Issue link: https://maltatoday.uberflip.com/i/487054
14 HEALTH has – paradoxically, in a sense – often proved a headache for Maltese governments in the past. And while it may not have been a major theme of the electoral cam- paign, there can be little doubt that disgruntlement with the national health service played a small part in the eventual outcome. The Labour Opposition had capi- talised on many past complaints – about waiting lists, out-of-stock medicines, staff shortages, union dis- putes, beds-in-corridors, the cost of building Mater Dei, etc/ – to eventu- ally present itself as a panacea to all our health problems. Its electoral manifesto almost read like a medi- cal prescription: 'to be taken by the entire country, in a single large dose on March 13, 2013…' Only it didn't specify whether there would be any side-effects. Either way, expectations of an im- provement in health service stand- ards were understandably high: and while some areas do seem to have improved – stocks of medicines be- ing the latest example – progress has not always been fast or rosy. Complaints can still be heard about waiting lists for certain operations, about overcrowding at Mater Dei… and ticking away in the background is the unspoken issue of long-term sustainability. Both parties are traditionally com- mitted to preserving the NHS in its current, free-for-all form. Yet both have promised increasing the serv- ices provided for free across the board… while not raising taxes in any other area. We also know that Malta's is an ageing population, and that demand for improved services is therefore set to increase exponen- tially. For the same reason, the fund which finances the entire sector is expected to shrink, even as medical- ly-related expenses soar. Clearly, there is a contradiction between the declared aims of the present government – i.e., to provide 'more, better, free' – and the under- pinning economic reality staring us in the face. Something, somewhere, has got to give. Or does it? Dr Chris Fearne, parlia- mentary secretary for health, almost radiates confidence that his govern- ment will deliver on its many health- related promises. In fact, he begins, it already has. "Am I satisfied with the rate of progress? Yes. We have built up a good momentum, and many of the targets we set before the election are being reached. Take out-of-stock medicines, for instance. In the past it was an endemic problem, faced by all who depended on free medicines on the POYC (Pharmacy Of Your Choice) scheme. For the last four weeks, the rate of out-of-stock med- icines has been zero. There may be shortages of individual medicines in future – if there is an international shortage, this would naturally affect us too – but not of the hundreds of medicines that up until two years ago were always out of stock. This was something we addressed from the first days we took over as gov- ernment. It was one of my priorities as a parliamentary secretary. It was a management issue, really: placing orders on time, being aware when things are running out…" Fearne however admits that not all problems are so easily resolved. "There are management issues, and then there are other issues related to resources. The problem is you have to have the resources to be able to manage them. And that's one of the hurdles we face: a lack of resources, both human and in terms of facili- ties..." He cites hospital beds as a prime example. "The situation in a nutshell is that we don't have enough beds. Simple. The hospital [Mater Dei] is too small, and the number of acute beds available is insufficient for the needs of the country. One can man- age the system better, yes, you can make arrangements here and there; but there is only a finite amount of management that can be done. At a certain point you have to increase the resources. The same applies to waiting lists: part of the problem is that we don't have enough human resources and theatre space…" The Health Ministry has recently outlined its general plans to address this shortcoming, and at a glance they seem to rely heavily on an input from the private sector. There has been talk of public-private partner- ships to reduce waiting-lists, and this has inevitably raised concerns. Some fear the thin end of the wedge: that the use of private sector facili- ties for public health services will mark the start of a gradual privatisa- tion process. Fearne however dismisses the no- tion with a solemn declaration that "the services we provide to Maltese and Gozitans will remain completely free for the patient. Whether we use Mater Dei, or a private hospital, the patient won't pay a cent…" He stresses that the partnerships are only intended as temporary, un- til human resources issues can be addressed. "The basic issue is that there is far greater demand for serv- ices than we are equipped to sup- ply. In the longer term, we need to address the issue by providing bet- ter preventive care – this is an area where Malta has fallen behind over the years – so as to reduce the de- mand as much as possible. But in the short term we need to increase the supply. We have to invest in re- sources…" From here, the decision is to either build up from scratch, or utilise what is already there. "What is it we lack? We have enough surgeons. But there is a lack of theatre space; of anaesthetists – and we are planning to hire more – and there is also a shortage of nurses. In the coming days we will be issu- ing a call for expressions of interest specifically for orthopaedic nurses, because that's where the demand is highest. But in the meantime, what we lack can be made available by pri- vate hospitals: nurses, anaesthetists, and the use of operating theatres. Our surgeons will perform opera- tions using the resources of the pri- vate sector…" He specifies that we are talking pri- marily about hip- and knee-replace- ment operations. "The areas with waiting list problems are basically four: orthopaedics, cataracts, MRI [Magneting Resonance Imaging], and varicose veins… With cataracts, we've already managed to bring the list down. By the end of this year we will have reduced the waiting time to a maximum of four months, which is the international benchmark. When we started out, it was four years… " Same goes for MRI: "From two years, they are down to not more than two months… a matter of weeks. As for varicose veins, we have introduced two new consultant sur- geons, increased facilities and equip- ment; and this year, the waiting lists have been slashed from a number of years to a few months…" Much of the improvement is down to management: operating theatres which had previously been used only in the mornings are now in use un- til 8pm and on weekends. The MRI scanner, he tells me, is now opera- tional 22 hours a day. "So if you need an urgent MRI – or even if it's not urgent – don't be too surprised if they call for you at 3am. You have a choice: if you prefer you can wait another two months. But if like most people, you need it urgently, because you're in pain or worried… you can do it at 3am. And I can assure you, the slots are being used…" All this may be good news for those waiting for an operation, but it doesn't really address the aforemen- tioned concerns regarding the deci- sion to rope in the private sector. After all, public and private health models operate very differently; and while one can easily see the benefits of partnership for government, the benefits for private companies are less clear. Given that they are, by definition, profit-oriented… how do they profit from the transaction? "The idea for us is to avoid rais- ing our own expenses; and for the private sector it is to make a profit. Our concept to achieve both goals is to rent hospital space and personnel from the private sector, and to utilise our own resources wherever possi- ble. Our resources include surgeons, who in the private sector are the most expensive 'assets', so to speak. So it keeps our costs down. In cases of hip-replacement operations, we can also procure the necessary pros- thesis for much cheaper than any private hospital, as we tend to buy in bulk. This way, the cost of rent- ing the theatre, the anaesthetists and the nurses will end up being more or less the same as if we had done the operation at Mater Dei." The private sector, he goes on, also profits because "it is more efficient than government. This is true all over the world. Generally, if an op- eration costs us 'X' as a government health service, it would always cost a private hospital less. And if we use our own resources, the private hos- pital's expenses will be less, too…" This may well serve to keep the service free for the individual patient on any one service; but at the same time the costs will still indirectly be borne by the tax-payer anyway. And the Labour government is commit- ted not only to retain the free health service, but also to enlarge it… with- out passing any additional burden onto the taxpayer. How achievable is this target in practice? "Our concept is that the health service has to find another source of revenue. We believe that this other source is medical tourism. We know there is a huge market for it, estimat- ed at hundreds of millions. And Mal- ta is ideally placed to tap into it. We have a good name: our doctors are known internationally to be of high calibre… we have already received requests from different companies, telling us they had a number of pa- Interview By Raphael Vassallo maltatoday, SUNDAY, 29 MARCH 2015 Medical tourism to We estimate that, to upgrade existing hospitals, to improve the service for the Maltese, and to create excess facilites to use for medical tourism, we would need €200 million. That, incidentally, is where the figure comes from... SUSTAINABILITY 'We need to create the facilities to attract paying patients from abroad. This will provide the revenue needed to keep the service free' €200 MILLION