The primary health service requires urgent attention

The editorial of July 25 (The Health Service Requires Urgent Attention) focused mainly on the area of competence of the Association of Private Family Doctors (APFD). This association, set up in 2005, has as one of its statutory aims: To ensure that all members can give optimal quality of care to their patients.

The "can give" is pivotal and the editorial served to draw attention to glaring stumbling blocks in the efficient delivery of some aspects of health care.

I added the adjective "primary" in the heading because this is the area that requires urgent attention. In the area of primary care (as distinguished from secondary - or hospital-based care), we private family doctors can do much more if we only "can give" of our best. We could shorten waiting lists at several out-patient departments and, indeed, in some cases avoid admission to the wards. For example, we cannot directly request a mammogram for a 50-year-old lady with a family history of cancer of the breast. A request from a private family doctor for a test of thyroid function is returned with a rubber stamped outright refusal: "Cannot be ordered by GPs" It takes two or three outpatient appointments, with the loss of three mornings work for the patient (and further prolongation of the waiting lists), to get this done.

It would be grossly unfair to lump all of the health service as being in a parlous state. One would be forgetting the excellent care and service provided in most areas. I can personally attest to this.

In primary care, while a diagnosis is always important, usually the first priority is to provide immediate relief to the patient. Similarly, whilst airing "long-festering shortcomings" is useful, there are so many things that could be done to relieve the problem without waiting for the conclusions of the many focus groups set up to tease out the problems.

Way back in December 1971, I, as a house officer, had written to the then Hospital Management Committee suggesting that all attendances at the Casualty Department be charged "nofs lira" (circa €1.16), to discourage inappropriate attendances. A visit merely for a routine blood pressure check after the Sunday drive was already common. I never received an answer. The government then was a different one but the solution was still political. Talk about pusillanimity! Thus, it is now important that a senior minister is putting his weight behind the wheel.

The government's own statistics show that fully 70 per cent of all primary care contacts occur in the private sector. Although competing with a free service, it is more than obvious that people are voting with their feet. The government is so aware of this that it feels it is unthinkable to take on board these 70 per cent too. Unfortunately, it stops there. Not providing more facilities for the private patient to be cared for by his/her own doctor is indeed short-sighted. Yet, a health centre general practitioner through merely being employed by the government has several of these facilities at hand.

The editorial suggests that the government should discipline staff (here read doctors) that take the easy way out by resorting to unjustified referrals.

We hold no brief to defend health centre doctors, as they themselves can do this very well, but it is worth noting that doctors working in health centres are all experienced doctors. Most would have worked in the Accident and Emergency Department in hospital and saved countless lives by treating acute admissions and grievous injuries. Are they now "incompetent operators" just because they work in the health centres? Indeed, the problems lie elsewhere.

The public already has a wrong perception that what is free is necessarily inferior. Moreover, some articles in the media unwisely put the health centre staff in a bad light. And then talk about crass impertinence!

Health centre doctors work shifts. The doctor cannot guarantee that the following morning he can review his/her patient. Record-keeping, so that another doctor can take over, is still in its infancy. Access to hospital investigations (except X-Rays now) and patient histories are unavailable. In such circumstances, it is much safer to refer to hospital. One must also consider the attitude of the patient and relatives who sometimes demand a referral to hospital.

Before pontificating, it would be useful to find out how many of these seemingly facile referrals are sent back without at least one investigation (or, indeed, a consultation by a specialist), not available to the doctor working in a peripheral health centre. It is worthwhile remembering that when something goes wrong, it frequently happens that instead of finding support from his superiors the doctor faces an inquiry. There are no divisions existing between doctors working within the primary care sector, apart from those coming from the fact that one is publicly funded while the other is private.

Continuity of care is a hallmark of primary care. This is precisely where the private family doctor scores and excels. Thus, the private GP is able to do a better job in keeping patients away from hospital, saving the government millions of euros in the process. The private family doctor is usually more experienced, knows his patient and has been trained to assume more responsibility. The private family doctor has been described by the Prime Minister as a treasure. And, indeed, he is: The benefits to society of an experienced family doctor goes way beyond mere monetary terms.

However, for the private family doctor, access to hospital records is also unavailable. Such access, which we have indeed been asking for, will be available "in the fullness of time"! Access to investigations is even less for the health centre doctor, unless the patient puts his hands in his pockets and goes private. There should be a level playing field in access to investigations and in authorisation to prescribe the appropriate medication to the patient.

The obscene 13-month waiting list for a newly-diagnosed diabetic to be seen by a diabetologist in hospital must be unheard of elsewhere. Yet, a fully qualified and trained private general practitioner is not allowed to prescribe insulin on the NHS - even though all diabetics are entitled to free treatment. The patient has to queue to be seen by a specialist first.

We cannot say that all is doom and gloom: The APFD is a prime participant in plans to address the onset of pandemic flu. We participate in administering the yearly flu vaccine provided for free by the government for the over 55s and this year will be no exception. We are asked to participate in the drawing up of guidelines for antibiotic use. We have been asked to give our input for the use of information technology for the primary care sector. We have given our detailed input as to where reform is needed. In the national conference organised by the Department of Health last November, we were happy to note that our ideas were taken on board.

A joint task group with the doctors working in health centres has been set up and includes the Medical Association of Malta and the Malta College of Family Doctors - the remit here being to formulate unified proposals but the essentials have already been made known.

On the home front, the Association of Primary Family Doctors has succeeded in establishing an esprit de corps among a professional group, which is by necessity solitary and highly individualistic in its outlook. Attainment of higher qualifications, improved record keeping, computerisation and upgrading of clinics are all proceeding apace.

We agree that a sustainable and a readily-available health service is a cornerstone of a compassionate and civilised society. The Association of Private Family Doctors augurs that the minister is wise enough to make his own judgment where euro savings could be made without compromising the service. The health centres might or might not be converted into something unrecognisable. Yet, by concentrating on the public primary care service without addressing the problems faced by doctors looking after the 70 per cent will be a disservice to us all.

The APFD has been in the forefront in asking for a reform in primary care, public but also private. We have spelled out where the deficiencies lie and proposed solutions. We only ask to be able to do more.

Dr Azzopardi is president of the Association of Private Family Doctors.