A doctor in the home

Later this month the Association of Private Family Doctors will celebrate its first anniversary. Association spokesman Martin Borg tells Cynthia Busuttil what changes the association is trying to bring about to improve GP practice.

Family doctors feel their work is not entirely understood in its complexity and not fully appreciated by both patients and the public, Martin Borg said.

This happens despite the fact that the private family doctor is very frequently the first point of contact when a patient falls ill. In fact, Dr Borg said, statistics indicate that about 70 per cent of first contacts at primary health care level are made through the family doctor.

He highlighted the importance of continuous education to raise awareness of the proper role of the family doctor who, apart from giving patients medical care, directs them, if necessary, to the right secondary care specialist and also acts as a friend and, above all, a teacher.

Family doctors working in private practice encounter similar problems and difficulties, and this was one of the main reasons why it was felt that there was need for an association to represent family doctors exclusively. The association was officially set up on April 29 last year, and Dr Borg said the majority of well-established full-time general practitioners are members.

"Our main aims are to bring family doctors together and enable them to share their problems and cooperate with one another, explore areas of common interest and liaise with other organisations or institutions."

The association aims to ensure that all members give optimal quality of care to their patients. For example, it is working on establishing minimum requirements for a private family doctor's clinic.

"Although the majority of doctors do have well-equipped clinics, standards can always be improved. We want to set up the minimum requirements to improve the service we give our patients and also to increase respect for our profession," he said.

In the past year the association has embarked on a number of programmes, including trying to work out the investment needed for doctors to open and run their clinic and the expenses incurred to manage one's practice. The ultimate aim is to quantify the real value of what a consultation costs, whether in a clinic or as a home visit.

In Holland, for example, for a telephone consultation a family doctor is paid half the fee of a face-to-face visit. This is not the culture in Malta "and we are not saying we will do this," Dr Borg said. On the other hand, he pointed out that a telephone consultation frequently disrupts an ongoing consultation with a patient, robs the doctor's time and could also be detrimental to other patients.

"It is going to affect the patient in front of you if you are interrupted, once, twice, three times because you have someone else on the other end of the line."

Another project embarked upon is the formulation of a standard sick leave certificate for private sector employees to be used by the members of the association. Care is being taken so that such certificate respects privacy in accordance with the Data Protection Act, something which Dr Borg said the Department of Social Security "certainly lacks".

The phenomenon of solo practices, where doctors practise on their own, is instilled in our culture. This means that if a doctor is ill or needs to take some time off, the clinic remains closed. Although the association is aware of this problem, it does not see a solution in the near future.

"We are trying to get our members round the idea of practice groups, where, although doctors continue to practise on their own, they would at least link their services with other doctors working in the same area," he said.

Practice groups would, in effect, lead to close collaboration between a small group of doctors. Apart from acting as a back-up when a doctor is unable to open his clinic, they can also invest in equipment or services that are not affordable to the individual doctor.

Closely linked is another important issue on the association's agenda: the setting up of an after-hours service. Dr Borg said the APFD was interested in setting up a system through which, when a private clinic is closed, calls would be diverted to a call centre, and the doctor on call would decide on the type of action needed.

"The stress of working on our own means there are days when we need to rest. Then there are instances when the doctor is following courses or lectures and is unavailable. Through this system we can make sure our patients can find a doctor at any time," he added.

Dr Borg pointed out that the existence of the Medical Association of Malta, of which a number of family doctors are members, did not lessen the importance of setting up a separate association for GPs.

"The MAM is more concerned with the general trade union issues of the profession, while we tackle problems which are solely experienced by family doctors. We are not there to replace MAM," he said, insisting that his "association is not a trade union".

Apart from maintaining good relations with the MAM, the association also works hand-in-hand with the Malta College of Family Doctors, which deals with academic issues and, therefore, doctor accreditation.

A problem being faced by family doctors is the unavailability of several medicines. Dr Borg said that not even the MAM was consulted about the matter, even though it affects the medical profession directly.

"We are being faced with a situation where the list of medicines we can prescribe has decreased, and patients cannot find medicines they were able to buy until a few years ago," he said. Doctors are also concerned with the high price of medicines, and would like to see more effective government control.

Another concern is about vaccines not being kept in the optimal temperature - between 2-8°C - before being administered. Dr Borg explained that doctors used to receive vaccines directly from the agent which guaranteed that the optimal temperature would be maintained throughout their journey from the production plant to the doctor's office. "This is called maintaining the cold chain."

However, all this is lost when a patient buys a vaccine from a pharmacy, carries it around in a paper bag and waits for an hour in the clinic's waiting room before the doctor can administer the vaccine.

"We are very worried then about the continued usefulness of the vaccines. It is imperative that patients are informed about the importance of keeping medicines at the ideal temperature. In the interests of good medical practice we are insisting that the law is observed and that these medicines can only be obtained from pharmacies by presenting a valid doctor's prescription."

Dr Borg highlighted the importance of family doctors being involved in any talks dealing with future national health reforms. "It is disappointing that family doctors are never consulted in any discussion regarding future health care reforms, notwithstanding the fact that they represent and care for more than half the patient population. In this way the public health system is also making enormous savings. This is why we cannot be left out of the planning stage."

He said it has finally been recognised that family doctors are specialists in family medicine. "Specialists in other branches of medicine might find that they do not have the breadth of knowledge to tackle the wide spectrum of conditions from the newborn to the very elderly that we see." He mentioned the importance of the patient's family doctor receiving feedback from hospital when he refers a patient. After all, in all likelihood, they will be the ones providing continuous care for the patient on discharge.

The association has participated in preparations for the possible influenza pandemic. "We have collaborated with Tanya Fenech Melillo, the former chairman of the National Influenza Pandemic Steering Committee, who is probably the best informed person on the threat of a flu pandemic in Malta. She has been extremely helpful all along by addressing our members and giving us all the information we required," he said, adding that this was the first and the only time that the family doctors' importance in the sphere was acknowledged.

Dr Borg said that, as a result, the association agreed to offer its help and has given the authorities proposals on how family doctors could cooperate in the event of the pandemic hitting Malta.

"In several countries the figure of the family doctor is almost extinct. In Malta we are fortunate in this respect. The Association of Private Family Doctors is striving to ensure that the Maltese patient will still be able to find in his doctor the trusted gateway to the health system," he concluded.