MMSA's Budget Recommendations in the Health Sector

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The Maltese Healthcare system has been rated as the second-best in Europe in a recent study by independent research centre Numbeo. However, no system is perfect. As current medical students and tomorrow’s doctors, we are starting to familiarise ourselves with the Government healthcare system. Through our clinical attachments and medical curriculum, we get to know the system’s strengths and our weaknesses. After meeting up with several stakeholders, some that are involved in administration and others who practice their medical profession within the government healthcare system, we had the opportunity to discuss issues that affect the healthcare system. MMSA’s Pre-Budget recommendations document is structured in a way that includes some of the most common issues that affected healthcare recently, followed by MMSA’s opinion and recommendations on what should be done to improve tackling the issue. Overview The Government affirms that healthcare is one of the main priorities as a “population in good health is a pre-condition for economic growth.” In fact, Malta is now in the top 20 countries with the highest life expectancy being 82 years in 2015. The Pre-Budget Document highlights the fact that healthcare has successfully matched the demand for medical services and equipment with the supply by solving the out-of-stock medicine crisis and reducing surgical and diagnostic waiting lists. The Government is also focusing to make the public health sector less demanding on the Government’s finances and able to sustain itself financially. This is being dealt with through the partnership with Vitals Global Healthcare who as a private company could produce many benefits. The Government has also settled agreements with other private operators through introducing the concept of medical tourism to Malta. This will be financially effective and provide more modern medical technology and services on the island. The Charter of Patient Rights is also being discussed by the Government in order to provide more defined guidelines on the citizen’s rights to access healthcare. From the pharmaceutical aspect, the Government Inventory Management and Stock Control has thought of better ways to obtain medications to encourage better competitive practices. This is going to be done even with the newer medications.

The Ministry for Health aims to get the most from any investments in public health and at the same time obtain funds through private capital. Alongside its employees, trade unions and management teams, the Ministry is also seeking ways how to deliver a more qualitative health service. The Government plans to concentrate on chronic diseases such as diabetes and cancer and aspires to prevent illness. For the treatment of diabetes, the Government will introduce new drugs as indicated in 2015. Regarding cancer treatment, the Ministry declares that innovative diagnostic and treatment modalities have been implemented and new drugs will be introduced. The Ministry also invested in more modern diagnostic and curative equipment through European funding. The Government encourages the use of the primary healthcare services as it believes that it offers continuous and holistic care towards its patients. It devised a plan for family doctors to check up breast cancer and mental health cases. Thanks to European funding, a primary care hub will be opened in the south of Malta. Additionally, cancer screening will be conducted in such centres. The Ministry has contributed to the Healthy Lifestyle Act to support healthy aging and illness prevention. Such contributions include legal action to stop smoking in cars and also other new policies. The Government emphasises that although investment on prevention will take time to yield benefits, it is the most promising - hence the reason why the Ministry for Health continues to invest in it. Medicine Stocks In the past 3 years, great improvement has been made with respect to medicine stock. Back in 2013, Malta’s current president, Marie Louise Coleiro Preca has pledged that medicines provided by the Government will be in regular supply, and that problems of drugs being out of stock would be “the exception, not the rule.� Unfortunately, free medicines were found to be out of stock under the Pharmacy of Your Choice scheme or from the main pharmacy at Mater Dei Hospital. This was such a serious problem that individuals were advised to check availability prior to going to hospital to collect them. Medication, such as treatment for breast cancer in particular, was also out of stock. The

majority of these medicines could be found in local pharmacies but unfortunately one could not obtain the medication for free. Measures to improve this situation were being discussed. During a press conference, an agreement was made to operate an IT system which could display the type and quantity of the medicine required. Furthermore, agreements were made with companies to provide medicine within 48 hours to solve stock problems while also keeping up to date with international medical recommendations. "Government's procurement system has been a total failure resulting in patients having to buy the medicine which they are entitled to receive for free. Others, who could not afford to buy the medicine ended up without taking any medicines at all”, Coleiro Preca said. The Government appeared to be impassive towards the system resulting in multiple cases of out of stock medicine. Instead of tackling the problem, the Government at the time was accused of even giving refunds to those who did not receive the required medication. In 2014, the Ministry for Health introduced a system whereby the POYC Unit’s Out of Stock Information List was updated every week. The published list served as an indicative guideline to help patients make better use of Government's free pharmaceutical services. The Ministry said that it had managed to drastically reduce the out of stock list of over 100 stock items to less than half. An Enterprise Resource Planning exercise was brought about to reduce wastage, while making effective and efficient use of the resources that were available across the entire National Health Services' (NHS) organisation. “The Ministry said that it had also centralised entitlement data; phased in IT infrastructure within key areas of the NHS that now enable audit trailing of pharmaceuticals; generated a pharmaceuticals' stock requirements for 2014, to track their usage across the NHS and ensure their monthly adjustment; set up an NHS team to pre-empting out-of-stock situations; and allow the NHS to submit an annual pharmaceutical demand to suppliers to facilitate procurement.”

Thus, it is evident that the Ministry during these times was doing its utmost to eradicate the stock crisis and reduce the effects of delayed deliveries of medications that patients might face.

In 2015, the issues with stock were greatly reduced. It was said to have been eliminated. In fact, numerous articles were published stating that for 10 weeks straight, no medicines were out of stock. The prices of 14 medicines were also reduced. During the first 21 weeks of the year 2016, no medicines were out of stock. Evidently, the stock crisis has been reduced and was no longer a hot issue. Criticism Even though the stock crisis has come a very long way and many issues have been solved, we are still facing some challenges. For example in August, Multiple Sclerosis patients did not have any medication such as dimethyl fumarate readily available. To this effect a patient indicated that “I was told I will have to wait for months because the medication won’t be available before November.” Recommendations All in all, the system has been taken care of by the Government recently. However, it is not a perfect system as occasionally medicines do run out of stock as in the case of the medication required by Multiple Sclerosis patients. More caution could be taken when stocks are running low. A text messaging system, through mobile phones, could also be introduced in order to inform the patient or any of his relatives when the required medication runs out of stock so that he can take the necessary precautions. Waiting Lists and Primary Healthcare What Has Been Done The Government has definitely strived hard to improve the waiting list situation in recent years. Statistics published within the hospital’s activity report shows that the number of patients being admitted to Mater Dei Hospital last year - as compared to those in 2008 - increased by more than a third totalling to 90.000. Therefore, as it can be clearly seen, the waiting list issue

continues to be an ongoing challenge that the Government must face continuously. As the General Secretary for the Medical Association of Malta, Dr. Martin Balzan once stated, “a real long-term solution” must be found – one which is smooth enough and adaptable to new challenges while also being able to provide a concrete foundation to work on. According to a Health Ministry spokesperson in an article published by the Times of Malta earlier this year, “operations at Mater Dei Hospital had risen from 36,000 in 2008 to 45,000 in 2012 and 53,000 last year.” Within the same article it has also been stated that: “The number of MRIs had quadrupled from 2008, ultrasounds had doubled to 33,000 last year and there were 3,800 cataract operations in 2015, compared to the 1000 in 2008.” In order to further combat the waiting list issue, a spokesperson within the Health Ministry also said that: “There has been a net increase of 57 specialists over-and-above specialists brought in to replace retiring ones.” Another article produced by the local newspaper, Malta Today, stated that Health Minister Chris Fearne confirmed that “waiting lists for knee replacement surgery have dropped from 1,700 to 770 in the past three years.” This was mainly due to the fact that knee replacement surgeries were performed on Sundays at Mater Dei Hospital “with 500 operations carried out in just the first three months of the initiative,” and other such surgical interventions within the Mosta Health Centre “leading to another 500 operations so far.” The article also affirms that a new agreement has been made whereby more of these surgeries can now be carried out at St. James Hospital to further lessen the burden on waiting lists at Mater Dei Hospital. Primary Healthcare is an essential force that must certainly be given proper financial support by the Government as it can alleviate the waiting list issue even further. Upon interviewing Dr. Renzo Degabriele, Chief Executive Officer at the Primary Healthcare Department, it was observed that substantial effort has been done to improve primary healthcare. He stated that “having a strong primary care is the solution to having a sustainable healthcare” and that it is essential to “have patients moving along the levels accordingly,” from primary to ultimately secondary healthcare if the need arises. This will prevent situations where patients take others’ place unnecessarily on the waiting lists, as well as decrease expenditure on procedures that probably would not have been needed.

The needs of primary healthcare are based on five basic pillars, in a “one-stop shop, holistic approach”: 

Strengthening Infrastructure Rabat and Mosta Health Centres have been refurbished.

Prevention Breast, colorectal, glaucoma and, as from last year, cervical screening have been introduced into clinics. Within 12 localities, lifestyle clinics in the district clinics have also been introduced to tackle obesity and diabetes. The hours for Immunisation services have been extended to the afternoon. A scoliosis programme in schools has been set up. In collaboration with the Health Promotion and Disease Prevention Directorate, freeof-charge education talks are held in local councils and various outreach clinics have been set up.

Investing in Equipment Two digital X-ray cameras have been bought in the past two years providing us with the possibility of taking all X-rays digitally. The Ministry has invested in two retinal cameras for retinal screening, vascular dopplers and physiotherapy equipment such as gait analysis machines together with visual field analysers and new ECG machines - the latter being available in all health centres in Malta as from this year.

Services Podiatry, physiotherapy and immunisation services are now also available during the afternoon. A point of care anti-coagulant clinic has been opened up to provide new dosages for patients on warfarin. Chronic disease management clinics will be introduced in all health centres by the end of this year. Private doctors are also offering some services in local health centres and prescriptions are now being made electronically thus preventing the problems that illegible handwriting entails.

Recruitment and Training A minor surgery course for General Practitioners has been organised and a group of nurses have now been trained to take retinal photographs. Criticism

As reported by the Times of Malta earlier this year, the General Secretary of the Medical Association of Malta, Dr. Martin Balzan has stated that “hospital waiting lists led many people to give up on more than 60,000 doctor’s appointments at Mater Dei last year”. Dr. Balzan indicated that patients still have to wait more than a year before being able to consult a specialist at Mater Dei Hospital. He said that the waiting lists themselves are an “illusion” – that the waiting lists for surgical procedures have merely shifted to ones of diagnosis at outpatient departments. Many patients had to wait for more than a year for a check up with the consequence that their health condition worsens and will show up at Accident and Emergency months before their scheduled appointment. Others who can afford to pay, will simply make a private appointment in order to check their health conditions. This, obviously, puts those 100,000 impoverished citizens of Malta at the risk of developing serious health conditions. Times of Malta staff phoned at Mater Dei Hospital to make a fake appointment with a diabetes specialist. They were told that they would have to wait 11 months for their appointment. Dr. DeGabriele emphasised that the Department of Primary Healthcare is currently “doing miracles” with the relatively small budget that they are given each year. When “80% of diseases can be healed within the community”, the Government maintains a discrepancy between the budget they allocate for primary and secondary healthcare, with primary healthcare receiving around €27 million - €23-24 million of which is reserved for payroll, leaving only around €3-4 million for investments in improvement, when this should be at the forefront of priorities in issues such as waiting lists. Recommendations Most of MMSA’s recommendations for the improvement of the waiting list issue are centred on the bettering of Malta’s primary health care system as this should be the first service that patients should seek. We believe that more funds should be allocated for the following:  

The Primary Health Care Department is seeking to establish a call centre to provide information on health centre services as well as aid patients in booking appointments. The Budget should also aid investments in human resources in order to provide healthcare workers such as psychologists, social workers, physiotherapists and

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occupational therapists in each health centre. Investments in educational campaigns and public relations should be made to increase awareness of what the primary health care system offers. More courses for GPs with special interests should be financed by the budget so that these can further contribute to the “one-stop shop” approach within local Health Centres as is being done with GPs interested in both orthopaedics and cardiology. The budget should also provide more incentives for group practices whereby GPs group together and offer primary health care services under the same roof. Further funding should be allocated for the refurbishments being planned in Health Centres at Gzira, Floriana and Qormi and the Primary Region Health Care Hub being planned for Paola in the years 2020 and 2021. More funding should also be allocated for the new health centre being built in Kirkop, which is intended to open by the end of 2017. Further agreements between public and private health sectors should be incentivised so that procedures that can be carried out in private health centres can be opted for instead of at Mater Dei Hospital, to alleviate waiting list strain.

Bed Availability What has been done As mentioned in the Mater Dei Hospital Health Report, at present, Mater Dei has 928 inpatient beds and around 86 day-care beds. To address the problem that was attributed to lack of proper investment in the geriatric sector, the Vitals Global Healthcare will be building three more wards at Karen Grech increasing the number of beds from 31 to 80 beds for the general public, and from 270 to 320 beds for the geriatric population and 70 beds for the private sector. By doing this, patients would progress to rehabilitation and beds at Mater Dei Hospital would be available for any admitted patients. Another article points out that a new system called the pre-operative assessment clinic has been established to reduce waiting lists and increase bed availability. This section is composed of 14 clinics where pre-operation tests will be carried out. Thus, patients would not have to be admitted two days prior to the operation and hence more beds will be available. At Mount Carmel Hospital, bed availability does not pose any problems yet. Since patients are shifted from one ward to another, the amount of bed availability fluctuates with certain wards

being more packed than others at times. A Mount Carmel spokesperson declared that if the size of Mount Carmel Hospital remains the same, bed availability should not be an issue. According to an Emergency doctor, whom we have also interviewed, patients at the Accident and Emergency Ward at Mater Dei Hospital are occasionally still being admitted to corridor bed but with the opening of the Orange Ward the situation has been greatly improved. Beds for ITU patients will be provided at all times. Criticism Bed availability has been a recurring problem at Mater Dei Hospital, with instances reported in the Times of Malta where emergency admissions were accommodated in the corridors and operating theatre recovering wards. This issue was believed to be attributed to the fact that about 140 beds were assigned to patients who were waiting to be transferred to Rehabilitation Centres and Elderly Homes. Based on the information from an Emergency doctor, it is more problematic to find beds available during the summer months. During these peak months, when the admissions for surgery and orthopaedics are numerous, a patient would have to wait about four to six hours before being allotted a bed. The Malta Independent revealed that even though ₏200 million are being invested in hospitals in Malta and Gozo, only 10 new beds will be added for Gozitan patients’ use whilst the rest will be used for medical tourism. Barts Medical School, which educates around 300 medical students, will use 450 beds in Gozo for educational purposes: 250 acute care beds, 80 rehabilitation beds and 12 dermatology beds all at St. Luke’s Hospital and 300 beds at Karen Grech Hospital. On the other hand, medical students at the University of Malta will attend Mater Dei Hospital during their clinical years for training. This is a worrying issue as it leaves fewer beds available for local students and their training. Recommendations The recommendations puts forward by MMSA focus on increasing space such as building more specialised centres like the Sir Anthony Mamo Oncology Centre. Another recommendation would be to invest in more public-private partnerships, where private hospitals offer their facilities to be used in critical situations. Also, more funding could be

allocated to purchasing of beds, as the cost of each bed could be as much as €1,177.96, as indicated in the Times of Malta back in 2012. Furthermore, improving the primary health care system would also help in this issue. As pointed out in The Malta Independent, more investments need to be made to improve geriatric care sectors like homes for the elderly and Rehabilitation Centres. All of the above recommendations would not only increase the amount of beds made available for certain patients, but also decrease the demand on Mater Dei Hospital and other hospitals. Moreover, it would decrease the waiting lists as more patients would be receiving the service they require all at once, in a smoother and faster way. Vitals Global Healthcare Agreement Background A deal which was struck between the Maltese Government and Vitals Global Healthcare saw the transition of management of Gozo General Hospital, St. Luke’s Hospital and Karin Grech Rehabilitation Hospital to the company earlier on this year. Negotiations which began in October of 2015, led to Vitals Global Healthcare being chosen as the preferred bidder with an initial investment of €220 million at the three hospitals. The 30-year concession agreement between Vitals Global Healthcare and the local government seeks to create a public-private partnership which will improve healthcare standards while also generating substantial revenue through medical tourism. Overall Plans The agreement promises to create 1000 new employment opportunities with Vitals Global Healthcare expecting to create some 600 additional jobs in Gozo General Hospital alone. Older workers will retain their previous status as government employees and will receive the same pay for the same work, as both Vitals Global Healthcare and the local government have asserted. With respect to the patient aspect of healthcare, Vitals Global Healthcare has promised that all services will remain free of charge as they have been in the past with both Maltese and foreign patients receiving the exact same healthcare. Both Vitals Global Healthcare and the government are seeking accreditation for all three hospitals by Joint Commission International - something which Mater Dei Hospital has not yet

been able to achieve and which could make Malta a major site for medical tourism. Further funding will also be diverted to research and development with an annual investment of €200 million. Gozo General Hospital, St. Luke’s Hospital and Karin Grech Hospital will also serve as teaching hospitals with Vitals Global Healthcare who will be partnering up with MCAST and Northumbria University to develop and house a nursing school at St. Luke’s Hospital as well as working with Bart’s Hospital at Gozo General Hospital. Plans for St. Luke’s Hospital Vitals Global Healthcare plans an extensive renovation and refurbishment of St. Luke’s Hospital with 350 beds to be added; 150 of which are to be reserved for rehabilitation purposes with 80 beds available to Maltese patients and a remaining 70 reserved for medical tourism. As a further means of expansion of medical tourism, Vitals Global Healthcare, in partnership with Walter Reed National Medical Centre, plans to invest in the development of the Centre for Women’s Health and Centre for Diabetes. A third centre for dermatology will be developed in partnership with the government. Vitals Global Healthcare also plans to have rehabilitation beds set up by September 2017, when the first 50 rehabilitation patients will be admitted to St. Luke’s Hospital. All works at St. Luke’s are to be completed by September 2017. Plans for Gozo General Hospital and Karin Grech Hospital Plans for Gozo General Hospital include a total bed provision of 450 beds, 250 of which are to be used for acute cases and the remaining 200 reserved for geriatric and long term patients. Of these, 350 beds will be used for Maltese patients with the further 100 beds to be used for treatment of foreign patients. The medical school which is to be set up within Gozo General Hospital is to be run by Bart’s Hospital. Vitals Global Healthcare will provide 320 beds for geriatric care, all of which will be available to Maltese patients. As with St. Luke’s Hospital, all works are to be completed by September 2017. Current Situation The popular opinion amongst medical professionals that were interviewed is that a publicprivate partnership between the government and Vitals Global Healthcare will be beneficial to the health sector provided that such developments are managed well. From the standpoint of Mater Dei Hospital, it is the opinion of Chief Executive Officer - Mr. Ivan Falzon - that development of the three hospitals under Vitals Global Healthcare’s management may alleviate

some pressures placed on Mater Dei Hospital in reference to patient load. Primary Health Care Chief Executive Officer Dr. Renzo Degabriele - stated his belief that such a partnership is beneficial to both parties as it would aid in preserving resources provided that the deal is negotiated and managed well. When interviewed, Karen Grech Chief Executive Officer – Mr. Charles Bugeja - asserted his believe that the investment will help Karin Grech Hospital in expansion of their facilities and their staff. His hope is that their partnership with Partners HealthCare International will allow Karin Grech to achieve accreditation. It is his opinion that the promises, made when the deal was stuck, have already been put into practice since Vitals Global Healthcare had already financed new requested equipment . Moreover it is Mr. Bugeja’s belief that Vitals Global Healthcare is capable of acting faster than other government institutions to achieve the goals which they have set.. When asked about his views regarding the Vitals Global Healthcare takeover, Medical Association of Malta President - Mr Gordon Caruana Dingli - informed us that MAM would not continue furthernegotiations with the Government regarding the deal until the contract is published and audited. Mr. Caruana Dingli stated that negotiations between MAM and the government were halted earlier this year when the then Minister for Energy and Health was one of the individuals named in the leaked Panama Papers. Recommendations It is our recommendation that the government increases its transparency in its business practices, especially with the private sector as this will improve its public image while instilling confidence in the workers unions. It will also help ensure local students that their studies will not be compromised with the introduction of such an agreement. We would also recommend that the beds provided by Vitals Global Healthcare be allocated to Maltese or foreign patients based on demand rather than capping the number of beds to locals and foreigners hence making the scheme more efficient.

MMSA’s final recommendation would be to make it a requisite for students who will be studying in Malta as part of Bart’s Medical School in Gozo General Hospital to achieve a degree of

proficiency in medical Maltese so as to acclimatise themselves to the clinical environment in Maltese hospitals, especially when dealing with Maltese patients. While the MMSA acknowledges the great work done by the Maltese Government in order to improve the healthcare system, we believe that the recommendations proposed in this document will help to ameliorate the system and establish Malta as one of the leading countries when it comes to healthcare. As medical students, who will possibly be working in the same healthcare service in the very near future, we only have the patient’s best interest in mind. MMSA believes that the implementation of these recommendations would lead to a more efficient and sustainable healthcare system. References   d_best_in_europe#.V_7ggeB97IU d_knee_replacement_waiting_lists#.V_kC5uh97IU st_down_from_1500_to_770#.V_jiveh97IU er_announces#.V_zr92XRbxA WAH0E-B9601 _takeover_kicks_off#.WAH0ReB9601

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