Doctors' group practice offered as health centres model

A doctors' group practice operating in Zabbar believes that its set-up could serve as a model for health centres.

The doctors suggest that the government set up a pilot project with a few doctors who are willing to try it out, to test whether the concept could be adopted for the government's primary health care sector.

Vanessa Macdonald spoke to doctors John Buhagiar, Daniel Sammut, David Sammut and Jason Bonnici about their experience and suggestions.

"We believe that the way ahead for a high standard primary health care service lies in the form of state-funded GP practices.

"Maltese GPs have to realise that sharing sovereignty gives them enormous advantage and better quality of life for themselves and their patients," the doctors running a group practice wrote in the latest issue of The Family Physician, the journal of the Malta College of Family Doctors.

The four doctors are urging the government to use their experience to set up a pilot project, convinced that it would be better for the doctors, the patients and the government's finances.

They proposed that doctors would get a basic wage with supplementary income derived from offering other services, to give an incentive for quality to be maintained. This would not mean getting paid for each time a patient visited a doctor, as this would be too open to abuse. The fees would more likely relate to home visits and night calls.

Adopting the model for a health centre would be based on giving the doctors the final say.

"A normal health centre set up involves doctors, nurses, nursing aides and so on. It would not be workable if the funding were shared out between them. The doctors in the group practice would have to have some level of autonomy, once the funding was received."

The doctors also explained that the option of a cooperative, raised some years ago, would not work as well as their proposal.

"The doctors in a cooperative would come from such different backgrounds, some of whom might only have worked in private practice. There would be different interests. A group practice would require a different work ethic. Without ownership, it would not work."

They envisaged a situation where a doctor would be able to work full time for that practice alone, rather than trying to supplement a low income with private work.

"If you have free time, you should spend it on self-education, not on more work," they said.

The doctors should be allowed to choose who to work with, they explained.

"After all, there are some doctors who prefer to work alone and who would just find it impossible to share. The problem is that in a public system, where you need to offer 24-hour service, a solo GP is not feasible," they said.

They admitted that not all doctors would fit into group practices, as there would always be those who preferred to work alone.

"They cherish their independence, but, on the other hand, to provide a comprehensive service, especially round the clock coverage, they must perforce be workaholics. Otherwise, they would have to agree on after hours coverage with another doctor."

Apart from the amount of effort put into a group practice, the doctors would also need to agree on various issues, such as having consistent prescribing patterns, and the length of a consultation (15 minutes for the practice).

The doctors insisted that the practice would not necessarily cost more, as so much waste and abuse could be curbed, from both the provider and customer sides. In fact, they were adamant it would cost less.

"The government needs to decide whether to invest in a system which works and give doctors a good income or continue with this vote-catching approach. Throwing money at it hasn't helped: the system does not work as it is."

A well run primary health care service would also help cut down on the relatively more expensive use of hospital services.

"The number of patients referred to hospitals could and should go down, as the situation at present is not functioning. The health centre should be a better filter.

"Health centres could probably deal with more problems themselves but many diagnostic tests are not available to them - or at least not all the time - so a patient has to be referred to outpatients.

"Doctors should have constant access to X-rays, ECGs, blood tests etc. And if the machines are there, then there should be trained personnel able to use them. For example, the ECG at Paola could not be used out of hours as there was no one who knew how to use it. Doctors should be trained to use it."

The lack of personal service at health centres is not only a problem for patients: it has also starved doctors of motivation, despite the best efforts of doctors who work there.

"How can you deal sensitively with a patient when the waiting room is full of howling patients? A ticketing system was introduced, but people find ways around it, keeping their ticket for the next time in an effort to jump the queue!"

"It is clear the system does not work. The doctors stop seeing patients at 5 p.m. but they stay on till 8 p.m., for example, even though the doors are closed.

The first step towards setting up the pilot project would be to have both clinical and financial audits to see where there is abuse. Then the next step would be to impose some kind of fee, unless abuse could be regulated and curbed.

"It would ultimately be a political decision, but it can be done. Most services could remain free of charge, but things like, for example, home visits should be regulated. Even a nominal fee of even 50c would help to curb the abuse, although there would be exceptions for those who could not afford it."

As with most things, information is the key.

"Computerised records would show us if someone is coming in for a blood pressure reading or check up four to five times a week, as now happens. He could be turned away and told to come back in a few weeks' time."

Appointments also deter people from "just dropping in on their way to the butcher", they said.

The doctors also made a strong argument for more specialist clinics to be held at the health centres, reducing the load on hospitals, but also making it more convenient for the patients themselves.

However, they also felt there was scope for patients to be referred back by the hospital to the GPs for care, rather than having all their follow-ups at the outpatients department.

"The Cardio-thoracic unit sends great reports but other wards do not send discharge letters which are prompt enough, or detailed enough.

"Many patients come to see us and they do not even know what medication they were prescribed at the hospital.

"The feedback from outpatients is even worse and we have to remind our patients to ask to be told what the outcome was. We have no idea what happens to them in most cases."

Health promotion clinics could also be run.

"We do some, but it is expensive for us to offer and, of course, we do not reap the long-term benefits: the health service does. If the model were adopted by the public service, there could be incentives for these services to be offered."

The group practice, based at St James Hospital, was originally set up in 1997 by John Buhagiar. It has grown over the years, and now has four GPs: Dr Buhagiar himself and doctors Daniel Sammut, David Sammut and Jason Bonnici.

As the concept was new to Malta, there were a number of areas to be sorted out, including the use of computerised patient records and finding a legal identity for the practice. It was eventually set up as a partnership with unlimited liability and is also covered by medical malpractice insurance.

The records list all the diagnostic tests carried out, important allergies, previous prescriptions and medical and family history.

"We know if someone is a smoker, so we can bring that up each time we see them. It is difficult to make a person change their lifestyle but at least you can try to motivate them if you know they have a problem with smoking, high blood pressure, obesity and so on."

The practice offers 24-hour service to around 4,000 patients, although the ability to share the responsibilities means each doctor works about 50 hours a week.

The practice hired a receptionist last March and offers an appointment system for each doctor. This makes it easier to maintain the balance between patients' desire to have their own GP and for a doctor to be available at all times.