The John Dalli report about Mater Dei Hospital reads like a story of overzealous politicians, pushy unions, non-existent management... and shocking waste.
John Dalli knows only too well it will take more than a reprimand to keep politicians’ hands off the hospital.
A veteran politician himself, Mr Dalli knows political decisions are more often than not conditioned by five-year electoral cycles. And evidence to this effect is found in the report he penned on Mater Dei.
Buried in one of the annexes is an admission by the current Mater Dei CEO Joseph Caruana that his efforts to change shifts of operating theatre nurses were scuppered last year because of an impending election.
The explanation was given in a note penned by the CEO highlighting the work done to implement some recommendations made by Johns Hopkins, a US teaching hospital that was tasked to propose a reform for the hospital.
The Hopkins report, which cost taxpayers €1.3 million, was concluded in June 2012 but a proposal Mr Caruana made soon afterwards to change nursing shifts was deemed problematic as it would create “a tussle with the union”.
Mr Caruana wrote that this was “not seen as the right thing to do just before the elections”, implying that the decision was taken by the Health Ministry.
But this one instance followed a decades-old pattern.
Mr Dalli noted that over the years management was weakened by interference from political masters who dictated the appointment of people without any consideration of meritocracy.
Politicians also forced staff movements “not necessarily on an as needed basis”.
It was a situation that culminated in a hospital grappling with more than 500 shift patterns for 3,242 staff members, mainly nurses.
This means that issuing wages became a very laborious and “tricky task” with 20 employees required to calculate payroll manually.
The hospital has a basic annual wage bill of €60.2 million that increases by €36.9 million when allowances and overtime are taken into consideration.
Overtime, which accounts for almost €4 million, is allowed with “no controls and inefficient authorisation”, according to Mr Dalli.
This is compounded by a lack of proper clocking in and out of consultants, doctors and nurses.
Mr Dalli accused politicians of pushing “pet vagaries” such as family-friendly measures which, although laudable, were taken to extremes.
“[This created] the absurd result of myriads of unmanageable rosters.”
But the problem is not just a payroll nightmare. It also has a direct impact on patients, with operations starting late because not all staff members involved start work at the same time, according to the report.
The Dalli report noted the Hopkins analysis had found staffing levels at the hospital were adequate compared to international benchmarks.
This contrasted with repeated claims by the Malta Union of Midwives and Nurses that the health service was short on nurses.
In 2010 the union had put the level of understaffing at 700 but the Dalli report said the insistence that Mater Dei had chronic shortages was a result of inflexibility and wasteful human resources.
Indeed, Mr Dalli noted that unions had filled the vacuum created by weak management, which allowed a culture of constant complaints by aggrieved members to take root.
This led to constant bickering between unions and management that resulted in wasted time since there was no system in place on how grievances should be handled.
Unions came in for some damning remarks by Mr Dalli.
“Union leaders seem to think that they should be running the hospital instead of management.”
The report said Mater Dei had extensive surgical capacity that was underutilised because of working arrangements handed down from one collective agreement to another.
Medicine stores with same drugs having different reference codes and no communication between them. Graphics: Studio, The Times
Dalli argued that the mix of part-time and full-time doctors should be maintained but insisted that the core clinical set-up had to be made up of clinicians who worked only for the hospital on a full-time basis.
“This applies in particular to the chairman of each clinical department who has to have ample time to deal with the administrative duties required of him while maintaining his clinical output.”
Overpaid contracts
Lack of accountability was also visible in contractual arrangements made with outside suppliers.
A breakdown of the major contracts in force last year showed the hospital paid €23.5 million for services that had a contractual value of €21.2 million.
Significant overpayments included €1.1 million to Mekkanika for building maintenance services and €660,000 to Servizzi Malta for cleaning.
Overpayment was symptomatic of improper accounting and record-keeping at the hospital.
But the most glaring example of poor practices was noted in the procurement and management of pharmaceutical and medical supplies, which cost the hospital €43 million.
The Dalli report said that no proper stock control was implemented and no physical stock takes were carried out.
Consultants bought excessive high-value medical supplies and there was no control over consumption, leading to waste and out-of-stock situations.
Over the years, management was weakened by interference from political masters, who dictated the appointment of people without any consideration of meritocracy
Medicines were stored in various stores with no singular IT system to track stock levels. Mr Dalli noted that the same medicine stored in different locations did not even have a single reference code.
This resulted in a situation where the hospital had too much of what it did not need and not enough of what it wanted, apart from expired stocks running into millions of euros.
The report author was shocked by a visit to the stores in the surgical area: “Access is open to everyone, there is no record whatsoever of the inventory carried, and there is no traceability... expensive supplies and equipment are ‘stored’ in unsecured rooms with excess to everybody, even visitors.”
Mr Dalli highlighted various examples of what he described as a free-for-all environment that ignored cost-effectiveness: surgical instruments were loaned to private hospitals at no charge; pneumatic driver attachments worth €164,000 sat on the shelves for months because they were bought without the attachments that made them useable; and surgeons had no standard procedure on which to base their choice for hip replacement implants that varied in cost between €700 and €1,200.
A better management infrastructure was imperative to bring about change, the report noted, adding that Malta had limited expertise, “if at all”, in hospital management.
Mr Dalli urged the government to be courageous in headhunting foreign expertise in hospital management until such time that Malta developed home-grown talent.
The way forward, Mr Dalli said, was a patient-centric health care system in which work practices were built around patient needs.
But achieving this will take much more than a 49-page report, it seems.
ksansone@timesofmalta.com
Ex-health minister keeps his silence
Former health minister Joe Cassar has so far refused to comment on aspects of the report that reflect on his time as health minister.
On two separate occasions when asked about the financial and management problems flagged by the Dalli report, Dr Cassar referred Times of Malta to the Nationalist Party’s health spokesman Claudio Grech.
Dr Cassar was health minister between 2010 and 2013, succeeding John Dalli, who was nominated for the post of European Commissioner.
Mr Dalli said certain changes he had started to make when health minister had been stopped in 2011.
Replying to this newspaper, Mr Grech said the only initiative he could trace back in the report to Mr Dalli’s stint as health minister was the relationship with Johns Hopkins, which at the time was being considered to take over the entire management of Mater Dei.
“This institute was commissioned to carry out an extensive review of Mater Dei Hospital in 2011 with the final reports delivered in 2012,” Mr Grech said, adding that initial steps were taken to execute some of the recommendations.