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Doctors will be the last to move to Mater Dei, due to open on Friday. But how much will change for Malta’s medical professionals in the state-of-the-art-hospital, Matthew Vella asks MAM secretary-general Martin Balzan?
Mater Dei finally opens it doors to the general public on Friday… although there will be little activity going in the costly Lm250 million state hospital – patients, administrative staff and doctors will be busy at St Luke’s. An IT system which was supposed to be up and functioning by the start of the year will not be anywhere to be seen after the tender process was interrupted by a police investigation into fraudulent activity. Between now and the final stage of the migration of hospital staff, it seems that there will be little for the government to “celebrate” at the hand-over of the hospital from Skanska to the state. The biggest drain on the Maltese economy has taken well over a decade to complete.
 Tomorrow the Medical Association of Malta’s council meets to discuss its negotiations with the government. As doctors’ union secretary-general Martin Balzan says, the two sides seem intent on reaching an agreement very soon.
“The MAM has listed a number of proposals for government. Of course, we look at doctors’ interests, but also at the long-term evolution of healthcare, for example when it comes to cutting down on waiting lists, both elective and urgent cases. One of the first problems the government has to address is to ensure that it has adequate manpower, especially in the face of losses from our pool of doctor graduates.
“I can say that from the latest batch of medical graduates, 51, eight of them have already left Malta to the UK without even having worked in Malta. We’ve had 70 per cent of new doctors leaving for other countries in recent years, but the average works out at 50 per cent,” Balzan says, a worrying situation to have half the country’s graduates opting out of the state’s healthcare for foreign health services.
It’s a well-known phenomenon amongst new medical graduates. Many lament the dearth of training that can lead to the advancement of doctors. Essentially, medical training stops at medical school. After two years under supervision working as a pre-registration house officer, for the ultimate aim of getting registration with the council, very little can be gained by staying in Malta within the hospital setting. Basic speciality training is essentially non-existent.
“Normally, graduates spend three to four years in state healthcare but when it comes to picking the doctors, you find that they have already left,” Balzan says.
So that is why the MAM wants government to ‘train and retain’ doctors, and that will mean creating a system of postgraduate training that will require investment, to allow Maltese doctors to be able to pursue their specialty training in Malta. Beneath this concern for the drain in young doctors, also lies the reality of Malta’s low-paid state doctors, whose income has to be necessarily supplemented by private practice.
“We have always told the government that it’s not only the stones – it’s also the human resources,” Balzan says, referring to the construction of the Mater Dei hospital, which has inexorably become the costliest healthcare investment ever, with little change in the way doctors are paid.
“And I think the government is understanding this. But we also understand the government’s limitations when it comes to doctors’ salaries. From our side, we need government to understand that it has to keep doctors in Malta, but we also have to be reasonable about the economic context of the country – they cannot offer the same salaries the British government gives to its doctors, for obvious reasons,” Balzan says.
Indeed, although the UK loses up to a fifth of its doctors to the US, the MAM states Malta is losing more than half of its doctors to richer EU states. That is a frightening figure, especially considering that the drain is encouraged by the UK’s inducements of better pay. Doctors’ basic wages range in the UK from around GBP22,000 (Lm14,000) for a first year postgraduate, to around GBP90,000 (Lm59,000) at consultant level. With on-call work, a doctor’s salary can be doubled. In Malta, a consultant earns Lm10,811, a senior registrar Lm9,560 and a house officer Lm7,827.
Which of course explains why consultants have to resort to private practice to get an income in accordance with their level of responsibility.
But there is a general sense of dissatisfaction with work in the greying corridors of St Luke’s Hospital, something Balzan points out, which has made it hard for doctors to cope with hours-long queues, and waiting lists have patients waiting for five years for a hip replacement. Put together, working conditions are poor, the pay is low, workloads heavy, and little opportunity to further one’s career. The pressure sees doctors working up to 60 to 70 hours a week, while authorities insist that health centre doctors should see one patient every four minutes.
The situation appears to be precarious for state GPs. A recent study by Dr Mario Sammut, a specialist in family medicine, revealed poor levels of satisfaction among doctors in primary care who say they are unappreciated and neglected, blaming poor pay and career progression. Doctors complained that patients were not respectful of their professional role, while the administration was uncaring and indifferent to their opinion. They also accused colleagues of “selfishness, side-kicking, and making obstacles”. They complained of clerical paperwork and inadequate remuneration and long working hours, while one-third of the interviewees said they receive verbal abuse from patients. Junior doctors also said they felt abused by their fellow colleagues.
But it’s this dissatisfaction, and the reality of the brain drain, that will become a concern when doctors are faced with more rooms in hospital to carry out their work – will there be enough doctors to even man the entire system?
“Government experts have prepared a migration plan – first it will be the administrative set-up to move in, then the outpatients, and finally, and within a compressed period of time, it will be the inpatients, ITU and casualty wards. This will be the critical point. What we are saying is that if doctors have to operate under these laboured conditions, we only make the move once we reach an understanding over this migration. Although the hospital is about to open, the migration itself is not imminent.”
Doctors will be given a larger number of operating theatres that will allow more people to be operated. The number, 25, will be double that of St Luke’s. And Balzan points out that doctors have to fight it out between themselves to make use of any room in St Luke’s. But to use this large number of theatres, government is expected to invest more in human resources if it is to welcome more patients to Mater Dei.
“Turnover has to increase. If you have an operating theatre, it needs to be kept open in the afternoon as well. Firstly you need a surgeon – and this is the most difficult man to train. It takes about ten years to produce a surgeon from the moment he or she graduates. It’s a gradual process. There is also the supporting staff, like nurses, who are directly involved. When you increase turnover of patients, it means that you are cutting down on waiting lists – but it also means that doctors will be moving the system around faster, and that means increasing costs. It means more medicines, X-ray charts, the lot. It’s a system that is bigger and moving faster because there is more work to be done.
“It is therefore desirable that the hospital’s units can be used for a greater length of time, maybe not for the evenings, but in the afternoons. Waiting lists can only be cut down if we increase turnover – and that will mean more manpower. If there is a hip replacement patient who has already been on the waiting list for four years, and there is no money to buy the hip, the operation cannot be carried out.”
The manpower cost in Malta is probably the least costly element in healthcare, when compared with the cost of medicines. That what makes Maltese healthcare efficient – the proportion of doctors’ salaries to the yearly Lm55 million expenditure on health is relatively small. Observers have noted that the state-of-the-art hospital at Mater Dei has turned out to be too costly to even serve as a state hospital: indeed, the point of public healthcare was never to supplant private healthcare, but to complement it with a basic health service for everyone.
“Private healthcare offers patients choice, and saves government money. If citizens don’t like government healthcare they can pay for private healthcare. Doctors want an arrangement to have a number of dedicated doctors for the state health service – not the entire cohort, because it would be counter-productive,” Balzan says.
“But government will have to invest in human resources, and not just in the structural work. Otherwise it would be like buying a Ferrari without even having the cash to buy the fuel to drive it.”
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