Health service reform

Recent Maltese history proves that to decide in haste is to repent at leisure. Education, the environment and the health service have all suffered. Not surprisingly, the PN announced Is-Sahha l-Ewwel, health first, in its 1987 electoral campaign.

While everyone recognises that the health service delivers, there is general concern about the way it delivers. No one is entirely happy with it and no one wants it to deteriorate further.

It is generally believed that there are many abuses and much wastage that have to end.

If a milk cow sickens you, treat it, not kill it. Otherwise replace it with a healthier cow, not with a bull. Try milking that! It is patently untrue that the health service is free. All who pay tax, pay for it.

The more one earns, the more tax one 'should' be paying, even if one uses the national health service less than others. Consequently, a changeover to a privatised medical service would only advantage the rich, known to be particularly tax-efficient.

With a free service at the point of delivery, one will have already paid for it before using it, in fact even if one does not use it. Because of this, one may not be aware that one is squandering one's own money by abusing the system.

Imagine having free or heavily subsidised water and electricity. The incentive to save is absent. Many abuses have crept into our health service. These must stop.

It is unacceptable that when a patient with health insurance is treated in the National Health Service instead of privately, the insurers enrich him with hundreds of liri and the government, despite having spent thousands, gets nothing.

If complications arise in the private sector, the patient is immediately transferred to the National Health Service at a high cost to the government.

If allowed, the private sector will pick and choose the profitable operations/treatment and burden the National Health Service with the difficult and expensive ones.

Again, if a patient is kept in hospital beyond clinical needs (as in granny-dumping), what is wrong with said patient's pension passing to the state, at least in part?

Because of political needs, NHS polyclinics have mushroomed everywhere. These should only be used for treatment like dressings and urgent first aid.

Instead, they have been transformed into convenient meeting places to seek advice on minor complaints, but when patients have serious concerns they go to their private physicians, which seems to indicate that the public does not have much confidence in polyclinic doctors - this is quite unfair and unjustifiable.

Strictly enforced regulations are required to ensure that concise notes for each consultation in primary care are kept to ensure continuity of service.

It would be a disastrous mistake for the government to assume responsibility for general practice.

There are inefficiencies and abuses with medicines. If ordering is done early, a lot of money can be saved. Urgent orders can incur the same expense for a month's supply as would otherwise suffice for six months or more.

There are abuses with the pink and blue/grey cards for free medicines. But when a widow, entirely dependent on the pension of a husband who had been only a fitter in the docks, does not qualify for a pink card, it certainly does not seem that it is given to all and sundry. Is there a need for a blue card?

Rumours abound about free medicine being prescribed for those not entitled to it, and that these medicines subsequently find their way into the commercial market.

If a patient indicates that he has enough medicine from the previous month not to require it for a given month, he may be refused it the following month when he does need it.

Consequently, a patient will take medicine that he does not need in order not to lose his entitlement to it. If for every item prescribed on a pink card, one had to pay 50 cents, not to say Lm1, there would be some incentive to reduce waste. For six items of medicine each month, one would only have to pay Lm3.

The same could apply to hospital consultations. What is wrong with everyone having to pay a small fee for each consultation, for each operation, for each day spent in hospital?

What is wrong with a contribution of, let us say, Lm10 for stitches and very minor surgery, Lm30 for moderately serious and Lm60 for all the other operations? Who is going to go bankrupt, so long as the truly deserving are exempted?

If one had to pay for such treatment as elasticated bandages, one might be tempted to take them and wash them for reuse at the subsequent visit instead of each time squandering money.

If one contributed towards the cost of each X-ray, less unnecessary ones might be taken. The same could apply for medical certificates.

The greatest waste is in human resources. So long as those who always present themselves for work drunk, those that stir hospital food with a toilet brush or are otherwise vindictive, those that err repeatedly and for no valid reason, those that take 'sickies', are not sacked, we shall never recover.

Why should the honest citizen suffer because of such sickening, political decisions? Why should the hardworking citizen who toils at more than one job, pays all due tax and labours to build a home, be victimised; while he who takes unemployment benefit, works in the black market and pays no tax, procreates out of wedlock and abuses single-parent payments, while everything is paid for him by the honest taxpayer?

In the context of Malta, particularly because discipline has flown out of the window in the last 40 years, it is easy for monopolies or cartels to develop, raising the cost of private medicine.

We have experienced some of this in many government contracts farmed out to private enterprise. I strongly believe in privatisation, so long as there is true competition and excesses are controlled.

I do not believe we have the wherewithal either to control or to ensure free competition. In fact, European Union statistics indicate that, in Malta, there is already a higher proportion of private as opposed to public medicine than in the UK, Germany, France, Scandinavia and other EU countries.

In a country where parastatal companies that are supposed to earn revenues actually lose many millions, like the dockyard, Air Malta and others, it does not make sense to destroy the monument of our National Health Service.

Once wrecked, it is very difficult to restore. We have destroyed a good, public education system and this has still not fully recovered. We must beware of doing the same with our health service.

We need strong motivation of each and every employee, from top to bottom. Where this is lacking, fair and firm discipline must take over. Always there must be justice with the citizen employee and the citizen customer.

Dr Tabone-Vassallo was consultant surgeon in charge of accident and emergency departments in London, and is founder and past president of the Section of Accident and Emergency Medicine at the Royal Society of Medicine.