Family medicine at a crossroad

Part of the primary health care system in Malta has been in the news over the past days or weeks... but for the wrong reason.

The terms "family medicine", "general practice" and "primary care" have been used interchangeably by many over the past years and it seems that not everyone is fully aware of the subtle differences in the meanings of these terms. I feel that some basic background information is important to put things in perspective.

I would like to start by giving the official definition of the general practitioner/family doctors according to the World Organisation of Family Doctors (Wonca).

General practitioners/family doctors are specialist physicians trained in the principles of the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and illness. They care for individuals in the context of their family, their community and their culture, always respecting the autonomy of their patients. They recognise they will also have a professional responsibility to their community.

In negotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilising the knowledge and trust engendered by repeated contacts. General practitioners/family physicians exercise their professional role by promoting health, preventing disease and providing cure, care or palliation. This is done either directly or through the services of others according to health needs and the resources available within the community they serve, assisting patients where necessary in accessing these services. They must take the responsibility for developing and maintaining their skills, personal balance and values as a basis for effective and safe patient care.

Family medicine has seen great developments and increasing recognition throughout the last 20 years as more and more governments recognise the benefits of placing family medicine as the basis for health care in the country, especially in view of increasing patient expectations and health care costs. International bodies, including the WHO, have for a long time realised that primary care is the solution that helps nations and communities sustain cost-effective high quality health care services. Many studies have shown that investment in primary health care is consistent with less expenditure at secondary health care levels and better outcomes.

In the local context, many individuals and organisations, notably the Malta College of Family Doctors since 1998 and the Association of Private Family Doctors since 2005 as well as many other individuals have been recommending changes in the health care system to shift the focus onto a family-practice-based system. Unfortunately, the government's priority has been the development of Mater Dei Hospital and there has been little if any tangible support for the development of primary health care except the development of the GP training scheme.

A properly functioning primary care service is based on a solid doctor-patient relationship based on mutual trust and on continuity of care, that is, the same doctor knows the patient and his family, deals with all medical problems and refers only when appropriate. Being specialists in their own field, family doctors are uniquely placed to practise health promotion and disease prevention in their practice, deal with most common illnesses seen in the community and manage the most common chronic diseases including diabetes, high blood pressure, heart failure and asthma.

One of the realities of family practice in Malta is a dichotomy of delivery - this includes a polyclinic - (aka health centre) based system provided by the government. The concept of the polyclinic is derived from a socialist vision of health care after its prototype developed in Eastern Europe by Shemansko. The system was launched at the time of the doctors' strike more than 30 years ago. This system works in parallel with the services offered by private family doctors of which there are those who are in full-time private practice and a significant proportion who work in the government health service and also practise in the private sector when not on duty in the government health service.

According to government statistics, 70 per cent of patient encounters in family medicine take place in the private sector. The private family practice system is intrinsically based on continuity of care as opposed to a system of mainly episodic care where the patient is seen by the doctor on duty at that point in time. This system, by its very nature, inevitably encourages fragmentation of care, over investigations and otherwise unnecessary referrals with resultant overloading of the already overloaded and overstretched secondary care (hospital) setting. This, in turn, results in the unduly long waiting times at emergency department for patients who resort to this department but who could otherwise be managed by their family doctor. This is also responsible for a sizable number of cases who are seen at outpatients and who could otherwise be ably managed by their family doctor and referred only when absolutely necessary.

Unfortunately, private family doctors are at a disadvantage when compared to their government-employed colleagues in that there are illogical barriers to the accessibility of a whole range of blood and radiology investigations. Patients who need such investigation have either got to seek the help of the polyclinic or do the tests privately. Doctors working in private family medicine have long been insisting on a "level playing field" in access to secondary care facilities in the interest of their patients.

It is bewildering for many doctors and patients alike that there are many obstacles to efficient patient management. A simple modification of the dose of a blood pressure tablet or addition of another drug in line with internationally-accepted guidelines usually entails referring a patient to see a secondary care specialist based at polyclinic to endorse this change. This means loss of time and unnecessary hassle for patients as well as inappropriate use of consultants' time. It would be much better had the consultant been there to consult in case of any specific management problem rather than to rubber-stamp the management plan of a colleague.

Before the last parliamentary elections, besides family doctors being compared to jewels, a public declaration was made that once Mater Dei Hospital was up and running, the family doctor would be able to view results of patient investigations done in the government health service by access to the hospital IT infrastructure, only to be further specified some time later that this will happen... "in the fullness of time". Patients regularly ask why this has not yet been implemented.

This lack of access only adds to frustration and inefficiency and it is only patients that will suffer unduly. If doctors have access to these investigations, they can manage their patients more efficiently and help reduce hospital overload with its consequent implications on hospital costs and efficiency. The difficulties in deploying such a system, with the state-of-the-art hospital the country has invested so heavily in, should not be insurmountable, especially with the introduction of a patient registration system where the patient registers with a family doctor of his/her choice and this doctor serves as the bridge between the patient and the government health care services.

The vast majority of family doctors working in private practice offer a great service to their patients at very low cost compared to any other health care professional and, indeed, to any other service provider.

The cost of a home visit is usually far less than the cost of a service call of a washing machine repairer. It is paradoxically the low fees that have served as a barrier to many doctors to invest further in the infrastructure of their practices and modern indispensable systems of equipment and record keeping.

Having said this, there has been a very consistent and positive trend by doctors introducing upgrades to their practice over the last 10 years.

The current problems in health care are symptomatic of many frustrations experienced by the public and doctors working within the government health service. There are many other issues that are frustrating to all other professionals involved, both in the private and public health service.

Many have created voluminous documents and participated in task forces to propose the necessary changes and have made valuable suggestions.

Implementation of these changes needs strong determined leadership and consensus by all stakeholders that the changes will benefit them and the patients.

It seems primary health care is at a crossroad... Let's hope the country will be wise enough to choose the correct path.

Dr Galea is a specialist in family medicine.