The elephant in the operating room | Paul Pace

MUMN president Paul Pace has a reputation for being ‘vociferous’. It’s a word he uses often when we meet at the union’s offices in Mosta… though he freely admits he heard it for the first time when used to describe himself on a radio programme.

“At first I thought they were saying ‘ferocious’,” he says with a sudden laugh. “What they meant was that I am outspoken, that I’m always a thorn in the side of the government. And it’s true. I am. I have to be, with things the way they are…”

And things certainly do not look altogether rosy in the health department at the moment. One year into a new administration which promised to take the bull by the horns, many of the problems associated with public health remain steadfastly unaddressed. Pace represents nurses, who stand on the frontline of what is often a chaotic and nerve-shattering situation. If he were to diagnose the specific problems afflicting the health sector, what would the main ailments be?

“Let me start by saying what the problem isn’t. It isn’t about the professionals, the doctors or the nurses. The issues affecting Malta’s heath service were never about the ability or professionalism of the medical staff. The issues are mainly two: work practices in the hospital, and an overall lack of infrastructure and planning.”

Most of these problems, he adds, were inherited from previous administrations. But this does not exonerate the present government from all responsibility: if not in actually causing them, at least in failing to come up with solutions.

Joe Cassar knew what needed to be done; but he never had the courage to do it. As for Godfrey Farrugia, he always was a consultants’ lapdog. Always took their advice, even if it never got us anywhere

“I don’t expect solutions in the first year. But we have compounded the problems by going too far away from the solution. We got off on the wrong foot. Not only did we not solve existing problems, but we created new ones…”

Yet Pace argues that solutions are not beyond the capabilities of this or any other government. “MUMN has been pointing out where the problems are for years. And we have been proved right. The latest scientific report by the World Health Organisation, which came out last week, found that we are short of 500 beds at Mater Dei. When I said exactly the same thing seven years ago, I was told to stop being ridiculous. They said that I was ‘going into politics’. In a word they told me I was being stupid…”

He leans back with a shrug. “Now the Prime Minister has admitted it, the WHO has confirmed it…”

Disappointingly, he resists the temptation to add: “Who’s looking stupid now, eh?”

Coming back to the bed shortage issue: as with most medical matters, diagnosis on its own is rather useless without a cure. That there aren’t enough beds at Mater Dei is now plain to see. Several medicines remain out of stock, too. But Pace argues that, instead of addressing the issue directly, successive administrations have invested their energies in creating committees and taskforces instead.

MUMN ruffled no few feathers by pulling out of the latest such committee… earning criticism (among others by the doctors’ union, MAM) for refusing to be part of the solution. How does he respond to that?

People are not stupid, you know... They can see that it might take a year and a half to get a hip or knee replacement at Mater Dei, but the same operation could be done by the same consultant straight away, for a fee

“Under Godfrey [Farrugia] it was a ‘management/union joint committee’,” he recalls. “Under [Joe] Cassar it was a taskforce. Different names, same thing. We didn’t join Cassar’s taskforce; we joined Farrugia’s, but later resigned from it. We don’t want to be part of something that is no solution at all, and that is avoiding the problem. Take the bed shortage at Mater Dei, for instance. What did the Cassar taskforce come up with? The ‘bed escalation policy’… this is one of the things we objected to. Do you know what this policy is? When faced with overcrowding, they would choose which corridors of the hospital they will fill with beds. Instead of addressing the issue, they put patients in corridors. But they called it a ‘bed escalation policy’…”

Under Godfrey Farrugia, the same policy was simply given a makeover. “Let’s burst another bubble, shall we? Farrugia recently boasted that he decreased the number of beds in corridors. But what he actually did was camouflage corridors as wards. Instead of corridors they became things like ‘mixed admissions wards 1, 2, etc’. Nice names. You can play with them all you like… but corridors they were, and corridors they remained…”

As for MAM, he reasons that it is easy for the doctors’ union to criticise. “MAM can go for these agreements all it likes. MUMN can’t. Our nurses work round the clock, taking all the flak from patients and everyone else. I could never agree with an arrangement that simply decides which corridors to put patients in. Consultants? They only spend around four hours a day at the state hospital. After that, they rush of to their private practices…”

He doesn’t conceal his contempt for this situation. “Mater Dei is an acute general hospital. It is supposed to be run on a 24-hour basis. Day or night, doesn’t make any difference. Yet Mater Dei only works three to four hours a day. In the past there was at least an excuse. Consultants working for the government used to be severely underpaid. But the situation has changed since 1977.” [the year of the doctors’ strike] “Since the agreement of 2007 consultants receive a salary of 70,000 p.a., on top of a fee from university. That’s more than the Prime Minister earns…”

From this perspective, he argues that it doesn’t make sense to continue avoiding the elephant in the operating room.

“Now that salaries have been increased, there is no longer an excuse for consultants to rush off to attend their private practices. The 2007 agreement should have addressed the hardships of the people… in finding a consultant at hospital when they need one, for instance…”

Meanwhile, he wryly points out that the same patients are always able to find consultants in their private practices. “People are not stupid, you know. They can see what the problems are. They can see that it might take a year and a half to get a hip or knee replacement at Mater Dei, but the same operation could be done by the same consultant straight away, for a fee. You can’t fool all the people all the time. They know they are being taken for a ride.”

Nor did the new administration make any effective management interventions at Mater Dei. On the contrary, Pace argues that it exacerbated matters by giving even more managerial responsibility to the consultants.

This, he adds, runs counter to the trend in Europe, where hospital management and medical staff are kept distinctly apart. “Management and medical staff should not mix. Hospital management should be independent, and not run by doctors. Conflicts of interest do arise…”

Yet Godfrey Farrugia in particular wanted to further empower hospital consultants within the hospital’s management structures.

“And as usual we would be presented with a fait accompli. At the last meeting of the joint committee, we were shown a power-point presentation. It was decided – without any consultation with MUMN  – to subdivide Mater Dei into units. Consultants were to be responsible for managerial administration of these units. In other words, Farrugia gave an even greater managerial role to people who only stay in hospital for three to four hours a day. Can you believe it? That’s why we pulled out.”

Nor was this the only step backwards taken since the last election.

“Another of Godfrey Farrugia’s decisions was to place Boffa Hospital under the management of Mater Dei. Boffa, a smooth running oncology hospitable with not even 1% of the problems associated with Mater Dei, is now to be used as a pilot project for the main general hospital. Unbelievable!”

All the same, we haven’t really talked about solutions yet. Criticising government’s health policy is easy enough, but proposing workable solutions is something else altogether. How would Paul Pace resolve these issues if he had the authority to take decisions himself?

“The solution has been staring us in the face all the time. We proposed it to both ministers. And we didn’t come up with it out of thin air… we based it on existing models, on how every hospital in Europe functions…”

He outlines his vision for Mater Dei: “You would have a patient flow chart – like every other hospital – divided into three phases: green, yellow, red. It’s like an alarm system. There will be TV monitors in the hospital corridors, updated every 20 minutes. Green is when everything is running smoothly, yellow for when it is starting to get overcrowded and red for when the hospital is full up. When it’s red, consultants will have to be present on site around the clock, signing discharge forms…”

And in a situation of ‘red alert’, he adds, various sectors of the staff may be fined by the hospital management “if they don’t do something about it.”

At Mater Dei, however, it is often difficult to find a consultant at such moments – without whom patients cannot be discharged from hospital – with the result that patients remain in hospital longer than necessary, even when the hospital is severely overcrowded.

“By 2pm, there will be no consultant to discharge patients. How can you solve a bed shortage without discharging patients? And what did the PN government do? Instead of introducing the necessary work practices, they came up with the bed escalation policy. I always challenged both Joe Cassar and Godfrey Farrugia on this. We don’t need taskforces. We gave a report to both ministers, with a proposed solution. And the model we are proposing already exists, it is in use in every hospital in Europe except for Mater Dei.”

Moving on from bed-space concerns, Pace observes a similar pattern in government’s failure to solve the ongoing issue of out-of-stock medicines. “Again, the writing is on the wall, and has been there for years. Admittedly there are logistical complications in this issue. We are an island; other countries have the luxury of overland supply routes, and can arrange for speedy deliveries in case of an emergency. In Malta this is not so easy; you have to rely on shipping schedules, and so on.”

But again, it all boils down to prevailing work practices. “Our proposal is for government, when issuing a tender, to give the contract to two suppliers on a 50/50 basis, not just one. This way, if one supplier cannot meet the demand, government will at least have a fall-back position.”

As things stand, however, government is at the mercy of a single supplier who, for various reasons, may sometimes fail to meet an order on time. “Why limit oneself to only one? Why not rely on more suppliers? It’s easy, other hospitals do it…”

He answers his own question. “Obviously, suppliers don’t like it. They want to have exclusivity. But we are not here to make suppliers happy. We are here to see to the needs of patients….”

The picture that emerges from Paul Pace’s complaints seems to be one of successive governments somehow unable to bring to heel certain lobby-groups that have an interest in retaining the status quo; in this case, the consultants’ lobby and that of the pharmaceutical distributors and suppliers. At the same time, this suggests that both these lobbies exert considerable influence over both parties. How realistic is this scenario?

Pace shrugs. “The consultants are a powerful lobby,” he says simply. “To give you an example: why was the John Hopkins report never published? I would have thought investigative journalists would be onto something like that in a flash…”

The report was commissioned by the Nationalist government and completed in 2012. Undertaken by a leading American medical centre, it is understood to point towards serious management problems and political interference in the decision-making process. Both PN and Labour governments have however refused to publish it, citing confidentiality clauses.

“One of the things the Hopkins report stated was that Mater Dei consultants were part-time,” Pace observes. “Clearly there was something in this report that the consultants didn’t like. So it was never made public…”

Another indication of the lobby’s strength is the reluctance of governments to ever cross it, even to their own exorbitant cost.

“Joe Cassar was too scared of them to do anything about the situation. And the PN paid a high political price for this. It took all the flak, but never managed to solve the problems at Mater Dei.  They preferred to take criticism from the Opposition… and from the MUMN!” he adds with another laugh.

“Our view has however remained the same no matter who is in government. If work practices need to change, let’s do it tomorrow. We don’t need more taskforces. Cassar knew what needed to be done; but he never had the courage to do it. As for Godfrey Farrugia, he always was a consultants’ lapdog. Always took their advice, even if it never got us anywhere. And he made matters worse by empowering consultants more…”

Is this why Farrugia was removed in the cabinet reshuffle? Pace refers the question to Joseph Muscat. “Why was he removed? I don’t know. The Prime Minister might have had his own personal reasons. I’m the last person to know. I’m sure it wasn’t just because of MUMN….”

Pace doesn’t hide the fact that his union agrees with the decision, though he points out how he had desisted from criticising the beleaguered health minister before he stood down. “This is why I walked out of a recent radio programme. There was a strong rumour that Godfrey was on his way out at the time, and I was challenged to criticise him on air. But it’s like the last two months of election campaign. Better to keep quiet. For me to blurt out these things then, with Godfrey already on his way out, was not ideal. Now, however, I can….”

He laughs again. “That’s why they call me vociferous, I suppose. That’s why they always accuse me of being in cahoots with the Opposition, no matter who is in government. That’s why they say I ‘have an agenda’. It’s because I always speak my mind. If the problem is this, I will say it is this…”

Meanwhile Farrugia has been replaced by energy minister Konrad Mizzi, with Chris Fearne as parliamentary secretary. What change in approach does the MUMN envisage under the new minister?

“It is too early to say. I would like to think there is light at the end of the tunnel. Mizzi took a managerial approach to energy issues, and it is a management approach that is needed here too. From our initial meetings the prospects look good. Both Mizzi and Fearne have indicated that they will take our considerations on board. One thing is certain, however. Labour can’t afford to go to an election in four years’ time with the same problems still in place. Like I said, people aren’t stupid. They know what the problems are. And they will know if they have been solved or not…”