A medical time-bomb? | Martin Balzan

It is perhaps ironic, but ‘health’ has traditionally always been a major headache for Maltese governments.

Back in the 1990s, Prime Minister Eddie Fenech Adami famously had ‘nightmares’ about the endlessly growing national health bill. The same bill sky-rocketed with the long-drawn out construction of Mater Dei Hospital… and all the while, medical expenses (the cost of medicines, hospital equipment, etc.) continued to rise exponentially.

With both parties agreeing on a basic model of ‘free healthcare for all, from the cradle to the grave’, questions inevitably arise concerning the affordability of such a service in practice.

The present government’s strategy is to invest in ‘medical tourism’ – providing local services for free, but charging foreign patients (from non-EU countries) for the same services to recoup costs. 

On paper, the maths seem to make sense. But inevitably, the co-existence of two vastly different models within the same regime – public and private health services – may give rise to problems.

Ever since the announcement of a 200 million euro investment drive for a public-private partnership to construct two new hospitals, MAM secretary Dr Martin Balzan has voiced his association’s concerns with the arrangement: arguing that the private sector model is incompatible with a ‘free-for-all’ model.

But first, let’s talk about the existing infrastructure, and its ability to cope with what looks like a demographics time-bomb.

It is a known fact that people in the 60+ age-group will outnumber the 30- bracket five to one by 2050. Even today, many of the waiting lists involve primarily third-age ailments (such as hip replacement operations, etc.). The strains of population growth can already be felt on the system today. How much more will they become an issue in a few decades’ time? 

“The demand will continue to rise, not only through demographic shift, but also by real estate developers attracting elderly EU citizens to retire in Malta,” Balzan begins. “Young working migrants might also opt to continue living in Malta and eventually retire here, adding to the demographic imbalance…”

So is Malta’s health infrastructure, in its present form, sufficient to cope with the increase in demand for services projected over the next 20 years?

“No,” he replies, with some emphasis. “Malta’s infrastructure is insufficient. Services for the elderly, acute medical beds and palliative care services for terminal cancer patients… all are at present in short supply. This will only get worse in future.”

It is debatable also whether public expenditure on health is sufficient, nightmare or no nightmare. 

“Malta currently spends around 7% of its GDP on health, of which 1.2% concerns private practice,” Balzan points out. “Most other EU countries spend around 10%...”

But doesn’t all this strengthen the argument for a radical change to the national health service model? If we can all see it is destined to founder in its present form, we must surely consider different models…

Balzan however argues that it is not the NHS model, in itself, that is the problem… but the way it is administered. He also expresses strong doubts whether ‘public-private partnerships’, of the kind now contemplated, can improve the situation.

“The National Health Service aims to improve an individual’s health, giving a comprehensive and full service to all – especially those close to or below the poverty line – while serving as a safety net for the community,” he explains. “The private sector, on the other hand, is driven by the imperative to make a profit, with a tendency to focus on profitable activities only.”

The two approaches can (and do) exist side by side: in fact, British health minister Aneurin Bevan himself – who created the NHS in the 1940s – acknowledged that free healthcare can only work in tandem with a private service.

The problem, Balzan suggests, is the lack of clear demarcation lines between the two systems. 

Nor is it limited only to the public tender for the Gozo hospital. Back in 2013, Balzan had already flagged concerns with similar partnerships regarding health centres.

“Minister Mizzi was intending to bring private money into the health centres,” Balzan recalls. “At the moment we feel that private general practitioners are the backbone of the service. Building a private health centre in Kirkop would only result in government money being used to compete with private medical practitioners. In practice, this will produce a nationalisation effect, rather than a privatisation one. It would increase rather than decrease expenditure...”

Similar concerns have meanwhile been aired on a different (but related) development. Another private-public agreement concerns a new medical school – with two campuses – to be run by the London-based Bart’s Hospital.

The Medical Students Association has since warned of a possible brain drain affecting the Malta Medical School as a result of this agreement. Does Balzan share these concerns? Can there be a level-playing field, when a state-run university finds itself in competition with a private institution, paying private sector salaries?

“Students are rightly concerned at the ‘business first’ agreement with Bart’s Medical School,” he nods. “This will result in problems of capacity at Mater Dei and other health services when it comes to bedside teaching. The government needs to guarantee enough resources for the University of Malta, which trains tomorrow’s doctors for the Maltese population, and ‘ring fence’ them through a formal agreement…”

Balzan makes it clear his objection is not to the existence of competition in itself; but like the students he argues that the Medical School may not be in a position to compete.

“While Bart’s may try to attract the best and most experienced Maltese academics, it is up to the University of Malta to retain them… by changing its ‘one-year contracts’ into more durable ones, for instance.”

Inherent to both scenarios is the same dilemma: the incompatibility of private sector and public service business models. 

At the same, however, isn’t there a contradiction here? One issue that has consistently ‘plagued’ (so to speak) Malta’s medical sector is the occasional blurred lines between private and public health services: cases have arisen of consultants at public hospitals referring patients to their own private clinics. There are no restrictions on national service doctors running private practices (as there are in some countries).

So aren’t the two models already under the same roof, even without the current private investment drive?

Balzan however disagrees with the analogy. 

“To date, the boundaries are clear. Mater Dei is a public hospital, and private hospitals and private practice are separate. In fact, consultants can have contracts with or without private practice. The model where private patients and public patients are in the same building will bring new problems, even though we are sceptical on medical tourism.”

It seems there are other reasons to be sceptical, too: the Opposition has raised doubts concerning the financial viability of the preferred bidder – the Vitalis Global Healthcare Group, which over the next 30 years will build and run the new Gozo general hospital, as new medical facilities at St Luke’s and Karen Grech hospitals. 

Was MAM involved in the negotiations to privatise these hospitals? Can Balzan shed any light about this little-known company: enough to confirm or deny existing doubts?

“What we know is what we have read on the internet. We do not know the track record of this company, and whether it has managed any hospitals.”

Balzan also echoes scepticism regarding whether sufficient due diligence was carried out. “It appears that this is a new shell company, with the support of an investment fund, but we have so far failed to identify any hospital or health service run by either despite their claims.” 

Ultimately, there is a transparency issue at stake here, too. Too little information has to date been disclosed about the Vitalis Global Healthcare Group.

“They appear to have two consultants – one from Virginia and the other from Massachusetts – but we fail to see an established and consolidated structure.”

Having said this, Balzan acknowledges that MAM was involved in discussions with the government before the announcement: even if only at the level of industrial representatives.

“We discussed improving working conditions for doctors at VGH, inserting the necessary safeguard in the event that this project either succeeds or fails.”

Speaking of which: what are his own prospects regarding success or failure? Aside from his doubts concerning private-public partnerships: is there any logistical or economic reason why ‘medical tourism’, as a general strategy, might not work?

“Medical tourism has not been successful so far, and in our opinion is unlikely to succeed. Even if we attract large numbers of paying tourists, the fact remains that retired EU citizens, migrant workers, and those having a residency permit through whatever means, all attempt to obtain access to the national health service for free. Futhermore, in the summer months large numbers of Maltese residing in Australia turn up requesting free services. By and large, they are accommodated…”

What is gained with one hand, it seems, is given away with the other. Nonetheless, in this system at least one of the hands is gaining something. Short of this sort of approach, what other models could successfully be adopted?

Balzan has long argued that the affordability issue can be addressed through better management of existing structures and resources. But how is this possible, when Malta has an ageing population… which in turn implies that health demands can only be expected to grow? 

This argument, he counters, is itself another reason why the present strategy is flawed. It is a point Balzan already made back in 2013, when the project was first announced: “the country cannot afford to invest in new hospitals, so the government must maximise the current infrastructure and offer health services for longer hours…”

In a nutshell: reform the existing service administration, rather than introduce new management concepts.

Is he still of this view today?

“Yes. There is still scope for more work to be done at Mater Dei Hospital, especially evening sessions, when the bed complement increases. The current hospital infrastructure is utilized in full swing only between 8am and 4pm. Just extending services from 4 to 8 pm would go a long way towards shortening waiting lists for operations, and outpatient visits. This has failed to materialize so far, even though both MAM and government are in agreement…”

Balzan cites other areas where weaknesses in the present service result in bottlenecks which cripple the entire system.

“Around 60 long term care patients, awaiting transfer to retirement homes, continue to block acute beds at Mater Dei because of insufficient provision of services for the elderly,” he points out. This is one of a number of issues that exacerbate the bed shortage situation, and contribute to waiting lists.” 

What is needed to address these problems, then, are administrative reforms rather than new private hospitals. Such reforms, however, have been known to encounter resistance in the past.

Balzan proposes extending working hours at Mater Dei; which would naturally imply a change to existing working conditions. Certainly, arrangements would have to be made to remunerate hospital staff for the extra hours. 

Couldn’t it be argued then, that the proposal is also a bargaining chip, placed on the table by a union demanding better work conditions for its members?

Balzan rejoins that it is not just doctors who are involved in the proposed reform. 

“A doctor does not work on his own, and needs supporting staff such as receptionists, nurses, clerks, and support services such as X-rays, blood tests, or ECGs, depending on the speciality.”

As for improved conditions, he argues that these are already envisaged in the present government-MAM agreement. 

The real issue, he insists, is with the administrative set-up. “To date, Mater Dei management has failed to organise the necessary supporting services with the result that most lists keep getting longer and longer…”

Meanwhile, controversies regarding other aspects of the health service seem to also keep surfacing. At present, the government is proposing a change to the ‘Embryo Protection Act’ – which regulates assisted fertility in Malta – to allow for the possibility of embryo freezing: a contentious practice, opposed by a vocal anti-abortion lobby.

MAM has so far not commented in public on this issue. Does the association have any position on embryo freezing?

“MAM has been traditionally against abortion… and prima facie, it appears that embryo freezing may result in accidental loss of embryos. But we prefer to look more in depth into the details of this technique before formally declaring our position.”