Issue link: https://maltatoday.uberflip.com/i/602004
14 IT is perhaps ironic, but 'health' has traditionally always been a major headache for Maltese gov- ernments. Back in the 1990s, Prime Minis- ter Eddie Fenech Adami famously had 'nightmares' about the end- lessly growing national health bill. The same bill sky-rocketed with the long-drawn out con- struction of Mater Dei Hospi- tal… and all the while, medical expenses (the cost of medicines, hospital equipment, etc.) contin- ued to rise exponentially. With both parties agreeing on a basic model of 'free healthcare for all, from the cradle to the grave', questions inevitably arise concerning the affordability of such a service in practice. The present government's strategy is to invest in 'medi- cal tourism' – providing local services for free, but charging foreign patients (from non-EU countries) for the same services to recoup costs. On paper, the maths seem to make sense. But inevitably, the co-existence of two vastly differ- ent models within the same re- gime – public and private health services – may give rise to prob- lems. Ever since the announcement of a 200 million euro investment drive for a public-private part- nership to construct two new hospitals, MAM secretary Dr Martin Balzan has voiced his as- sociation's concerns with the ar- rangement: arguing that the pri- vate sector model is incompatible with a 'free-for-all' model. But first, let's talk about the ex- isting infrastructure, and its abil- ity to cope with what looks like a demographics time-bomb. It is a known fact that people in the 60+ age-group will outnum- ber the 30- bracket five to one by 2050. Even today, many of the waiting lists involve primarily third-age ailments (such as hip replacement operations, etc.). The strains of population growth can already be felt on the system today. How much more will they become an issue in a few dec- ades' time? "The demand will continue to rise, not only through demo- graphic shift, but also by real es- tate developers attracting elderly EU citizens to retire in Malta," Balzan begins. "Young working migrants might also opt to con- tinue living in Malta and even- tually retire here, adding to the demographic imbalance…" So is Malta's health infrastruc- ture, in its present form, suffi- cient to cope with the increase in demand for services projected over the next 20 years? "No," he replies, with some em- phasis. "Malta's infrastructure is insufficient. Services for the elderly, acute medical beds and palliative care services for ter- minal cancer patients… all are at present in short supply. This will only get worse in future." It is debatable also whether public expenditure on health is sufficient, nightmare or no nightmare. "Malta currently spends around 7% of its GDP on health, of which 1.2% concerns private practice," Balzan points out. "Most oth- er EU countries spend around 10%..." But doesn't all this strengthen the argument for a radical change to the national health service model? If we can all see it is des- tined to founder in its present form, we must surely consider different models… Balzan however argues that it is not the NHS model, in itself, that is the problem… but the way it is administered. He also expresses strong doubts whether 'public- private partnerships', of the kind now contemplated, can improve the situation. "The National Health Service aims to improve an individual's health, giving a comprehensive and full service to all – espe- cially those close to or below the poverty line – while serving as a safety net for the community," he explains. "The private sector, on the other hand, is driven by the imperative to make a profit, with a tendency to focus on profitable activities only." The two approaches can (and do) exist side by side: in fact, British health minister Aneurin Bevan himself – who created the NHS in the 1940s – acknowl- edged that free healthcare can only work in tandem with a pri- vate service. The problem, Balzan suggests, is the lack of clear demarcation lines between the two systems. Nor is it limited only to the public tender for the Gozo hos- pital. Back in 2013, Balzan had already flagged concerns with similar partnerships regarding health centres. "Minister Mizzi was intending to bring private money into the health centres," Balzan recalls. "At the moment we feel that pri- vate general practitioners are the backbone of the service. Building a private health centre in Kirkop would only result in government money being used to compete with private medical practition- ers. In practice, this will produce a nationalisation effect, rather than a privatisation one. It would increase rather than decrease ex- penditure..." Similar concerns have mean- while been aired on a different (but related) development. An- other private-public agreement concerns a new medical school – with two campuses – to be run by the London-based Bart's Hos- pital. The Medical Students Associa- tion has since warned of a pos- sible brain drain affecting the Malta Medical School as a result of this agreement. Does Balzan share these concerns? Can there be a level-playing field, when a state-run university finds itself in competition with a private in- stitution, paying private sector salaries? "Students are rightly concerned at the 'business first' agreement with Bart's Medical School," he nods. "This will result in prob- lems of capacity at Mater Dei and other health services when it comes to bedside teaching. The government needs to guarantee enough resources for the Uni- versity of Malta, which trains to- morrow's doctors for the Maltese population, and 'ring fence' them through a formal agreement…" Balzan makes it clear his ob- jection is not to the existence of competition in itself; but like the students he argues that the Medical School may not be in a position to compete. "While Bart's may try to attract the best and most experienced Maltese academics, it is up to the University of Malta to retain them… by changing its 'one-year contracts' into more durable ones, for instance." Inherent to both scenarios is the same dilemma: the incom- patibility of private sector and public service business models. At the same, however, isn't there a contradiction here? One issue that has consistently 'plagued' (so to speak) Malta's medical sector is the occasional blurred lines between private and public health services: cases have arisen of consultants at public hospitals referring patients to their own private clinics. There are no restrictions on national service doctors running private practices (as there are in some countries). So aren't the two models al- ready under the same roof, even without the current private in- vestment drive? Balzan however disagrees with the analogy. "To date, the boundaries are clear. Mater Dei is a public hos- pital, and private hospitals and private practice are separate. In fact, consultants can have contracts with or without pri- vate practice. The model where private patients and public pa- tients are in the same building will bring new problems, even though we are sceptical on medi- cal tourism." It seems there are other reasons to be sceptical, too: the Opposi- tion has raised doubts concern- ing the financial viability of the preferred bidder – the Vitalis Global Healthcare Group, which over the next 30 years will build and run the new Gozo general hospital, as new medical facili- ties at St Luke's and Karen Grech hospitals. Was MAM involved in the ne- gotiations to privatise these hos- pitals? Can Balzan shed any light about this little-known company: enough to confirm or deny exist- ing doubts? "What we know is what we have read on the internet. We do not know the track record of this company, and whether it has managed any hospitals." Balzan also echoes scepticism regarding whether sufficient due diligence was carried out. "It appears that this is a new shell company, with the support of an investment fund, but we have so far failed to identify any hospital or health service run by either despite their claims." Ultimately, there is a transpar- ency issue at stake here, too. Too little information has to date been disclosed about the Vitalis Global Healthcare Group. "They appear to have two con- sultants – one from Virginia and the other from Massachusetts – but we fail to see an established and consolidated structure." Having said this, Balzan ac- knowledges that MAM was involved in discussions with the government before the an- nouncement: even if only at the level of industrial representa- tives. "We discussed improving working conditions for doctors at VGH, inserting the necessary safeguard in the event that this project either succeeds or fails." Speaking of which: what are his own prospects regarding success or failure? Aside from his doubts Interview By Raphael Vassallo maltatoday, SUNDAY, 15 NOVEMBER 2015 A medical time-bomb? Services for the elderly, acute medical beds and palliative care services for terminal cancer patients… all are at present in short supply. This will only get worse in future ACUTE SHORTAGE It appears that this is a new shell company, with the support of an investment fund, but we have so far failed to identify any hospital or health service run by either despite their claims GOZO HOSPITAL MANAGEMENT