care is GP vocational training. Up till now, whoever graduated and finished his housemanship can work as a general practitioner. However, nowadays, family practice is considered as a specialist area in its own right and requires additional training. We have reached an agreement with the government on the structure for this type of training, we have a draft agreement but nothing has been signed yet because of bureaucratic delays. Here I must emphasise that we must get this up and running as soon as possible and to cut any bureaucratic red tape.
Unless we organise ourselves as soon as possible, we risk a brain drain. This risk will increase with EU membership. Although Maltese doctors never had too many problems in going abroad, the EU will make it much easier and they will enjoy better salaries and conditions of work. This will put pressure on Maltese doctors to go abroad. That is why we need get our act together, or we risk losing more doctors.

This will require a considerable set up. Are you looking at the same level of specialisation as that obtained abroad or a lower level of specialist training?
It depends on the speciality. Where there is a good throughput of patients, we can train them to the full. Where we do not have enough cases, there might be the need to send them abroad for supplementary training. I am sure that our specialists, whether trained fully locally or not, will be of the highest standard as they have always been.

The EU offers higher salaries and better conditions of work. Will Malta be able to match these two ‘incentives’ in order to keep Maltese doctors in the country?
When we talk of salary increases, we are not expecting to receive the same level of increases that are given abroad. But if you compare the ratio of what a doctor earns to what other workers in the public sector do, the ratio is lower than that in the UK. A doctor’s salary is also low even when one takes into consideration the local GDP or the purchasing power. You have to consider not only what impact an increase will have on the country, but the impact on the country if the increase is not given. How much does it cost to train a doctor? That is money that would be lost if they leave overseas. It would be more cost-effective to improve conditions and retain doctors in Malta. Can the country manage without the required number of doctors? If Maltese doctors go overseas, the service will suffer and more patients will have to be sent abroad because the doctors’ complement is not sufficient for our needs. It is therefore essential that salaries and conditions of work are improved even we want to avert a brain drain.

What other advantages does EU membership have for medical professions? MAM has always been in favour of Malta join the EU.
Not exactly. MAM has not commented on the issue. We have remained neutral because as a council we felt that we should not be paternalstic and tell our members how to vote. We informed our members on what the EU will mean for our profession and the health sector in general so that they could reach an informed decision themselves. We never directed our members in this regard, however we studied the situation closely, invited experts and looked into developments overseas so as to be able to provide enough information to them.
One of the advantages, the main one I suppose, is freedom of movement of doctors overseas and mutual recognition of qualifications. As I said, this has not been a problem although EU membership will make it easier for them. At the same time, this could be a disadvantage for the country because our doctors could decide to leave. The EU also sets a number of standards and basic requirements that the profession in Malta will have to adopt, especially with regards to training.

How would you describe the relationship between the medical profession and insurance companies?
Relations are very good. We have only had some problems with certain insurance companies. And we are meeting regularly to discuss reimbursements by insurance companies, for example. At present we are negotiating a new agreement on the amount an insurer will reimburse patients for a particular procedure or treatment. We hope to reach an agreement soon.

There have been some problems over promotions in the public health sector. Can you give any details?
What needs to be improved is career progression and this is related to training. When a doctor enters into specialisation, he follows a programme and if he is successful, he gains status as a specialist in a particular field. That should not be a problem once we establish a structured training framework. But we also need to take into consideration those doctors who have already completed specialist training. Unfortunately, there are a number of doctors who are fully specialised, who can work in the private sector as specialists, but have still not attained ‘consultant’ status in the public sector. This is quite frustrating because you cannot remain in a junior post for ever. After a number of years, you should be appointed a consultant. There is a small group of doctors who have many years of experience, but they have remained in a junior post even though vacancies exist within the service for consultants. The authorities have argued that there are not enough junior doctors and these promotions would only cause a further depletion in manpower. We counter that by telling the authorities that by creating vacancies in junior posts you are also giving an incentive to junior doctors to work for those posts and the possibility of further career progression when they specialise. Junior doctors get frusrtated when they see that doctors who are many years their senior still have not attained a consultant status. This serves as a potent incentive for them to go overseas. I must also state the foreign TAEIX expert also said that there is an urgent need to promote these doctors, but this has fallen on deaf ears.

What are the current trends in the medical field?
One area that Malta could benefit from is medical tourism. Countries like the United Kingdom have long waiting lists, especially for procedures like hip replacements. As EU members they are offered the chance to go to another hospital in Europe to have the operation etc. And this, I believe, is one area that Malta can tap. We have the infrastructure, especially in the private sector, and we have a good reputation. Above all, tapping this niche market will help the economy. Not only will the private hospitals benefit but ancillary services such as airlines, hotels and related services will do so as well. It is one area that should be encouraged further however we need to promote ourselves abroad just as we advertise to tourists to come here on holiday.

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